As clinicians, we are often faced with decisions on when to restore a tooth.  Take the old amalgam on #18 (lower left 2nd molar).  The patient presented for an exam and the exam revealed the offending tooth with the old amalgam restoration.

Now the cervical decay on #19, the tooth in front is a no brainer. Clean it out, place some glass ionomer or resin and you are good to go.

But what about the tooth behind it?  What do we do with that tooth? There is no radiographic decay, there is no clinical decay.  Yes, there is some slight leakage around the margins but the tooth is not blown out by any means.  The patient is completely asymptomatic.

So if we choose to leave the tooth alone and "watch it" then are we leaving an area underneath the amalgam that will eventually cause the demise of the tooth?  If we choose to go in and treat the tooth, then find that the amalgam goes so far sub gingival, so now instead of a simple composite or GI restoration, we are faced with a much more challenging and expensive procedure for the patient.

If we choose to replace the amalgam, are we in essence speeding up the demise of the tooth so that instead of letting sleeping dogs lay, we are now causing them to wake up and make the situation worse than it is.

These are not easy decisions for clinicians on what to do.  I think the take away message from this is when we restore a tooth, decide what type of restoration to place, what material to use, we are not making that decision in a vacuum.  We are not immune from the consequences of that decision.  We are in fact going to have to live with the consequences of our treatment that we provide for patients for years to come.

Id like to get the community's opinion on this.   What would you do?
Treat now or treat later?

treat now. Had one yesterday very similar, however there was a conservative DO composite on it. Upon removing all the restorations......composite and amalgam, there was leakage (from the amalgam not the composite) and obvious fractures under both buccal cusps. Cerec full crown gave us fabulous results. Treating now versus later certainly was less traumatic for all involved.

I definitely see the dilemma this poses. I think I would present this picture to the patient and advise them that we should definitely think about treating this tooth now. The amalgam is clearly failing at the margins. I would probably give them a treatment plan for the "worst case " scenario" (maybe crown and some possible crown lengthening on the buccal) and remove the amaglam and re- evaluate . If it stays small, and GI is acceptable, you can place it , save the patient money and time and look like a hero. If it is more complex , you go ahead with the treatment you originally prescribed. You could present the patient all of this and also give them the option to do nothing at this time with the knowledge that there is a failing restoration on the back tooth. If they decided to opt for no treatment, I would re-image and go through this same process at every recall. My two cents. Good post.

I would treat now. How often do you take out an old amalgam that looks like this and say, "Well that wasn't as bad as I thought." Almost never, it is almost always worse than you thought. Brian is correct in telling the patient that may be a RCT and Crown and should be prepared to spend the money to save the tooth before opening it up.

Nice revisit of a recurring dilemma for many of us - think resisting slapping a "right" answer is important and involving the Pt is the key. As long as the Pt understands the pros and cons of either choice, there's no wrong answer. Not every Pt will automatically choose to let symptoms or lack thereof decide. If the Pt asked me what I would do (as we all hear), it might be related to age - someone in their 20s or 30s should probably consider replacing this more definitively, while someone in their 50s or 60s may elect to take their chances and be more passive.

Cheers

always a tough one - i would lean toward treating both - based on what i can see and what i see everyday clinically, that would seem like the better outcome, but i would leave the decision up to the patient after giving them all the info.

See my post on multiple restorations to see what happens when we "watch" for a while. I was excavating caries for days after I pulled those crowns off.

Brad

Definitely treat now. There is clear clinical evidence that the amalgam is failing, and 10 times out of 10 there is always recurrent decay under old amalgams such as these. I would much rather treat an asymptomatic patient than one who comes in later with pain or an abscess. In this situation I would let the patient know that their amalgam is failing and that the restoration type would depend on the amount of solid tooth structure left...could be a simple filling or if the functional buccal cusps are compromised, than an onlay or crown. What did you end up doing Sam?

This patient requires treatment - but restorations are not a cure for caries!

High caries risk - educate into low risk then consider replacement
Low caries risk - watch old restoration and if no further deterioration leave well alone.

Ultimately it is the patients choice - all you can do is give them the information and consequences of treating or not treating taking risk status into account