By Gordon J. Christensen, DDS, MSD, PhD
Q When do you suggest performing an indirect or direct pulp cap, endodontic treatment, or extraction? I'm often confused when making these decisions. I notice dentists do endodontics when preserving the vitality of the tooth looks possible if adequate indirect or direct pulp capping procedures were accomplished. I see many dentists extracting teeth that look quite salvageable, and placing implants. There do not seem to be any rules relative to which procedures are best and when to do them. Could you please provide some guidance?
A After many years of practicing dentistry (prosthodontics), I recognize that the longer I've practiced, the more conservative I've become. When a hard- or soft-tissue procedure has been accomplished, the result is usually not reversible. When enamel is removed or the dental pulp is extricated, the result is final. Occasionally, the aggressive approach is justified and better than a conservative technique, but very often the reverse is true.
Currently, patients have an average life span of about 80 years, with women living slightly longer than men. If aggressive procedures are accomplished in early adulthood or even middle age, failure of the treatment often requires redoing it several times before the patient dies. This reasoning has influenced my clinical techniques toward the conservative orientation and is directly related to your question.
To illustrate my statement, I will use a series of images demonstrating a clinical situation that could have been treated either very conservatively or very radically.
Fig. 1 is a periapical radiograph of a mandibular canine in a 40-year-old patient who has a large family and, in recent times, minimal financial resources. Fig. 2 shows the major part of the carious lesion removed with a significant amount of discolored hard dentin still in the tooth.
Numerous successful techniques could be considered for this tooth. Among them are:
There are other options in addition to the ones cited here, but let's consider the ones I've enumerated, the specifics of my choices for the financially compromised patient I described, and observe the outcome of that conservative treatment.
Obviously, the more expensive treatments have better odds of success. However, as you know, many patients who do not have adequate discretionary money to spend on an expensive procedure will elect to have teeth extracted and have no replacement. The conservative treatment usually allows them to keep the tooth and risk the occurrence of pulpal death. They should be clearly informed about the potential future positive and negative expectations for the tooth.
For the patient described, we decided to carry out Option 1. The clinical details are described here:
Many alternatives could have been accomplished for this patient. The patient and I elected to gamble on the long-term viability of the tooth. It survived. At this time, the patient still does not have adequate funds to place a crown, and she is satisfied to have the current restoration serve for more time. I see no reason to suspect that the restoration will fail anytime soon. When and if a crown is placed eventually, the tooth will be a vital tooth, and the patient will have received many years of service for a minimal amount of money.
As I have discussed, there are many ways to treat almost any clinical oral condition. Depending on numerous factors discussed here, a most adequate treatment for the patient's specific conditions becomes obvious. In the case described, a conservative plan was best. However, when finances are not a severe limitation, usually the more expensive alternatives are more predictable.
Gordon Christensen, DDS, MSD, PhD, is a practicing prosthodontist in Provo, Utah. He is the founder and director of Practical Clinical Courses, an international continuing-education organization initiated in 1981 for dental professionals. Dr. Christensen is a cofounder (with his wife, Dr. Rella Christensen) and CEO of CLINICIANS REPORT (formerly Clinical Research Associates).
In this monthly feature, Dr. Gordon Christensen addresses the most frequently asked questions from Dental Economics® readers. If you would like to submit a question to Dr. Christensen, please send an email to [email protected].
Conservative procedures are often more desirable than the more predictable and expensive alternatives for many reasons, including finances and patient desire for conservative treatment. Our recent video, Affordable Treatment of Complex Rehabilitative Needs (item V1964), shows how to treat typical patients with normal income, even though they have extensive treatment needs.
Practical Clinical Courses has two popular hands-on courses in Utah that offer practical and proven techniques and materials for patients you see every practice day.
Go to www.pccdental.com or call Practical Clinical Courses at (800) 223-6569 for additional information.