From: Liviu Steier
To: ROOTS
Sent: Wednesday, November 04, 2009 6:01 PM
Subject: [roots] Quiz - how would you treatment plan this case?

Terry, I like your Quiz Case very much.

I used to run a column in a UK based journal called Private Practice. The column had the name
"How would you decide?". As such I continue myself which this kind of quizzes for education
purposes. Have a look at this case and please treatment plan. - Liviu

47 years old male in good general health.
Stopped smoking about 6 years ago.
Fair oral hygiene.
Occlusal dishamony.
Finances are an issue.
Implant was placed about 1,5 years ago.

Vitality test negative on the following teeth:
18 / 17  26
CAP on tooth 25
Pockets over 8 mm depth:
18 / 17 / 16 / 26 / 27 / 28 / 37 / 38
Pockets over 5 mm
45 / 34 / 35 /
Furcation involvment class III
17
Furcation class II
18  / 16 / 26 / 27 / 28
BOP
18 / 17 / 16 / 26 / 27 / 28

-  Dr. Liviu Steier, PhD










Hi Liviu, What a messy case!   Lots of questions before treatment planning that one; i.e.
medical history, what drugs? etc. then a diagnostic wax up, check out occlusion, then
determine which teeth clearly have to go and those that might have to go, re-evaluate
healing and remaining bone after extracting losers and caries control, then final treatment
planning, possibly including onlay grafts etc.

If finances are a problem, nothing close to ideal is possible.  I usually explain the
ideal treatment planning needs to the patient highlighting unknowns and the likely decision
points along the way. This one would be a long conversation with multiple scenarios and
paths branching off decision points.  As a specialist I would hope that the restorative
dentist already had a plan that I could work with as a template for discussion.

Teeth with questionable perio sometimes look better after adjacent losers are extracted
and initial perio therapy is implemented.  If a primary endo/secondary perio etiology is
suspected on some of the teeth (e.g.. 18, 17, 26) you might consider exploratory access
and CH placement to see if perio improvement occurs.

Given the smoking history I would presume there is chronic perio and it's unlikely that
endo disease vectors are primary.  The diseased roots likely have chronically degenerated
PDL with mature biofilm established.   No money, means removables and a path to eventual
dentures.  Expensive heroics do not seem to be in the picture for this patient.

I'd venture to guess that the implant was placed to fill a hole rather than treat the
patient's disease - Terry

Hello Terry,  do fully agree with you: only whole care treatment planning is a viable
solution for this case.

We have been educated and aged in this profession by performing whole care treatments.
...but today we are "disappearing / dying dinosaurs"!
So called "minimally invasive dentistry" ( " I do not touch because I do not know what to do!"
= lack of knowledge); "the credit crunch" = lack of financial option;
"badly understood economic competition" among dental practitioners, and last but not least
"exploding prices" in health care stopped the so called "full mouth rehab" cases - Liviu

Liviu, This type of presentation is incredibly frustrating and unfortunately these patients
present to my office for "single tooth" endo consultations almost every day.  I really can't
freakn' stand it anymore.  Ignorance is rampant, preventative care is not being performed,
idealists are being bashed for not wanted to fold into the "extreme makeover" agenda of
quick and dirty profits and let all the malpractice bullshit fall where it may.  Tort reform
and maintenance of quality health care isn't even in the dialogue for this stupid-assed health
care bill that is going to bankrupt the USA filling the pork barrel to feed the hoodlums now
running the country.

No ethics, no quality, no brains......that pretty much describes the current health care
crisis and the misdirected focus on access to care which is just a smoke screen to hide more
egregious pilfering of the decrepit system.

We are the last of the Mohicans and about to be wiped out by the carpetbaggers loitering on
the cherished property we pay rent and taxes on.

Who is going to change the dialogue and change the world? -  Terry