Memoirs From Pull and Be Damned Road
When is a saving a tooth with advanced periodontal or endodontic involvement worth the time and effort?
When is a saving a tooth with advanced periodontal or endodontic involvement worth the time and effort? This question was brought to mind when an old friend returned a textbook that he borrowed in 1974. It was written in 1965 by John I. Ingle, DDS, MDS, a noted endodontist who taught at the University of Washington School of Dentistry and later became dean of the School of Dentistry at the University of Southern California.
According to the preface, Ingle had written the text during a long sabbatical at Snee-oosh Beach overlooking Puget Sound in the San Juan Islands, just north and west of Seattle. Hard-by the Beach was Pull And Be Damned Road (his capitalization). He cited several local landmarks, including Deception Pass and Hope Island, as metaphors to encourage the retention of endodontically involved teeth whenever possible.
While at first glance this would seem self-evident, it should be remembered that he was writing at a time when focal infection theory was waning, but still held as gospel by many clinicians. In spite of the fact his mindset was that of an endodontist writing in a different era, his basic premise still resonates.
IT IS TRUE TODAY THAT IT OFTEN TAKES LESS EFFORT TO REMOVE A TOOTH THAN FIGHT TO KEEP IT
It is true today that it often takes less effort to remove a tooth than fight to keep it. Whether the diagnosis is moderate to severe periodontitis, or a highly calcified or tortuous root system, the effort by the therapist and patient to keep the tooth — not to mention the economic and temporal consequences of treatment — can often be justified.
The questionable habit of quickly choosing extraction in these cases has been exacerbated after a large percentage of our profession came to appreciate the long-term success of root-form implants. One should not take this as a condemnation of dental implants; in fact, placing these devices is the primary source of my practice income. But while implants provide excellent replacements for natural dentition, they clearly lack some of the attributes of teeth — and they are not always perfect replacements.
The decision to retain or remove a tooth should be made with the realization that it belongs to a human being with individual ideas concerning tooth retention or removal. The desires and abilities of the patient who will be receiving therapy should always be taken into account. To successfully retain teeth with advanced periodontitis, patients must demonstrate they are willing to do their part in making therapy successful. Those who consent to the needed therapy, self-care, and maintenance are often good candidates for retaining their natural teeth. The same applies to individuals who present with difficult endodontic conditions.
While one does not wish for the Pull And Be Damned credo to be taken literally, it behooves us — and often benefits the patient — to respect clinical realities and, whenever possible, design therapies that retain the natural dentition.
Thomas G. Wilson Jr., DDS
Editor in Chief
From Decisions in Dentistry. November 2021;7(11):5.