The periapical radiograph shows the carious lesion in the crown of the lower right first molar to be extensive, involving the pulp cavity. The mesial contact has been completely destroyed and the molar has drifted mesially and tilted. There are periapical radiolucencies at the apices of both roots, that on the mesial root being larger. The radiolucencies are in continuity with the periodontal ligament and there is loss of most of the lamina dura in the bifurcation and around the apices. The bitewing radiographs confirm the carious exposure and in addition reveal occlusal caries in all the maxillary and mandibular molars with the exception of the upper right first molar. No approximal caries is present.
CONSERVE FIRST, EXTRACT ONLY IF REQUIRED.
Extraction of the lower right first molar may well be the preferred treatment. The caries is extensive, restoration of the tooth will be complex and expensive and problems will probably ensue in the long term. The missing tooth might not be readily visible. To a large degree the decision will depend on the patient’s wishes. If he would be happy with an edentulous space, the extraction appears an attractive proposition. However, if a restoration is required, a bridge will require preparation of two further teeth. A denture-based replacement is probably not indicated but an implant might be considered at a later date. Any hesitancy or uncertainty on the patient’s part might well influence you to propose extraction. Another factor affecting the decision is the condition and long-term prognosis of the other molars. If further molars are likely to be lost in the short or medium term it makes sense to conserve whichever teeth can be successfully restored.
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