A patient taking denosumab (anti-RANKL monoclonal antibody) presents with significant bone loss and a negative pulp test on a tooth with an intracoronal attachment. What is the appropriate initial endodontic treatment?

Correct answer: B. Root canal therapy (RCT)

• A. INCORRECT. Extraction is relatively contraindicated in a patient on denosumab due to the risk of medication-related osteonecrosis of the jaw (MRONJ). Invasive surgical procedures that violate alveolar bone should be avoided when possible. Root canal therapy is preferred to preserve the tooth without extraction.
• B. CORRECT. Root canal therapy (RCT) is the treatment of choice because: (1) The pulp test is negative (necrotic/non-vital pulp), (2) The patient is on denosumab which carries significant risk of MRONJ with extractions, and (3) RCT allows treatment of the endodontic pathology while preserving the natural tooth, avoiding the osteonecrosis risk associated with tooth extraction in anti-resorptive drug users.
• C. INCORRECT. Pulp capping requires a vital, minimally exposed pulp. A negative pulp test indicates pulp necrosis, making pulp capping inappropriate.
• D. INCORRECT. Crown lengthening is a periodontal surgical procedure to expose more tooth structure. While it may be eventually needed for restorative reasons, it does not address the acute endodontic pathology (necrotic pulp with bone loss).