Almost daily, I remove a fractured posterior tooth which has had root canal treatment but no cuspal coverage restoration. Usually, the patient's dentist has treatment planned a crown, but the patient just did not get it done. This is often due to lack of finances. Many times, however, the patient fractures the tooth while waiting on their appointment for the crown. We then have a very unhappy patient who has just spent $600-$800 for a root canal and now faces the loss of a tooth plus the additional cost of a bridge or implant. This tragedy can often be avoided by reducing the occlusion on all posterior teeth which have had endodontic treatment. By reducing the occlusion, I mean removing enough tooth structure so that a #557 bur can fit between the treated tooth and the opposing dentition. This may seem aggressive, but if a cuspal coverage restoration is indicated anyway, no harm will be done. Furthermore, the patient will experience less postoperative pain as they will be able to close their teeth together without percussing the treated tooth.

Differential Diagnosis of the Patient with Multiple Perioral and Oral Melanotic Macules

When clinical examination of a patient reveals multiple pigmented lesions of the oral tissue and/or perioral skin, the following entities should be considered in the differential diagnosis.

Peutz-Jeghers Syndrome is a condition that causes mucosal and skin melanotic macules and intestinal polyps. The condition is autosomal-dominant. These patients usually have both melanotic macules and intestinal polyps. The polyps have a significant potential for malignant transformation while the pigmented lesions are almost always benign melanotic macules. Referral to a gastroenterologist for colonoscopy is warranted.

Addisons disease is an endocrine disorder which results from insufficient production of hormones from the adrenal gland. These patients suffer from a myriad of symptoms which usually include weakness, hypotension and gastrointestinal problems. Melanotic macules are often present on the skin and/or oral tissues. Histologically, these lesions are identical to benign melanotic macules, so biopsy will not confirm this disease. If Addisons disease is suspected, referral to an internist or endocrinologist is warranted.

Smoker's Melanosis represents an increase in melanin pigmentation of the oral mucosa of tobacco smokers. This discoloration represents a true pigment change and is not stain. Smoking cessation will usually result in a significant decrease or total elimination of these lesions.

In conclusion, consider Peutz-Jeghers Syndrome, Addisons Disease and Smoker's Melanosis in your differential list the next time you evaluate a patient with multiple melanotic macules of the oral mucosa and perioral skin. Biopsy of one or more of these lesions should be considered to rule out melanoma and evaluation by a medical specialist may be necessary.