She had come in for a second opinion on a retreatment quote. Upper right second premolar, root-canal-treated nine years ago in general practice, the original filling still in place, no pain on percussion, no swelling, no sinus tract, no temperature sensitivity. Her domestic dentist had taken a periapical the previous week, noticed what he called a small dark spot at the apex, and referred her to me for retreatment with a quote attached. The quote was for $2,800 AUD. She was not in pain. She had not been in pain for nine years. She wanted to know if she should book.
The radiograph was on the screen when she sat down. I had reviewed it before she arrived, which is the part of the job a patient does not see. The small dark spot was a 1.5 mm radiolucency consistent with a stable apical scar — the radiographic residue of an old infection that had resolved, not the marker of an active one. The root filling looked adequate to within a millimetre of the apex. The lamina dura was intact around the rest of the root. The coronal seal was intact. There was no clinical sign of failure and no radiographic sign of progression. The previous radiograph in her file, from a routine bitewing nine months earlier, showed the same shape at the same size. The lesion had not changed.
I have written elsewhere about when to save a tooth and when to replace it, and the framework there is mostly about treating teeth, not declining to treat them. This case sat the other way around. Treating it would have done nothing for the patient and something for my appointment book. Declining it would do nothing for my appointment book and something for the patient. That is the consult I want to describe today.
What she wanted
She wanted certainty. She wanted to know she had done the right thing. She had been told there was a spot, she had been quoted a number, and she had spent two weeks reading about failed root canals on the internet. She was not anxious in the way patients are anxious when they are in pain. She was anxious in the way patients are anxious when they have been told something is wrong and they do not yet have the vocabulary to evaluate it.
A retreatment for a stable, asymptomatic lesion that has not changed in nine years is, in my hands, a procedure that would deliver no clinical benefit and would introduce real procedural risk — separated instrument, perforation, lateral root weakening, post-treatment flare-up — for a problem the patient does not have. The literature on outcomes of asymptomatic post-treatment apical radiolucencies in long-followed teeth has been consistent for a long time on this point: stable lesions without symptoms, without sinus tract, without coronal leakage and without a deficient root filling do not require intervention. They require monitoring.
I told her that. I said it plainly. I said that if the periapical area increased in size on a future radiograph, or if symptoms developed, the recommendation would change. I said the right next step was a high-quality periapical in twelve months, compared to the one on the screen, and a careful look at the coronal restoration to make sure the seal was sound. I said I would not be booking her in for a retreatment.
What she didn’t want to hear
She did not, at first, want to hear it. She had taken a half-day off work. She had a quote in her hand. She had emotionally committed to the idea that this tooth was the problem and that the problem had a solution and that the solution had a price tag and a date.
The conversation that followed is the part of clinical practice that does not appear in continuing-education courses. It is not technical. The technical part — reading the radiograph, evaluating the percussion test, palpating the buccal sulcus, checking the mobility — took about four minutes. The conversation took thirty-five. I went through the radiograph with her. I showed her the bitewing from nine months earlier. I drew the difference between a stable apical scar and an enlarging periapical lesion on the side of the chair. I told her what would constitute evidence that the picture had changed. I told her that I have, in twenty-three years of practice, retreated teeth I should not have retreated. I told her that the cases I regret most are the ones where I treated a radiograph rather than a patient.
She asked me, near the end, whether her general dentist had been wrong to send her. I said no. I said the referral was reasonable. The referring dentist saw a radiographic change he could not evaluate against the prior film, recognised the limits of his own training, and sent her to someone whose job is exactly this. That is what a good referral looks like. The mistake would have been mine, if I had taken the consult and the procedure and the fee without doing the work to decide whether either was indicated.
What this changes about the day
She left without a booking. She left with a recall scheduled for twelve months, a copy of the radiograph on a USB stick, and a one-page note for her general dentist explaining the reasoning. She did not pay for a procedure. She paid for the consultation, which is what the consultation was actually worth.
I am writing this on a Friday afternoon. I have, in the last six weeks, declined three other consults of similar shape: a patient who wanted veneers on teeth with no aesthetic problem the patient herself had named when I asked her to describe what she did not like; a patient who wanted an implant in a site where the natural tooth was restorable; a patient who wanted a crown on a tooth that needed only a direct restoration. In each of those cases the patient had been quoted, had taken time off work, had emotionally arrived at the decision before they walked in.
I do not enjoy the conversation. It is harder than booking the procedure. It is slower, it requires more diplomacy, it produces less revenue, and it leaves the patient — at least at first — feeling the visit was unproductive. The pattern of patients whose international dental treatment goes well and the structural reasons the patient cannot tell good clinics from bad ones are both about the same problem read from the patient’s side. This piece is about it read from the clinician’s. The clinician who quotes the procedure makes the money. The clinician who declines the procedure does the work.
There is no reason to think this is unique to me. Most specialists I respect tell some version of this story when you ask them what their week looked like. The consults that did not happen are not the ones that make it into a continuing-education talk or a clinic’s annual report. They make it into the quiet column of the diary that is not invoiced. They are, on a Friday, the part of the work I am most glad I did.
She is on a twelve-month recall. If the radiograph changes, I will retreat the tooth. If it does not, I will not. Either way, she will not have paid for a procedure she did not need, and either way she will have a record of why.