Reinfection after root canal, exam before retreatment, Dental Education Lecture

谢谢诸位对本例关注（一，二），明天病人就要回来治疗，对于失败病例做进一步治疗需要收费吗？Dr. Fang and others: Thanks for further advice and encouragement. I will let the patient decide what to do tomorrow. My last and the toughest question is whether I should let the patient pay the rest of the treatment or not. My wife as an office manager says that we should not charge him at all. I do not agree with her. The outcome of the treatment from now on is also dependent upon patient's condition. If he does not have desire for treatment, including payment, I am going to stop doing anything. Probably I am not so competent for the tough case. What do you think? Xin Thu, 2 May 2013 19:02

病人回来时说已经不太痛了，但是颊侧近中根尖仍有轻度肿胀，触痛（图三箭头），反复告诉他不处理不行，他强调采纳最保守治疗，不愿拔牙植牙，左下第二磨牙植牙（图四I）不好用，好像与真牙不一样。其实他牙齿磨耗尤其严重（图一至图四显示四个象限后牙，*代表第一磨牙），两个磨牙牙冠一定要有金属合面，否则陶瓷会断裂，而且牙冠容易脱落。左下第二磨牙植牙折腾部分原因是对合牙（左上第二磨牙）往下掉（supraerupted，图二S），没有空间放植牙，基牙和牙冠。

找专家重做根管治疗，或者根切都提出来了，最后病人愿意留下做根切，他明白根切不成功，就需要拔牙。好了，就开始动手吧。治疗后受到以下两位来信。

Dr.Wei:

我有点偏向你太太的意见。

如病人不想做，即停。如想做而且有保险，且能cover implant 最好；如只能cover 根切，就做根切。如想做又没保险，free做个根切（但这时一定要讲得很活，如伤口长不好，可能复发，我平时都是这样，保险不好的就讲得严重些，好的讲轻些，免得吓跑了）。因为3年了，炎性肉芽组织很多，很厚，只重做RCT，我感觉还会复发。

根切的关键在于前庭沟浅还是深，深好做，因为暴露好。

Good luck!

杭晴 Friday, May 3, 2013 2:12 AM

Thank you very much for sending this message to me before seeing the patient. In fact I did not check it until surgery (apicoectomy). Do not feel bad providing advice not consistent with that of Dr. Fang.

Probably due to our similar background (oral surgery), I chose surgical mode. I particularly like your idea: 根切的关键在于前庭沟浅还是深，深好做，因为暴露好。In fact the vestibule is deep in this case as will be shown soon in my web. What incision should I make, gingival sulcus or apical semilunar, for the best exposure? Xin

You can avoid financial issue by referring pt. to an endodontist who you work with. Pt. probably understand that there is a small percentage of risk of rct failure requiring retreatment (stated on consent form). If this is done by a specialist, the outcome is more predictable and you are out of burden of guessing your technique. Financially, either w/ ins. Or w/t ins., the retreatment with the crown in place is much less expensive to the patient than the implant and the new crown.

Spring is everywhere and here in the northwest, with warm sun and beautiful blossom of flowers, bushes and lot of flowering trees too. We should slow down, take some time off, embrace the nature.

Thanks everybody for written and unspoken support. In fact, the patient chose apicoectomy. Before decision, I almost had heart attack, although he did not give me any pressure. I did feel guilty. He wanted to save the tooth in the most conservative way. There is an unexpected (to me, but not to Peter) finding. How to handle the issue is probably unexpected indeed. Can you guess what they are (finding and management)? I will show the case in intraop photos. In fact, we did not talk about finance. He walked out without copay for apicoectomy. His insurance is not so bad. More importantly I got something money cannot buy. In all, thanks again. Xin Friday, May 3, 2013 05:58 PM