The Perio Perspective
The Burden of Care
One of the concepts that seem underappreciated by doctors is the burden of care. Some treatment modalities require more time, pain, expense, risk, and long-term care than others. When we discuss treatment options with our patients, the burden of care is an important factor in reaching a decision.
Tooth #14 above has a long, sad history. Our patient, who was highly educated and motivated, and who was otherwise dentally and periodontally healthy, had an abscess a few years after incomplete endodontic therapy and crown fabrication. Before seeing us, he was treated twice with an apicoectomy for the mesiobuccal (MB) root. The abscess recurred both times and he was referred to us. What would you recommend?
Our thought process began with considering the possible causes for the abcess. The most likely cause seemed to be residual necrotic pulpal tissue in the MB root. When a pulp canal cannot be instrumented and obturated, an apicoectomy may seal the apex and eliminate the source of infection. But the success rate for an apicoectomy is variable, depending on the tooth type and anatomy, and for this tooth it was unsuccessful. Twice. A second possibility was a root fracture. This seemed less likely since there were no signs or symptoms other than swelling. In either case there were two treatment alternatives: extraction and implant placement or resection of the MB root.
Extraction, socket grafting, implant placement, and restoration would require 2 surgical procedures and a total of 7-10 visits (including follow-up appointments) spread over a minimum of 6 months. The cost to the patient would be approximately $5000. Root resection would be completed in one visit followed by 2 post-op appointments, at a cost of approximately $1500. This approach would require cutting a window in the facial bone, which after removal of the root should receive a bone graft to fill the defect. This would prevent a ridge deficiency that could compromise future implant placement, and would add another $500 to the cost.
The risk of implant therapy for this case would be minimal for the foreseeable future, since the patient had none of the main risk factors for early failure or peri-implantitis. We estimated a 10% risk of implant complications or failure, and a 10% risk of component complications, such as screw loosening, over 10 years. The principal risk following root resection is fracture of the remaining roots. Multiple long-term studies have indicated that this risk for our patient would be 20% over 10 years. Over 20 years, all of these risks would approximately double.The burden of care would be initially greater for the implant option, but either option had a gradually increasing risk for complications or failure.
This is the information we offered to our patient and his referring dentist. Now you have it too. If this were your tooth, what would you do? If this were your patient, what would you recommend?
Our patient chose root resection. This aligned with two themes that we have discussed in several previous newsletters. The first is analysis of risk factors rather than reflexive extraction and implant placement. The second is a preference for conservative options, leaving more aggressive approaches for the future when possible. Salvaging his tooth, while preserving the site for eventual implant placement if necessary, made sense to him and to us.
We – and our patients – want our treatment to last forever. When “forever” means several decades, this is unlikely. Like a good chess player or quarterback, when we can see several moves ahead, and when we can preserve our options, we have the best chance for success over a lifetime, with the least burden to the patient.