When to extract and when to restore

This is a common dilemma for patients and dentists alike. When has a tooth had all the dentistry it can take and so should come out and when is it worth having one more go at restoring it.  The answer is usually arrived at following a thorough examination and detailed discussion with tooth’s owner regarding all the possible treatment options along with a list of possible outcomes, relative costs and potential risks. It is beyond the scope of this blog to detail all the permutations of this sort of discussion but I will say that listening to a patients needs and wishes and helping them arrive at a decision that is right for them is a really important part of my job.

The decisions we make about teeth often take the form of a SHEEP score where we look at the amount of remaining tooth structure (S), the dental history of the tooth (H) the endodontic health of the tooth (E) the experience of the operator or the given procedure, including audited outcomes (E) and the periodontal (gum)  health (P).  In reality the process of decision making is not usually as structured as this but however we do it our decisions need to be supported by current evidence where ever possible. The case below shows a fairly typical re treatment of root canal filling that had failed to control the infection at the tips of the root (the dark area at the tip of the root in the first picture is an abscess that had been worsening and had begun to cause the patient pain). The tooth had been scheduled for extraction by one dentist but the patient was not keen and requested a second opinion. Current evidence seems to suggest that teeth that have been successfully treated with a root canal filling are just as likely to be present at 10 years as an implant retained crown (IRC). This is important because IRCs are a the biggest growth area in dentistry and are often seen as the solution to all ills. At StoneRock we are very proud of the implant work that we provide and we recognise that they are a valuable part of the dental “toolbox” but we also know that the natural tooth is still the best thing to do the job and we are keen to delay the loss of teeth for as long as possible. The decision to re treat the root canal filling was based on the fact that the original result was considered to be “sub-optimal” and the remaining tooth tissue was sufficient to warrant the effort. The gum health was not ideal but this responded to treatment as well and has since remained stable. The re treatment was provided by myself (Ian Kerr) as I have extensive experience in this field. The re treatment was successful as shown in the second picture taken 2 years later showing no shadow around the tip of the root, indicating that bone had returned to this area.  The tooth is now present and symptom free almost five years later and is showing no signs of deterioration. The fact that this was achieved at less than the a third of the cost of an implant retained crown was certainly an added bonus for the patient!

When ever a decision is made to remove a tooth because “it cannot be treated” it is not unreasonable to ask “can it not be treated at all, or just not by you?” A tooth should never be removed simply because the dentist making the decision thinks the job is too hard for them. Every dentist has a duty of care to indicate when they feel a treatment is beyond their ability. There is no shame in this and I routinely refer to colleagues who are better skilled than me at various procedures; and on these occasions I always say “they are better, slicker and quicker than me- go and see them and you will get a better job then I can offer”.

StoneRock Dental Care supports the campaign to save teeth.