When it comes to creating endodontic treatment plans, one size doesn’t necessarily fit all. Depending on each particular patient and their unique situations, what seems to be the obvious treatment plan may not be in the cards. This tooth story is a great reminder of how important it is to give our patients the individual attention they deserve. 

A Critical Bitewing

The patient in question was a sweet 84-year-old woman. This wasn’t her first visit to my practice—her dentist had  referred her to me previously for a root canal on another tooth. This time around, she was suffering from cold sensitivity pain on the lower left side of her mouth, especially when biting. 

She was originally referred for tooth #18, and her periapical x-rays showed recurrent decay under #18’s crown. But there was more behind this tooth story. Her bitewing revealed that she had some recurrent decay under the crown of tooth #14, as well.

I always want to perform the most thorough exams possible, so I took another periapical radiograph of tooth #14. Even though this x-ray didn’t show any obvious periapical pathology, it let me see that there was more than one problem. After completing my diagnostic tests, I diagnosed tooth #18 with Symptomatic Irreversible Pulpitis and Symptomatic Apical Periodontitis. Tooth #18 was still sensitive to cold and tender to percussion.

This process was just one example of a lesson I’ve learned many times over in my practice: it’s critical to take a bitewing when you’re examining a patient to make sure you make the correct diagnosis and treatment plan. Overlooking something like this could come back to haunt you!

Since I’ve made it my mission to save as many teeth as possible, I knew I needed to evaluate whether this patient’s teeth could be restored. This was going to require removing the crowns, excavating the teeth, and finally reassessing the teeth for restorability and potential crown lengthening. 

An Appropriate Treatment Plan Requires Observing And Listening

After making the diagnosis, there were still a few mysteries left to solve. Not only did I need to find out how viable the teeth were, but also why the referral slip I’d received from her general dentist was essentially empty. It was important that I know what the patient had discussed with her general dentist so I could familiarize myself with the treatment plan. As it was, I had almost no information to go by. 

So, I started forming a treatment plan the old-fashioned way: I asked questions, listened, and observed. As we spoke, I noticed the patient’s hands were trembling. It made me wonder about how her manual dexterity was affecting her oral hygiene. 

The patient also seemed very confused, and I had to repeat myself several times when speaking with her. When she told me that her husband was with her, I offered to invite him in so he could be involved in what was happening.

She replied, “No, don’t. He won’t understand or remember anything.” It was then that I learned her husband was suffering from dementia, and that she herself had been diagnosed with Parkinson’s.  

Sadly, this meant that the patient was losing her ability to care for her teeth. I knew that the procedures in her potential treatment plans would have daunting recovery times. Although I hadn’t asked about her financial situation, I guessed that she was her husband’s sole caretaker, and that they might already be shouldering significant medical costs. 

One Diagnosis Doesn’t Have One Solution

This new information was going to affect the patient’s treatment plan options. I knew it was more important than ever that I present her with all the choices. This sweet woman really needed my time, and I needed to ensure she understood everything well. So, I presented her with these treatment plan options:

  1. Extract the teeth and do nothing else
  2. Extract the teeth and replace them with implants or bridges
  3. Try to save the teeth by doing the root canals with some buildups
  4. Try to save the teeth by doing the root canals with crowns and possible crown lengthening
  5. Do nothing
  6. Excavate and see what’s left, and then make a decision

Throughout this process, I was open and honest with the patient. I told her my concerns about whether or not she could keep the area clean enough to prevent further problems, and I was upfront about what each option would take in terms of both cost and recovery time. 

I learned more and more about the patient as I continued speaking with her. People had told her not to extract her teeth. She was also so nervous about dental procedures that she wanted me to sedate her (I don’t offer any sedation beyond valium). 

A Treatment Plan Depends On The Individual Patient

In the end, the patient elected not to schedule treatment with me. Even as an experienced tooth saver, I think that doing nothing was the best treatment plan for this patient. (If she had been 60 years younger and in perfect health, it might have been a different story!)

She understood that even though I was happy to do the root canals, I would do whatever her heart desired. I wanted her to understand what it was going to take for that to happen before allowing her to make her own decision. She wouldn’t have been able to make an empowered decision about her own dental health if I hadn’t taken the time to talk to her.

And that’s my challenge to dentists everywhere:

Talk to your patients. Observe them. Listen to them.

Understand their unique situation and give them all their options. Keep explaining until you feel confident that they understand everything—even if that means you have to repeat yourself.

Minimize your number of referrals, when possible, so your patients end up in the right hands for what’s best for them as soon as possible—and so they can put their hard-earned money towards the appropriate treatment plan.

Give your patients the information, time, and care they deserve, and their gratitude will be immense. 



  • Never underestimate the importance of bitewing x-rays in diagnosing patients.
  • It’s critical to observe your patients and truly listen to them to determine a treatment plan that is right for them.
  • Present patients with their options (and what each option means in terms of recovery time and financial impact) to enable them to make empowered choices about their own dental health.