Multidisciplinary management of an endodontic failure in a hypertensive and anxious patient

Managing an endodontic failure on a mandibular molar is a common procedure, but the challenge becomes systemic when the patient presents with severe dental anxiety coupled with uncontrolled arterial hypertension. This case report describes the complex management of a 56-year-old patient suffering from a persistent odontogenic infection on tooth #19. The main clinical obstacle lay in her physiological response: her baseline hypertension (160/80 mmHg) soared to 180/140 mmHg upon entering the practice, prohibiting any immediate invasive intervention.

The precise objective of this presentation is to detail a coordinated care pathway to secure the surgical procedure and optimize clinical outcomes. The approach is based on the implementation of a rigorous protocol including prior medical stabilization with the attending physician, an atraumatic extraction with alveolar preservation using bovine xenograft, and a complete digital workflow. This report tests the viability of an implant-supported rehabilitation planned by CBCT and finalized by a screw-retained restoration, associated with orthodontic follow-up, to guarantee long-term functional and occlusal stability in a medically compromised subject.

Case report methodology

This case report documents the multidisciplinary management of a 56-year-old female patient presenting with systemic arterial hypertension and severe dental anxiety, with the objective of rehabilitating a left mandibular first molar (#19) following the failure of endodontic treatment (persistent apical periodontitis).

The clinical protocol was structured according to the following steps:

• Preliminary phase: Medical stabilisation after observation of reactive hypertension at the practice (180/140 mmHg from a baseline of 160/80 mmHg) through coordination with the general practitioner.
• Surgical phase 1: Atraumatic extraction under local anesthesia followed by alveolar ridge preservation (ARP) using particulate deproteinized bovine bone xenograft and an absorbable collagen membrane.
• Healing: 3-month waiting period for the maturation of soft tissues and the graft.
• Digital planning: Three-dimensional analysis by Cone Beam Computed Tomography (CBCT) for prosthetic implant positioning.
• Surgical phase 2: Placement of a MIS conical implant (5 x 13 mm) according to a delayed two-stage protocol, followed by the placement of a healing abutment after osseointegration.
• Prosthetic phase: Use of a complete digital workflow including an intraoral optical impression with scan body for the fabrication of a screw-retained crown.
• Follow-up: Clinical and radiographic evaluation at 1 year post-rehabilitation, including a complementary phase of interdisciplinary orthodontic treatment.

Hemodynamic stability and anxiety management

The first notable result of this clinical case concerns the patient's physiological response to dental stress. While her baseline blood pressure (BP), documented by her attending physician, was 160/80 mmHg, her entry into the clinical environment caused an immediate elevation to 180/140 mmHg. This stage 2 hypertension, exacerbated by severe anxiety, necessitated the postponement of the initial intervention and medical coordination for stabilization.

Surgical phase and alveolar preservation

After obtaining medical clearance, the atraumatic extraction of tooth #19 was performed. Clinical observations confirmed post-treatment apical periodontitis on this mandibular molar. The alveolar ridge preservation (ARP) strategy yielded the following results:

• Material used: Deproteinized bovine bone xenograft and absorbable collagen membrane.
• Healing: A follow-up at approximately 3 months revealed complete soft tissue maturation and satisfactory preservation of the alveolar ridge architecture.
• Bone quality: The delayed protocol allowed for the optimization of the bone volume required for prosthesis-guided implant positioning.

Digital implantology and integration

Three-dimensional analysis by CBCT confirmed adequate bone volume for the placement of a 5 x 13 mm conical MIS implant. The results of this phase include:

Clinical Parameter	Value / Observation
Implant dimensions	5 x 13 mm
Primary stability	Satisfactory (measured during placement)
Positioning	Conforms to digital planning (radiographic validation)
Secondary phase	Healing abutment connection after osseointegration

At the end of the second surgical stage, the examination revealed a healthy peri-implant soft tissue profile. The patient was then referred for an interdisciplinary orthodontic consultation to treat generalized dental crowding and malocclusion identified during the restorative phase.

Clinical analysis: risk management at the service of precision

This case report highlights a frequent clinical reality: the systemic impact of psychological stress. The patient, although monitored for hypertension (160/80 mmHg routinely), presented a peak at 180/140 mmHg upon entering the practice, making any immediate intervention dangerous. The decision to defer the extraction in favour of medical stabilisation illustrates rigorous risk management, prioritising cardiovascular safety over dental urgency. Clinically, the use of a bovine xenograft combined with an absorbable membrane for alveolar preservation allowed for the maintenance of optimal bone volume despite the initial infection, facilitating the placement of a wide-diameter implant (5 x 13 mm).

The integration of the digital workflow, from CBCT planning to optical impression, has secured implant positioning and prosthetic precision. One-year success, characterized by bone stability and peri-implant health, validates the multidisciplinary approach. However, the limitations of this study lie in its nature as a single case report (n=1). While the strategy worked here, the generalization of this protocol depends on the responsiveness of the attending physician and the patient's compliance with her antihypertensive treatment.

Implications for practice

The study confirms that a three-month healing period following alveolar ridge preservation is sufficient to achieve satisfactory primary stability, even in a previously infected site. Switching from an immediate implantation protocol to a delayed protocol reduced surgical unpredictability in this case. Finally, the identification of a malocclusion at the end of the restorative phase serves as a reminder that implantology must not be isolated from a global occlusal vision, justifying post-operative recourse to orthodontics here.

Summary of results

This case report documents the rehabilitation of a 56-year-old patient whose severe anxiety generated a hypertensive crisis at 180/140 mmHg, requiring prior medical stabilization. Following an atraumatic extraction with alveolar preservation (bovine xenograft and membrane), a 5 x 13 mm implant was placed after three months of healing, resulting in bone and clinical stability confirmed at the 12-month follow-up.

In concrete terms, for the practitioner:

• Manage blood pressure: Faced with stress-induced hypertension (here 180/140 mmHg), the systematic postponement of invasive procedures and coordination with the attending physician are imperative to minimize intraoperative cardiovascular risks.
• Secure bone volume: In case of endodontic failure, prioritize alveolar preservation during extraction to secure the volume necessary for a delayed implant protocol (2 stages), guaranteeing better primary stability.
• Integrate orthodontics: Identify malocclusions during the prosthetic phase; post-implant orthodontic correction may be necessary to ensure the long-term occlusal and functional integration of the restoration.

Implantology and high cardiovascular risk patient: management of a complex case combining severe hypertension and dental anxiety", "article_content": "The management of a patient suffering from uncontrolled arterial hypertension (AHT) coupled with severe dental anxiety represents a daily challenge in oral surgery. This clinical case details the multidisciplinary care pathway of a 56-year-old patient whose systemic and emotional state initially paralyzed any intervention.

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