This, Not That.
Short one today.
This is what a maxillary second molar root canal treatment should look like:
Rethink what you are doing if your cases look like this:
This is what a maxillary second molar root canal treatment should look like:
Rethink what you are doing if your cases look like this:
Wednesday, November 9, 2011
Consult Along: A Day at Alpharetta Endodontics
Rather than try to have an overarching theme to this post, I will present each of today's patients as each case was complex and each illustrate rather important points. For the sake of brevity, I will only post significant findings (and I apologize for poor consistency and errors in grammatical tense) . Unless otherwise stated, assume medical history is non-contributory. I would love for readers to post feedback, alternate treatment plan ideas, or other approaches to these cases.
Patient 1:
This patient presented with a history of root canal treatment on #20 by an endodontist 1-2 years ago. #19 was treated by her general dentist ~8 months ago, and #18 was fractured and replaced with an implant within the last two years. The crown came loose and was replaced with a post 1 month ago. Following this treatment, she described severe pain upon chewing and swelling on her tongue side of the tooth. There is no extraoral sign of swelling or lymphadenapathy. No intraoral swelling or sinus tract. Around #19, the gingiva is edematous and inflamed with bleeding on probing. The crown margins are open and overextended. The probing depths on #19 are 3 mm interproximally and 8-9mm mid buccal and mid lingual. The radiograph reveals a laterally widened PDL with a hint of an apical radiolucency. The restoration on the mesial is into the furcation and associated with horizontal bone loss. #20 displays an apical radiolucency as well. The implant on #18 is bulbous and overcontoured to the mesial with some signs of horizontal bone loss.
Unfortunately, I recommended extraction of #19 due to the likelihood of a vertical root fracture and a poor restorative prognosis. I recommended she return to her previous endodontist for reevaluation/recall of #20. I also provided her some proxibrushes to maintain oral hygiene around #18. Would you rather have that root canal/crown or that implant...or neither?
Patient 2:
This patient is referred by her general dentist for evaluation of #3 and initially presented two weeks ago. She reports having root canal therapy a year and a half ago by another local endodontist, no microscope. Since the time of treatment, she has had spontaneous "shooting" pain that is localized to tooth #3. It is worse in the morning and with mastication. A history of symptoms indicates that the tooth was likely vital preoperatively and so persistent bacteria is not a feasible etiology. No extraoral swelling or lymphadenopathy. No intraoral swelling or sinus tract. Probing depths 2-3mm, crown margins are in tact. Occlusion is light in MI with no interferences. No palpation tenderness, no swelling, no sinus tract, no percussion tenderness, no mobility. Slight bite pressure tenderness on the MB cusp and P cusp only.
Preop, no radiolucency, slight ligament widening in the palatal, short palatal obturation, overenlarged mesial obturation in the cervical third, undermined/weakened mesial tooth structure. Diagnosis: previous treatment/acute apical periodontitis. Possible etiology: restorative recontamination, root fracture, strip perforation of MB/MB2. I recommended retreatment but cautioned that a finding of a root fracture would indicate a need for extraction.
Upon access, blood was found on the palatal canal, and, in spite of anesthesia, the GP was tender to pressure with fluid built up around it. No fractures were found. Additionally, a strip perforation was found in the cervical third of MB2. It was repaired with MTA and the palatal canal was retreated. The patients symptoms resolved immediately, and the case was finished this morning.
Patient 3:
This patient went to her new dentist for a broken restoration on #30. Decay was found encroaching on the pulp chamber and she was referred for root canal therapy. She is asymptomatic. #31 was treated 2 years ago by another endodontist, no microscope. The anatomy appears to be very challenging. A history of symptoms of cold sensitivity and throbbing pain prior to the previous treatment indicate that #31 was likely diagnosed as irreversible pulpitis preoperatively.
Treatment on #30 was completed at today's visit and treatment options for #31 were discussed. Restoratively, the case is compromised with a crown on a buildup with voids. Additionally, retreatment of the mesial root is going to be challenging if not impossible. If, as it appears, the distal root is the primary source, retreatment may be successful. One alternative, if retreatment is not successful, is to place spacers to loosen the tooth and then try an intentional reimplantation. Apical surgery is difficult to impossible in this location with such long roots (25mm working length on #30).
Patient 4:
Asymptomatic, original treatment over 15 years ago. Her crown and posts came off and extensive recurrent caries was found beneath. Her dentist cleaned the area and placed a temporary crown before referring her for evaluation. While radiographically, the ligament is in tact, her history indicates bacterial contamination and retreatment was recommended.
Case #5:
This patient is asymptomatic. She recently moved here and her new dentist noted a parulis buccal to #30. She is ~85 years old. Probing depths were 2-3mm with bleeding on probing and a class 1 furcation involvement. The margins on the composite were open. Due to the compromised restorative prognosis and the furcation radiolucency, I recommended extraction. She does not wish to replace this tooth at this time, but an FPD is likely her best option. She is fortunate to have full molar occlusion on her left side.
I hope that our readers learned something from these cases. You will probably realize that I started no new root canal treatment today, and that all our cases were complex diagnostically and involved molars. This is typical for our practice.
If you have any input or questions, please voice them in the comments, but please remain constructive. As always, I invite readers to see more cases posted regularly on our facebook page at www.facebook.com/alpharettaendo.
If you have any suggestions or requests for future posts, please leave them in the comments!
Thursday, October 27, 2011
Saving Teeth: Repairing a Resorptive Defect with MTA
In 2006, #19 was diagnosed as necrotic pulp w/ acute apical periodontitis. An irregular radiolucency was noted on the mesial aspect of distal root. This was diagnosed a resorptive defect. While some may have elected to remove the tooth and place an implant or bridge, this patient wanted to preserve her tooth, so a root canal and root repair was performed.
During our RCT procedure, the resorptive defect was cleaned out without perforation of the root. The appearance of the post-op radiograph appears to show some kind of communication.
At 20 months, the patient returned for recall and a large furcal lesion was present. Once again, more may have elected to extract the tooth and replace it with an implant or bridge. We discussed options/prognosis and decided to retreat and try to repair the resorptive area with MTA.
#19 was retreated and resorptive defect repaired with MTA. You can see the resorptive defect was opened more aggressively and there was extrusion of MTA into the periodontal ligament.
3 year recall (since the retx and repair with MTA) shows complete healing of the furcal lesion. The tooth is fully functional and asymptomatic. This is a tooth was was saved by endodontic therapy using the right material. This tooth was saved by endodontic therapy and the use of MTA to repair and seal the resorptive defect.
Monday, September 26, 2011
Avoiding Root Canal Therapy with MTA
Dr. Hale's excellent post on pulp canal obliteration inspired me to share these few cases where a coronal barrier was also used to avoid root canal therapy. The most recognized reason to avoid complete pulpal debridement is biological, to maintain pulpal vitality, and thus continue root formation, subsequently improving fracture resistance, but there also exist technical limitations on the debridement procedure, imposed by anatomy or resorptive defects, that might prevent success of conventional root canal therapy.
This first example is a straightforward partial pulpotomy (or Cvek pulpotomy) with an MTA direct pulp cap. This patient had cerebral palsy and toppled out of his wheel chair causing a complicated (pulpal involvement) crown fracture of #10. You will note #9 was treated at this time as well, and if I recall correctly, was discolored and non-vital from a previous similar trauma. Multiple dental injuries (and traumatic injuries of all kinds) are very common in CP patients due to negative effects on balance. Fortunately, working with a pediatric dentist who scheduled OR time, the patient was seen within two days of the incident and the pulp vitality of #10 was maintained. Remember, inflammation in traumatic exposures very slowly spreads apically, and immature pulps with large vascular supplies are largely resistant to necrosis in the short term.
PreOp
Post-op
1-Year Recall
Please note the complete root formation.
At a 1 year recall, #10 responded normally to vitality testing. Radiographs revealed a complete formed root and a dentin barrier beneath the MTA. Astute viewers will note this success is amazingly in the absence of a coronal restoration (unfortunately, not the only time I've seen bare, unrestored MTA pulp caps succeed at 1 year recalls).
This next case is similar, although a little less conventional. As you can see in the preoperative radiograph, the root is severely dilacerated. While certainly it is possible to perform root canal therapy on this type of root (see my previous post for an arguably more challenging S curve), the difficulty level is unquestionably high. This treatment plan not only reduces the risk of instrument separation, but also saves the patient time and money, and the operator from fatigue.
PreOp
Post-Op
The key here is that this was an asymptomatic carious pulp exposure. In the case of symptoms of irreversible pulpitis, it is generally thought that an MTA pulpotomy is a more risky procedure. It is certainly contraindicated in cases with symptomatic apical periodontitis (although I have had success direct pulp capping an immature tooth with apical periodontitis).
This last case is open to the most controversy. This patient had multiple large composite restorations across the anterior maxillary dentition. He admitted to being far more motivated by financials than esthetics. His previous composite restoration and crown had sheered off unconventionally at an oblique angle to the buccal leaving a substantial cingulum. The fractured portion had been rebonded by his general dentist. This tooth had a history of trauma over 40 years ago and some extensive external resorption is visible overlapping an obliterated pulp chamber and canal. The PDL is definitely in tact and there is no history of symptoms. The option of extraction and implant placement was discussed and encouraged. The alternative treatment plan chosen by the patient is less than ideal and the patient was more than okay with a compromised long-term prognosis. I intentionally described a grim outlook to the patient, as I do with most unconventional treatments, although here I can admit that I am confident in the predictability of the patient's choice. As you can see from the preop radiographs, conventional root canal therapy is impossible due to the irregular resorptive defect sandwiched between obliterated canal space.
PreOp
PostOp
I am still waiting on the general dentist to forward over a restored recall radiograph. Hopefully I will have the image to edit in by the end of the week. You can see the post space that I prepared using a 2 round bur and a gates-glidden with the tip flattened. The post space communicated with the resorptive more coronal than I anticipated, necessitating the use of MTA as a sort of resorptive cap. I feel as long as the area remains aseptic, it is reasonable to assume a successful result.
Here is a bonus case posted on our facebook page, http://www.facebook.com/pages/Alpharetta-Endodontics/137382942943581 . I'd encourage everyone to follow there (and check the backlog of case photos) for more interesting cases.
The patient's symptoms were intermittent, spontaneous, a 6 or 7 out of 10 on the pain scale, occasionally throbbing, and worse with mastication and pressure. The key history here is the patient's remark, "it feels like my gums are coming loose from my tooth."
Make the diagnosis. I have obviously helped by circling the key components.
Friday, September 16, 2011
Calcific Metamorphosis (Pulpal Obliteration) and Internal Bleaching
It has been reported that 11.6% - 33% of boys and 3.6% - 19% of girls suffer some kind of dental trauma before age 12. Internal staining is common following a traumatic injury to a tooth. Calcific metamorphosis is the partial or complete obliteration of the pulp following dental trauma. An interesting study of 168 traumatized, discolored, anterior teeth found that 47.6% were partially obliterated, 31.6% were totally obliterated, and 20.8% were found necrotic. Necrosis was more associated with fractured teeth, while pulpal obliteration was associated with subluxation and concussion injury. It was also noted that injuries suffered in the 1st and 2nd decades of life resulted in more pulpal obliteration, while those suffered in the 3rd decade resulted in necrosis more often.
To remove this discoloration, typically endodontic therapy is performed and internal, non-vital bleaching is performed. The following case is a variation of this procedure.
This 13 year old boy previously suffered a traumatic injury. Tooth #8 has discolored. The tooth is asymptomatic. Non-responsive to thermal testing, normal to percussion and probing.
It was decided to perform endodontic therapy, prior to internal bleaching to improve the esthetics of this tooth.
Partial pulpal obliteration is noted. A 1mm thick calcific barrier is found just below the level of the CEJ.
RCT is initiated and a complete calcific barrier is noted. It was decided to perform the internal bleaching without endodontic therapy.
A standard internal coronal barrier (glass ionomer) is placed over the calcific barrier to prevent internal bleach from exiting through cervical dentinal tubules and causing an inflammatory reaction in the pdl. A walking bleach technique is used. (Opalesence Endo)
After 1 week, pt returns and the internal bleach is removed. This tooth will be recalled to monitor vitality over time.
If pulpal obliteration occurs without necrosis, there may not be a need for endodontic therapy prior to internal bleaching. If a coronal barrier can be placed, without exposure (and possible contamination) of the pulpal tissue, then it would seem that internal bleaching could be performed without the need for complete endodontic therapy. Long term recall to monitor vitality will be done with this type of approach.
SOURCE:
Adeleke O Oginni and Comfort A Adekoya-Sofowora "Pulpal sequelae after trauma to anterior teeth among adult Nigerian dental patients", BMC Oral Health 2007, 7:11doi:10.1186/1472-6831-7-11.
To remove this discoloration, typically endodontic therapy is performed and internal, non-vital bleaching is performed. The following case is a variation of this procedure.
This 13 year old boy previously suffered a traumatic injury. Tooth #8 has discolored. The tooth is asymptomatic. Non-responsive to thermal testing, normal to percussion and probing.It was decided to perform endodontic therapy, prior to internal bleaching to improve the esthetics of this tooth.
Partial pulpal obliteration is noted. A 1mm thick calcific barrier is found just below the level of the CEJ.
RCT is initiated and a complete calcific barrier is noted. It was decided to perform the internal bleaching without endodontic therapy.
A standard internal coronal barrier (glass ionomer) is placed over the calcific barrier to prevent internal bleach from exiting through cervical dentinal tubules and causing an inflammatory reaction in the pdl. A walking bleach technique is used. (Opalesence Endo)
After 1 week, pt returns and the internal bleach is removed. This tooth will be recalled to monitor vitality over time.
If pulpal obliteration occurs without necrosis, there may not be a need for endodontic therapy prior to internal bleaching. If a coronal barrier can be placed, without exposure (and possible contamination) of the pulpal tissue, then it would seem that internal bleaching could be performed without the need for complete endodontic therapy. Long term recall to monitor vitality will be done with this type of approach.
SOURCE:
Adeleke O Oginni and Comfort A Adekoya-Sofowora "Pulpal sequelae after trauma to anterior teeth among adult Nigerian dental patients", BMC Oral Health 2007, 7:11doi:10.1186/1472-6831-7-11.
Thursday, September 1, 2011
Cone Beam (CBCT): To Use or Not to Use?
There has been some discussion about the indications for use of CBCT in endodontics. The AAE and AAOMR released a joint position statement regarding the use of CBCT in endodontics.
The section on patient selection criteria states, "CBCT must not be used routinely for endodontic diagnosis or for screening purposes in the absence of clinical signs and symptoms. The patient’s history and clinical examination must justify the use of CBCT by demonstrating that the benefits to the patient outweigh the potential risks. Clinicians should use CBCT only when the need for imaging cannot be answered adequately by lower dose conventional dental radiography or alternate imaging modalities."
I would suggest that there are times when a clinician has no way of knowing what additional information a CBCT would provide prior to starting treatment. This information may often prevent complications, such as perforation, which potentially could affect long term prognosis.
The following case is a perfect example.
This patient came to SSE for emergency treatment. #18 DX: Necrotic pulp w/ Symptomatic Apical Periodontitis. RCT initiated. 3 canals located, however a 4th distal canal is not found. 2 distal roots are apparent the pre-op film. The ML, MB and a distal canal are located. The distal is opened looking for the 4th canal. After 20-30 minutes of searching for 4th canal, the patient is re-appointed for 2 step treatment.
Upon return for second visit, the symptoms of SAP have not completely resolved. Slight vestibular swelling noted. We decided at that point to take a CBCT to help us located the 4th canal.
The CBCT clearly shows us that a perforation has been created (red arrow), and the additional canal/root is lingual to the DB canal. A sagittal view, provided only by CBCT, can provide information that is not available by conventional radiography.
With these images, the 4th canal is easily located within minutes of opening the tooth.
In this case, a CBCT provided valuable information that identified location of the 4th canal. If taken prior to starting, the 4th canal would have been located more quickly and without the small perforation in the distal.
I am not suggesting that CBCT should be used on every patient, but I am suggesting that with multiple rooted teeth, the sagittal & axial view provided by CBCT can save time and prevent endodontic complications, both of which provide justification for a more routine use of CBCT in endodontics. In our practice at SSE, the CBCT is not a profit center. We have priced these images to make them affordable to all patients. Our implementation of CBCT is to provide the highest quality of endodontic care available.
The section on patient selection criteria states, "CBCT must not be used routinely for endodontic diagnosis or for screening purposes in the absence of clinical signs and symptoms. The patient’s history and clinical examination must justify the use of CBCT by demonstrating that the benefits to the patient outweigh the potential risks. Clinicians should use CBCT only when the need for imaging cannot be answered adequately by lower dose conventional dental radiography or alternate imaging modalities."
I would suggest that there are times when a clinician has no way of knowing what additional information a CBCT would provide prior to starting treatment. This information may often prevent complications, such as perforation, which potentially could affect long term prognosis.
The following case is a perfect example.
This patient came to SSE for emergency treatment. #18 DX: Necrotic pulp w/ Symptomatic Apical Periodontitis. RCT initiated. 3 canals located, however a 4th distal canal is not found. 2 distal roots are apparent the pre-op film. The ML, MB and a distal canal are located. The distal is opened looking for the 4th canal. After 20-30 minutes of searching for 4th canal, the patient is re-appointed for 2 step treatment. Upon return for second visit, the symptoms of SAP have not completely resolved. Slight vestibular swelling noted. We decided at that point to take a CBCT to help us located the 4th canal.
The CBCT clearly shows us that a perforation has been created (red arrow), and the additional canal/root is lingual to the DB canal. A sagittal view, provided only by CBCT, can provide information that is not available by conventional radiography. 
With these images, the 4th canal is easily located within minutes of opening the tooth. 
In this case, a CBCT provided valuable information that identified location of the 4th canal. If taken prior to starting, the 4th canal would have been located more quickly and without the small perforation in the distal. I am not suggesting that CBCT should be used on every patient, but I am suggesting that with multiple rooted teeth, the sagittal & axial view provided by CBCT can save time and prevent endodontic complications, both of which provide justification for a more routine use of CBCT in endodontics. In our practice at SSE, the CBCT is not a profit center. We have priced these images to make them affordable to all patients. Our implementation of CBCT is to provide the highest quality of endodontic care available.
Wednesday, August 17, 2011
Persistent Post-Treatment (Apical) Periodontitis.
Before we get into diagnosis and cases, it is essential to understand the sources of apical periodontitis. With few exceptions, the source of symptoms is either trauma, occlusal or otherwise, or bacteria, apical or otherwise. It really is that simple. It is up to the clinician, through history and exam, to determine the source of symptoms.
Briefly, a common scenario would be a tooth with an apical radiolucency, sensitivity to percussion, and a lack of cold response. Our diagnosis is necrotic/symptomatic apical periodontitis and the source of both is bacteria. By removing the insulting bacteria with root canal therapy, we can resolve the apical periodontitis and the radiolucency will heal with time. The below images are from a patient with that exact scenario and illustrate an important point.
This #18 clearly has a challenging s-curvature in the apical third of the mesial root. If we are unable to instrument and clean around that curve, we run the risk of bacteria persisting, and consequently, symptoms persisting.
Fortunately, with a little luck, I was able to clean around the curve and the patient's symptoms resolved within a day of initiation of treatment and calcium hydroxide placement. Also, note the mid-mesial canal. There is an important point here:
With a necrotic tooth, if symptoms persist following treatment, especially if the treatment is deficient in cleaning or rife with errors such as a perforation, then we must suspect bacteria as the source and look to treat the tooth endodontically (possible retreat and/or surgery).
Here is another scenario, this patient was referred for evaluation and treatment of symptoms in the lower left. Symptoms were described as a short, sharp sensitivity to chewing over the past year and a half, and a moderate sensitivity to hot and cold that lingers for a few minutes over the past few months. The patient points to #19 for the chewing sensitivity and farther back for #18. Clearly, we have two issues at hand as an endodontically treated tooth will never cause the type of sensitivity described by the patient.
The previous root canal treatment was done by an endodontist a year and a half ago. This endodontist evaluated the patient and placed him on penicillin and methylprednisone. I must stop here and say that I do not support treating this situation with these medications. I have never felt compelled to prescribe steriods and rarely prescribe antibiotics. It is easy to understand why when we realize that neither of these medications will address the possible sources of the patient's symptoms. Permanently resolving the inflammation will not happen without removal of the trauma source and systemic antibiotics will not have any effect on bacteria within a root end. Symptoms can be masked, but even a placebo can help a patient's symptoms. In this case, following medication, there was some improvement in symptoms but they soon returned.
Let us ignore the cold sensitivity for a minute, which was traced to #18, found to linger and be associated with a cracked tooth, and was treated appropriately. What questions are important to ask the patient at this point? Maybe we can deduce the diagnosis of #19 prior to treatment. As it turns out, with more specific questions, I learned that the tooth was cold sensitive prior to root canal therapy, and that these symptoms resolved. I also learned the tooth was actually asymptomatic until the crown was placed a few weeks following treatment. Now, I can proceed to the clinical and radiographic exam knowing that the most likely cause of apical periodontitis is a traumatic occlusion, since even a poor root canal on a vital tooth will likely be asymptomatic for many years before bacteria can negotiate to the apex.
Exam revealed #19 to be sensitive to percussion and bite forces (in MI and with a bite stick), and #18 to be hypersensitive with a prolonged cold response and a fracture. I also located a 5mm ML probing depth with associated erythematous and edematous gingiva. The crown on #19 was bulbous, overhanging the lingual, and flat on the occlusal with wide contacts.
In the below radiographs, we see a short obturation on the mesial and distal roots of #19 with some slight and debatable ligament widening. Not a perfect root canal but unlikely to be the source of symptoms.
Another radiograph revealed overhanging cement on the mesial.
Local scaling removed the excess cement and crown recontouring with a diamond bur combined with an occlusal adjustment was performed. The patient returned for treatment of #18 a few days later and all his symptoms from 19 had resolved. A reevaluation in a few months will determine if our treatment worked permanently. Incidentally, here is the completed treatment on #18 (and check out the distal root of 17 curving at the x-ray plane).
The point to be learned from this case is that an accurate and complete history will illuminate possible sources of the problem, exam can confirm that source, and conservative local treatment will often be enough to resolve symptoms. Occlusal trauma is the most common cause of post-treatment apical periodontitis.
Here is a case I treated that exhibited persistent symptoms and is similar in many respects to the one above. The original symptoms and exam were indicative of irreversible pulpitis and extensive recurrent caries was located underneath the buccal margin. I painted a grim picture and recommended extraction. The restorative prognosis was compromised, decay reached into the furcation and alveolar crest. Nevertheless, the referring dentist was confident and capable, and the patient was well informed knowing the risks and that periodontal therapy was in her future. She was anxious to avoid implant treatment due to a prior bad experience with one in another site.
At the second visit of treatment, the patient reported her symptoms to cold had quickly resolved. However, her tooth that was not previously symptomatic to percussion was now hypersensitive to occlusal forces. I had not cleaned long at the first visit, and I had not yet placed the obturation material (not that these usually cause any problems). Likewise, I had merely placed CaOH within the top of the orifices as a barrier to reinfection and not deep into the canals (again, not that this usually causes a problem). The tooth was out of occlusion as well so the only possible source of ligamental inflammation was the buccal area where decay had been removed to the level of the alveolar crest and into the furcation. This area was not well restored yet, merely patched with IRM, and was a definite irritant to the ligament. I cautioned patience, completed treatment, and recommended returning to her general dentist for evaluation and restoration.
When the patient returned for reevaluation a month later, complaining of chewing sensitivity in the temporary crown, I was impressed with the quality of the buccal composite restoration and the buccal gingiva was minimally inflamed. The distal gingiva was inflamed with bleeding on probing. The patient had plans for an evaluation with a periodontist and I again counseled patience with symptoms until all periodontal treatment was complete. The occlusion was found to be heavy in non-working lateral excursion and adjustment relieved the patient's symptoms in the chair.
The important point here is since I had done the initial root canal treatment, I knew that the tooth was vital preoperatively. There is no way I would consider touching this tooth with any endodontic therapy since I know that I cannot improve upon my root canal treatment. The dental history leads me to look for sources of trauma to the ligament, occlusion and biologic width infringement in this case.
One other common cause that I see of persistent apical periodontitis is when a patient wears an occlusal splint or night guard, dentist fabricated or store bought, that is not well adjusted following a new crown on the tooth. Consider how a kids teeth feel after an orthodontic visit and you will understand the source of these symptoms.
This last case was treated by a general dentist 2-3 years ago and has exhibited persistent symptoms that have only seemed to worsen through multiple occlusal adjustments. The dentist reports an instrument separation in the distal root. Her symptoms had only recently become spontaneous and were described as a minor dull ache or pressure. In discussing the situation with the patient, she remembered the tooth being asymptomatic and the crown having been placed years prior to the root canal treatment. She claimed the referring dentist saw signs of a problem on the radiograph and recommended treatment through the crown. Clinical exam revealed no relevant findings and occlusion appeared well adjusted. A distal shift radiograph, the most important radiograph to take on a maxillary molar, displayed an all too common radiographic finding in maxillary molars treated without a microscope, a radiolucency on the mesial root.
The most common cause of this problem and one that we see every week is a missed MB2 (also called MP or ML) canal. This tooth was unusual in that I speculated a missed MB canal outlined below.
Upon retreatment, the untreated MB canal was found and is seen on the below photograph and radiograph.
The patients symptoms resolved quickly following the first visit. Here is the post operative radiograph.
Not all cases of persistent apical periodontitis require endodontic retreatment or surgery. In fact, most don't. By a taking a careful dental history, it is often possible to discern the preoperative diagnosis, which informs how and where bacteria could be causing a problem. It is also possible to create a timeline as to when symptoms first occurred and what events could have initiated them. If symptoms started with restorative work, then carefully examine the occlusion, margins, and gingival health. Only when we have a radiolucency or a smoking gun, like a missed canal, a short obturation in a previously necrotic case, or a case recontaminated with recurrent caries, should we be looking into endodontic therapy as our first choice to solve the problem. Often times, diagnosis is not clear, and I start with the conservative options, occlusal adjustments and periodontal therapy, before proceeding to endodontic therapy. I cannot think of a single instance where I have recommended medication as a primary therapy.
I hope these cases will help those of you out there to think like an endodontist. Some may point out that I have not talked about tooth fractures. I plan to discuss my philosophy on those in future posts. I look forward to any feedback and invite everyone to check out more cases on our facebook page: http://www.facebook.com/pages/Alpharetta-Endodontics/137382942943581
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