After placement of veneers in 2007.  

In 2016, nine years later four lower incisors and the cuspid, patient developed apical pathology.

Referral to an endodontist for treatment of the periapical lesions involved endodontic therapy on  the three lower incisors. 

However, in 2017 following endodontic treatment there was recurrent infection, most obvious on  tooth #27 which had been previously treated years prior, as well as the lower incisors. 

A 3D scan was taken raising the concern about a possible neoplasm. 

A referral was made for a biopsy. The oral surgeon felt that all the teeth should be removed.  However, at the time of the biopsy the patient did not accept extractions because it meant the  removal of five lower incisors and a long, difficult and challenging restoration. 

After a long discussion with the patient, it was decided that she would be referred to an  endodontist who specialized in periapical surgery, a current professor at a university who has  developed expertise in treating teeth with recurrent periapical pathology. 

The teeth were retreated  

There is no periapical pathology and the teeth are stable, 7 years later. 

There are numerous lessons that can be taken from this particular patient’s journey. 

Even teeth with veneers only, especially lower incisors, can develop periapical pathology years  after restoration. Lower incisors are particularly vulnerable to periapical pathology with often  minimally invasive procedures. 

Teeth well treated endodontically can develop a recurrence periapically. Whether it be the  patient’s intrinsic resistance or the anatomy of the teeth, it is difficult to ascertain in all cases. 

The rush to take out teeth with often rather challenging surgical and restorative issues should be  reconsidered and patients should be made aware of other options, as was in this case. 

Periapical surgery, essentially redoing the endodontics from the apex of the tooth, not just  putting a seal, by an experienced endodontist can make a significant difference in teeth that  otherwise would be lost. 

All too often we throw out the baby with the bath water in dentistry. Attempting to maintain the  natural teeth should be the first option in dental care, particularly when the other options have a  significant degree of morbidity and challenging restorative and economic outcomes. 

As always, I appreciate your feedback 

Yours truly, 

Dr. Victor M. Sternberg 

By Westchester Center for Periodontal & Implant Excellence

December 31, 2023