Treating the Individual Tooth, Not the Patient: Case Reports

Four patients presented to either the Emergency Dental Clinic or the Oral Diagnosis Clinic at a dental college with previous root canal therapy and the absence of other necessary dental treatment. All 4 patients presented in January and February of 2007. Three of these patients had untreated dental caries, and one had untreated periodontitis. All of these patients had been treated previously in private practice settings for emergency endodontic care. From the histories and radiographs, it appears that these patients had presented to private practice dentists with tooth pain and were appropriately treated with initial pulpectomy/pulpotomy/endodontic therapy. However, after the initial treatment for pain, instead of further evaluating the patient and completing a treatment plan, the endodontic therapy was completed. In some cases, crown restoration was completed after the endodontic therapy. But it appears that a complete oral dental evaluation, patient education, and treatment planning were neglected in all of these 4 dental patients.
These 4 cases present a troubling view of present-day dentistry. Christensen has remarked on the credibility of dentists,1 pointing out that patient dental care that enhances financial gain rather than patient health tends to hurt the credibility of dentists in general. The medical histories for all 4 of these patients were essentially negative, and therefore did not appear to be an issue with regard to the patients’ dental therapy. The old phrase, “Save a tree and save the forest” has been turned around to “Save a tree and lose the forest.” These 4 cases are presented and discussed.

CASE REPORTS

Case No. 1

Figure 1. Case No. 1: Panoramic radiograph of a 22-year-old female who reported pain in an upper left tooth.

A 22-year-old female reported with this chief complaint: “A tooth in my upper left hurts.” The panoramic radiograph revealed a periapical radiolucency of the maxillary left second bicuspid. This tooth was also noted for a large amalgam restoration. The panoramic radiographic (Figure 1) and clinical examinations also revealed several other findings, including completed root canal and crown restorations for both the mandibular second molars; an impacted mandibular right third molar; multiple carious teeth (the maxillary left second molar and the mandibular right first molar); and a defective amalgam restoration. The mandibular right third molar was described as a horizontal impaction. Furthermore, a 6-mm infrabony pocket on the distal aspect of the right second mandibular molar (with root canal and crown restoration) was noted.

Case No. 2

Figure 2. Case No. 2: Panoramic radiograph of a 22-year-old female with a chief complaint of pain in the lower left area of the mouth.

A 22-year-old female reported with this chief complaint: “I am having pain in the lower left.” The panoramic radiograph (Figure 2) revealed root canal therapy of the mandibular left first molar, with an incomplete root canal fill of the mesial roots. Also, the radiograph revealed a previous root canal therapy that was completed on the mandibular right second molar. Neither of these teeth had been restored. The mandibular right second molar was noted for extensive caries, which rendered this tooth nonrestorable. Furthermore, multiple carious teeth were radiographically evident (the maxillary left first and second molars and the mandibular right second molar). This patient appeared to be uncomfortable in the dental operatory environment. She reported that the root canal procedures had been painful, and she was reluctant to undergo further dental therapy.

Case No. 3

Figure 3. Case No. 3: Panoramic radiograph of a 24-year-old female who requested a “dental check-up.”

A 24-year-old female reported with this chief complaint: “I need a dental check-up.” The panoramic radiograph (Figure 3) revealed severe generalized caries with many non-restorable teeth. The mandibular left first molar had previously been treated with endodontic therapy. This tooth was severely decayed and not restorable. All 4 third molars were impacted. The patient appeared to be lagging in her dental development, as evidenced by the incomplete formation of the roots of the impacted mandibular third molars. The maxillary and mandibular anterior teeth demonstrated severe caries, with questionable restorability for many of these teeth. Furthermore, severe caries was noted on the maxillary right first bicuspid, left first and second bicuspids, and second molar, and the mandibular right first molar and second bicuspid.

Case No. 4

Figure 4. Case No. 4: Radiographic study of a 32-year-old female who requested “braces.”

A 32-year-old female reported with this chief complaint: “I have a loose front tooth and I want braces.” The panoramic radiograph (Figure 4) revealed moderate to severe bone loss consistent with periodontal disease. The maxillary left second molar was noted for severe caries and previous endodontic therapy. Furthermore, the tooth was not restorable. Root tips of the mandibular left second molar were evident. Periodontal pocket probing depths varied from 3 to 8 mm. The maxillary left central incisor was noted for class II mobility and was displaced labially.

DISCUSSION

Patients presenting with dental pain require diagnosis of the pain complaint and treatment to relieve it. The relief of pain accompanying an acute condition is a priority in regards to treatment planning. Discomfort may be due to acute pulpitis or several other diagnostic entities.2 It appears that in all 4 of these cases, the patients’ initial pain complaints were addressed with reasonable diagnostic and emergent dental treatment. However, it seems that dentists in these 4 cases were focused upon completing the therapy on the 1 or 2 individual teeth that required root canal therapy, and in case No. 1, the subsequent crown restorations. In case No. 1, the treatment plan should have also considered the importance of the impacted third molar.3 If the endodontic therapy and crown therapy were completed before the removal of an adjacent impacted third molar, the surgical therapy could result in damage and possible loss of the reconstructed second molar. This patient should have had the option to have the impacted third molar removed prior to the endodontic and crown procedures. Such oral and maxillofacial surgical treatment could have successfully eliminated the large periodontal pocket between the second and third molars.
Case No. 3 also involved impacted mandibular third molars, the removal of which could spare the second molars from further potential problems. Also, in case No. 3 the maxillary left second molar with a large carious lesion might have benefited from the extraction of the maxillary left third molar. The removal of the third molar first would prevent the exposure of the adjacent tooth to possible extraction trauma after definitive restorative procedures. Therefore, the proper sequencing of therapies would tend to result in less opportunity for completed therapies to be affected negatively.
There is some suggestion that the treatment in the 4 cases presented reflected an economic incentive to the dentists. These dentists may have believed that moving the patient into a treatment path of root canal and possibly crown therapy provided the greatest economic benefit These dentists may have also believed that the completion of the root canal (and subsequent crown procedure) to address the emergency dental pain of the involved teeth was the most reasonable therapy for dental patients with these emergencies. However, as these 4 cases demonstrate, completing definitive treatment on a singular tooth without formulating a comprehensive treatment plan may not be in the patient’s best interest. After temporarily relieving these patients’ pain, these dentists would have had the opportunity to educate them about their dental health issues, propose a sequenced treatment plan, and successfully restore these patients to reasonable dental health. In so doing, these dentists may well have established positive doctor-patient relation-ships with the possibility of patient-to-patient referrals and long-term economic success for the dentists.4 There is also a slight possibility that one or more of these patients did not have other significant findings such as advanced caries and/or periodontal infection during their initial emergency dental appointments.
Educating patients is an intricate and extremely important aspect of dental therapy, and is stressed in all dental schools. Possibly some of these concepts may have been forgotten after graduation.5-7 It appears that there is an economic incentive for dentists to begin expensive dental procedures as quickly as possible. However, it is quite possible that the more successful economic model would be to convert some of the emergency dental patients into comprehensive dental patients. Certainly, not all emergency dental patients will accept comprehensive care, but those that can be converted may become solid, reliable patients. By exhibiting a greater degree of professionalism, the dentist has the ability to advance patient dental health and still succeed financially.6
None of the presenting patients were happy with the results of their endodontic care and with the dental profession in general. If these patients had been treated in a manner more focused on advancing their long-term dental health, there is a very good chance that the dentists would have benefited financially to an even greater extent.1,8 Converted emergency dental patients may become long-term patients and even excellent recruiters for new dental patients. With dental pain alleviation, patient education, treatment planning, and proper counseling, dentists have the opportunity to accomplish comprehensive long-term patient care, and a greater financial gain at the same time.

It is established that many emergency dental patients are not interested in comprehensive care.9-13 Many emergency dental patients, particularly those patients in the underserved minority and economically depressed population, are concerned only about the alleviation of pain. In view of the expense of endodontic and crown procedures, many emergency dental patients prefer extraction rather than restoration. However, these 4 patients all returned for the completion of the endodontic procedures. Therefore, it appears reasonable to suggest that these patients would have returned also for comprehensive dental care, including treatment planning. The importance of patient education cannot be overestimated. Many patients have little knowledge of what modern dentistry offers with respect to the importance of home care, including the deleterious effects of periodontal disease and the many different dental restorative modalities.11,14 Many patients are not aware of the destructive effects impacted third molars can have on adjacent teeth and on bone health, nor of the pathological entities that can be associated with these teeth.

The comprehensive treatment model for patients presenting initially with dental pain should be as follows:

1. The diagnosis and treatment of the patient’s pain complaint. If the diagnosis of irreversible pulpitis is confirmed, then a pulpotomy or pulpectomy procedure would be a reasonable therapy to address the diagnosis. (Of course, the patient should be informed of extraction as an alternative therapy.)
2. After the patient is comfortable, the next appointment would be a complete examination with necessary imaging.
3. The following appointment should be for a comprehensive treatment planning consultation.
4. The next appointment would begin the series of appropriate dental therapies upon which both the patient and dentist have agreed.15

Furthermore, the patient must be educated as to what to expect with regard to dentistry, and with regard to the possible alternative therapies during the treatment-planning conference.16 It is important for dentists to understand the dynamics of caries control, the caries process, and relevant therapies, and communicate these concepts to their patients.17
Also, at issue is the timing of restoring teeth with crowns after the endodontic therapy has been completed. Rivera and Yang, as well as many others, have suggested the importance of restoring severely broken down endodontically treated teeth as soon as possible after the root canal therapy has been completed.18,19 Failure to crown these teeth immediately after root canal therapy would leave such teeth at risk for fracture and eventual extraction. Therefore, once the dentist determined an initial plan of root canal therapy, he or she was locked into the next therapy of restoring the recently completed root canal treated tooth. Both the root canal therapy and the buildup with crown therapy are reasonably complicated and expensive procedures, both having the potential to be labor and time intensive. Therefore, the patient’s more pressing dental needs may be neglected and left to smolder and worsen.
Patient education, including treatment options, allows the patient to decide on the most reasonable individual course of action. However, the decision process has limitations because of the lack of clinical trials that directly compare one treatment approach to another.20 Generally, accepted guidelines exist for the ethical consideration of treatment planning and informed consent, and these ethical guidelines should provide a framework for all clinical decisions.21 Of course, it is important and often helpful for the dentist to provide input as to which therapy the dentist believes is the most reasonable and best for the patient. According to the ADA’s principles of ethics and code of professional conduct, quality dental therapy can only be provided when both the dentist and the patient make treatment decisions that are based solely on the patient’s general health status and specific oral health needs.22 The recommended therapy should be safe, predictable, cost-effective, and respectful of patient preferences, aimed at preserving normal anatomy and function, and based upon the best available scientific evidence.21-24

CONCLUSION

Four cases have been presented that may or may not necessarily demonstrate a general problem with regard to the treatment of emergency dental patients. The presentation of these cases demonstrates that some dentists may be focusing on completing endodontic procedures prior to the completion of a comprehensive dental treatment plan. In these 4 cases, the painful teeth of the patients were treated with endodontic therapy, and the patients’ overall dental concerns were neglected or not addressed. Future evaluative studies are necessary to determine the extent of this issue within the private practice community and to consider the need to address this issue within the dental education and private practice communities.

References

1.  
   1. Christensen GJ. The credibility of dentists. J Am Dent Assoc. 2001;132:1163-1165.
   2. Rosenstiel SF, Land MF, Fujimoto J. Contemporary Fixed Prosthodontics. 3rd ed. St Louis, MO: Elsevier; 2001:59-82.
   3. Peterson LJ, Ellis E III, Hupp JR, et al; eds. Contemporary Oral and Maxillofacial Surgery. 4th ed. St Louis, MO: Mosby-YearBook; 2002:180-183.
   4. Finkbeiner BL. Practice Management for the Dental Team. 6th ed. St Louis, MO: Mosby; 2005:45-65.
   5. Masella RS. The hidden curriculum: value added in dental education. J Dent Educ. 2006;70:279-283.
   6. Masella RS. Renewing professionalism in dental education: overcoming the market environment. J Dent Educ. 2007;71:205-216.
   7. Botto RW. Addressing the marketplace mentality and improving professionalism in dental education: response to Richard Masella’s “Renewing professionalism in dental education”. J Dent Educ. 2007;71:217-221.
   8. Christensen GJ. Elective vs. mandatory dentistry. J Am Dent Assoc. 2000;131:1496-1498.
   9. Pau AK, Croucher R, Marcenes W. Perceived inability to cope and care-seeking in patients with toothache: a qualitative study. Br Dent J. 2000;189:503-506.
   10. Johnson JT, Turner EG, Novak KF, et al. Factors associated with comprehensive dental care following an initial emergency dental visit. J Dent Child (Chic). 2005;72:78-80.
   11. Anderson R, Thomas DW. ‘Toothache stories’: a qualitative investigation of why and how people seek emergency dental care. Community Dent Health. 2003;20:106-111.
   12. van Palenstein Helderman W, Lo E, Holmgren C. Guidance for the planning, implementation and evaluation of oral health care demonstration projects for under-served populations. Int Dent J. 2003;53:19-25.
   13. Whyman RA, Treasure ET, Ayers KM. Dental disease levels and reasons for emergency clinic attendance in patients seeking relief of pain in Auckland. N Z Dent J. 1996;92:114-117.
   14. Anderson R. Patient expectations of emergency dental services: a qualitative interview study. Br Dent J. 2004;197:331-334.
   15. Bain CA. Treatment planning in the general dental practice: case presentation and communicating with the patient. Dent Update. 2004;31:72-82.
   16. Christensen GJ. The ‘new’ operative dentistry. J Am Dent Assoc. 2006;137:531-533.
   17. Featherstone JD. The caries balance: the basis for caries management by risk assessment. Oral Health Prev Dent. 2004;2(suppl 1):259-264.
   18. Rivera EM, Williamson A. Diagnosis and treatment planning: cracked tooth. Tex Dent J. 2003;120:278-283.
   19. Yang SF, Rivera EM, Walton RE. Vertical root fracture in nonendodontically treated teeth. J Endod. 1995;21:337-339.
   20. Bader HI. Treatment planning for implants versus root canal therapy: a contemporary dilemma. Implant Dent. 2002;11:217-223.
   21. American Association of Endodontists Special Committee on Implants. AAE position statement: implants. AAE Web site. www.endoexperience.com/documents/implantsstatement.pdf. Published April 3, 2007. Accessed February 23, 2008.
   22. American Dental Association. Principles of ethics and code of professional conduct. ADA Web site. www.ada.org/prof/prac/law/code/ada_code.pdf. Published 2005. Accessed February 23, 2008.
   23. Doyle SL, et al. Retrospective cross sectional comparison of initial nonsurgical endodontic treatment and single-tooth implants. Compend Contin Educ Dent. Jun 2007;28(6):296-301.
   24. American Dental Association. ADA policy on evidence-based dentistry. ADA Web site. http://www.ada.org/prof/resources/positions/statements/evidencebased.asp. Updated April 4, 2003. Accessed February 23, 2008.

Dr. Reid is the clinical director of the Oral and Maxillofacial Clinic at Howard University College of Dentistry. He is responsible for the daily operation of the clinic, which includes patient care and the instruction and supervision of junior and senior dental students. He also oversees postgraduate residents on rotation through the clinic. Dr. Reid, a graduate of Howard University College of Dentistry and its Oral and Maxillofacial Surgery Residency Program, spent 16 years in private practice in Maryland and the District of Columbia before returning to Howard University College of Dentistry as an assistant professor. He has multiple published articles and is actively involved in teaching as well as coordinating the Major Oral and Maxillofacial Surgery Courses for junior and senior dental students. He can be reached at e_reid@howard.edu.

Dr. Sam completed her DDS at Howard University followed by an oral and maxillofacial residency at the same institution. She is currently an assistant professor in the Department of Oral and Maxillofacial Surgery at Howard University and can be reached at fesam@howard.edu.

Dr. Jones is a graduate of Howard University and its dental school. He is a Diplomate of the American Board of Oral and Maxillofacial Surgery and a Fellow of the American Society of Oral and Maxillofacial Surgeons as well as many other professional organizations. Following a 31-year career in the private practice of oral and maxillofacial surgery, Dr. Jones entered academia as an assistant professor of oral and maxillofacial surgery at Howard University College of Dentistry and Howard University Hospital. His current interests include anesthesia and pain management, and he is actively involved in teaching and research in these areas. He has lectured nationally to dental, medical, and lay organizations on current topics in dentistry and can be reached at rob_jones@howard.edu.

Dr. Brown is associate professor in the Departments of Oral and Maxillofacial Pathology and Oral Diagnosis and Radiology at Howard University College of Dentistry, and a clinical associate professor in the Department of Otolaryngology at Georgetown University Medical Center. He is past president of the American Academy of Oral Medicine. He can be reached at rbrown@howard.edu.