We do not dispute the fact that comorbidities as identified by Marx existed in our case. However, the presence of these comorbidities does not preclude the evidence of an abnormal sequence of healing. We feel that it would be unwise to ignore a 100-day course of an open, non-healing wound by stating that these could have been caused by any one of these comorbidities alone. In fact, the presence of these factors may reinforce the diagnosis of BON as a predisposing condition.
We contend that the appropriate treatment sequence was followed in this case. Our report states that the patient was initially referred by a local hygiene program, where the patient had received both prophylaxis and hygiene instruction. A periodontal examination did not reveal the presence of significant attachment loss; therefore, additional periodontal procedures were postponed at that time in order to treat the carious lesion, which was of greater importance. The examination did not reveal a periapical abscess. It was imperative, therefore, to attempt caries control as soon as possible to avoid further complications.
There is no argument that the use of electrosurgery in dentistry has traditionally been a controversial topic. However, this mode of treatment, first used in the 1960s, has been improved through better knowledge of operating currents, frequencies and techniques.1–3 Radiosurgery (high-frequency electrosurgery) used with the technique as described in the case report utilizes this knowledge.
We do not dispute that it is possible that one of the precipitating factors in the osteonecrosis was thermal insult from the procedure. However, every precaution was taken to minimize lateral heat. Ultimately, the resulting nonhealing lesion was completely atypical for this mode of treatment.
Although the historical references cited by Drs. Fugazatto and Lightfoot describe bone resorption and necrosis, there is no mention of actual bone sequestrum. In fact, in all of the cited articles, the extent of bone resorption and necrosis is either not stated, is stated in microscopic histological terms or is on the order of fractions of 1 mm in overall loss of attachment.
We agree that there are a few similarities between one case study and ours, but the clinical course and sequelae in each case are significantly different. In the Ferreira and colleagues4 case, the electrosurgical wound healed on its own in 45 days, without any sequestration or intervention, except for placement of a temporary crown. The case we presented in our August article involved a protracted healing sequence, which did not resolve until after multiple interventions and a large, macroscopic sequestrum was recovered.
Lastly, the restoration that was placed at the time of intervention was not definitive treatment. The importance of a coronal seal when performing endodontics is well-known.5,6 This interim restoration was placed to ensure a coronal seal for the endodontic procedure completed at that same visit.
It is important to remember that prudent overall management of patients with complex problems may not always fall into "textbook" terms, as was seen in this case. Regardless of the appropriateness of the treatment, we stand by our conclusions.
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