Retreatment Options

This 48 year old male patient was referred to me by their dentist for consideration of Endodontic treatment of tooth #36. The patient had a history of discomfort that was described as minimal . The pain was localized to the tooth and buccal gingival area and was relieved by Advil. There was no swelling and the patient was relatively asymptomatic on presentation. His referring dentist was concerned about the periapical radiolucent finding at the mesial root apex. The tooth had been restored with an extremely large amalgam/ post/ core . It is my understanding that the buccal cusp fractured off after the Endodontic treatment was completed and that a new core was placed sometime after. The referring dentist was considering restoring the tooth with a full Crown but was concerned regarding the persistence of the radiolucent finding at the Mesial root apex.

Because the patient was asymptomatic on presentation, his motivation level was rather low. I explained that the radiolucent finding at the root apex was of concern to his general dentist and that he could not comfortably place a final restoration on this tooth knowing that the area had not adequately healed. I offered the patient both nonsurgical and surgical treatment alternatives as well as the possibility of extraction and implant replacement in another office. I reiterated that the mesial root was thin and that as more tooth was expended during conventional retreatment, the chance for fracture increased. It was also possible that the tooth may still require surgical retreatment if it did not respond to conventional endodontic retreatment.

This discussion goes to the complicated concepts of “disease versus disease that matters”. In the eyes of patients, asymptomatic disease ( asymptomatic radiolucent findings or minimal symptoms)  frequently results in them rejecting  further treatment and leaving “well enough alone”. Dentists wishing to restore over such teeth are faced with the prospect of either restoring over teeth that have radiographic signs that these areas have not healed or rejecting the patient’s request for treatment until these issues are addressed as they see fit.

Ultimately, it is the patient’s decision as to whether they wish to proceed. If we choose to place the Crown in this tooth in its current condition, there is a possibility that the tooth would remain completely asymptomatic for the rest of the patient’s life.

Alternatively, should the restoration be placed and THEN the tooth become symptomatic,  the option to retreat the tooth conventionally becomes much more complicated because need to access through the crown/post/core complex of the new restoration. That may push us toward a surgical solution.

As long as the patient understands the risks involved and the increased chances that any further retreatment may have to be done surgically, then informed consent has been satisfied and restoration may proceed without retreatment, as they request. It may not be the best solution as we see it, but ultimately it is the patient who must make the choice of whether to treat or not treat what we believe to be a less than optimal situation. In such cases a documented, signed consent to treatment should always be part of the patient’s chart.

Adjacent Pathology Influences Treatment

A 41 year old female patient was sent to me for continuation of treatment of tooth #47. The truth had been previously endodontically accessed by the referring Dentist become of symptoms in the area and a pulpectomy had been performed to get the patient comfortable. The referring dentist wished me to complete treatment. No other information was provided as to the original reason for treatment. Was a distal marginal ridge crack the reason for the endodontic intervention?

Clinical examination showed that was some percussion and chewing sensitivity in this tooth but this was consistent with the history of recently accessed incomplete endodontic treatment. However,  the patient’s symptoms had not changed at all since the pulpectomy.  Perio probings were normal. I was concerned that the problem may be related to the adjacent impacted wisdom tooth, #48, that also had a large radiolucent area associated with it as seen in the cbCT.

Prior to completion of Endodontic treatment of tooth #47, I recommended that tooth #48 be extracted. Once the extraction was complete symptoms needed to be re-evaluated. #47 also will need to be re-examined to determine whether there was enough post extraction distal bone support and what the long term Periodontal prognosis of #47 would be. Would it justify continuation of treatment?

The  patient was referred to an Oral Surgeon to extract #48 as I had recommended. cbCT imaging was also sent and Endodontic treatment of #47 was delayed until further information was obtained from the Oral Surgeon.

The surgeon’s report included a surgical pathology report for the patient. It noted that the material removed from the pericoronal region around tooth #48 and running up the mid distal root surface of tooth #47 was consistent with a dentigerous cyst. Due to the size of the cyst, during removal, the oral surgeon found that there was no bone support for the distal surface of tooth #47 . Additionally, he was unable to remove the entirety of the cyst without removing the root of #47. For that reason BOTH teeth were removed during the surgery, as I originally suspected may be required. After the teeth were removed, the symptoms resolved and the area healed without incident. The oral surgeon was pleased with the results, given the size of the lesion and the proximity of the inferior alveolar nerve to the extraction site.

The patient will have an implant placed into position of tooth #46, which will be in better occlusal relationship with the opposing maxillary dentition.

This case teaches us a couple of things:
#1.  The patient’s original symptom may not have been entirely related to problems with #47. Patients whose symptoms do not improve with initial emergency treatment can signal misdiagnosis.
We always need to take a more broad view of symptoms and consider whether associated or adjacent structures and pathology may be contributing to the patient’s current complaint.

#2.  Where adjacent pathology (unknown radiolucency/Perio issues)  threatens support for the tooth or treatment, it is prudent to deal with that pathology first because it frequently compromises the proposed endodontic treatment tooth. If the tooth is treated first, this may result in the previously  Endo treated tooth being extracted and needless expense for the patient. Comprehensive treatment planning and assessment ensures that the right treatment is done, in the right sequence, the first time.

BWs and Communication with the Referral Best Manages the Case

A 52 year old male patient was referred for Endodontic treatment of a mandibular left first molar. The patient had a history of gross swelling in the buccal vestibule adjacent to the tooth. The tooth had been restored with full gold Crown and the referring dentist saw a periapical radiolucent finding at the apices, diagnosed an acute apical abscess  and requested that I perform Endodontic  treatment through the Crown. The patient was given an antibiotic and by the time he arrived in my office, he was relatively asymptomatic aside from some chewing and buccal palpation sensitivity.

It is customary for my staff to take a new periapical image and a bitewing radiograph for any posterior tooth that we are considering treating. The referral’s periapical image did not show anything unusual, but my periapical image and the bitewing showed a radiolucent finding underneath the mesial aspect of the Crown margin (red arrow below). The bite wing clearly showed the defect was significant. It was close to the bone crest. Was that ECIR? (External resorption?) Closer examination of the mesio-buccal Crown margin showed what appeared to be an abfraction lesion or possible carries in this area. The clinical appearance was quite unusual because the area did not feel like caries or an ECIR when explored. The surface of the defect felt smooth but I was pretty sure that this was not a short margin. The defect was deep enough that I thought it may be close to communicating with the pulp. Whatever it was, it needed to be examined and dealt with before the endodontics could be started.

In any case, this problem would need to be assessed during treatment planning of this tooth. Further pre-treatment (removal of the crown at a minimum) and exploration of the defect would need to be performed. Crown lengthening may be necessary which may place the whole re-restoration aspect of the new Crown in jeopardy because of the proximity to the furca. Certainly the patient would want to know if further Periodontal procedures would be required prior to us attempting to restore the tooth. Ultimately, we do not want to create a situation where chronic Periodontal problems make management of this buccal margin difficult for the patient, leading to hygiene issues, further caries or eventual extraction.

If we added the costs of Crown lengthening to the Endodontic treatment and new Crown, we are starting to get close to the cost of extraction and replacement with an implant.

I contacted the referring dentist and told them that there was a defect on the mesial aspect of the tooth. I could not in good conscience continue to perform the Endodontic treatment until the Crown was removed and the referring dentist assessed the tooth for restorability in his office. If further procedures were necessary, he would have to decide whether the Crown margin was at an acceptable level and whether further Periodontal procedures would be necessary. All these procedures and the associated costs would have to be explained to the patient before we initiated Endodontic treatment and committed the patient to rehabilitation of the tooth.

The patient returned to his dentist and I subsequently received this note: “The gold crown was removed with crown removing forceps The amalgam core is intact with good tooth ferrule.  Margins were re-prepped deeper along the buccal. The crown was re-luted with Voco Bifix temp cement, with the open margin on the buccal sealed. I believe I can restore the tooth in its current condition. Please proceed with the Endodontics.”

Since the crown seemed secure and was going to be remade, I chose to access through it. The case was cleaned and shaped and medicated with Ca(OH)2. The patient returned several weeks later, asymptomatic, at which time we obturated the case.  The crown was sufficiently sealed that I was confident the defective area would not be an issue between appointments and the tooth was ultimately restored.

Coordination of the treatment and good communication with the referring Dentist allowed us to achieve the optimal results with no compromises.

In any case, this problem would need to be assessed during treatment planning of this tooth. Further pre-treatment (removal of the crown at a minimum) and exploration of the defect would need to be performed. Crown lengthening may be necessary which may place the whole re-restoration aspect of the new Crown in jeopardy because of the proximity to the furca. Certainly the patient would want to know if further Periodontal procedures would be required prior to us attempting to restore the tooth. Ultimately, we do not want to create a situation where chronic Periodontal problems make management of this buccal margin difficult for the patient, leading to further gingival problems, further caries or eventual extraction.

If we added the costs of Crown lengthening to the Endodontic treatment and new Crown, we are starting to get close to the cost of extraction and replacement with an implant.

I contacted the referring dentist and told them that there was a defect on the mesial aspect of the tooth. I could not in good conscience continue to perform the Endodontic treatment until the Crown was removed and the referring dentist assessed the tooth for restorability in his office. If further procedures were necessary, he would have to decide whether the Crown margin was at an acceptable level and whether further Periodontal procedures would be necessary. All these procedures and the associated costs would have to be explained to the patient before we initiated Endodontic treatment and committed the patient to rehabilitation of the tooth.

The patient returned to his dentist and I subsequently received this note: “The gold crown was removed with crown removing forceps The amalgam core is intact with good tooth ferrule.  Margins were re-prepped deeper along the buccal. The crown was reluted with Voco Bifix temp cement, with the open margin on the buccal sealed. I believe I can restore the tooth in its current condition. Please proceed with the Endodontics.”

Since the crown seemed secure and was going to be remade, I chose to access through it. The case was cleaned and shaped and medicated with Ca(OH)2. The patient returned several weeks later, asymptomatic, at which time we obturated the case.  The crown was sufficiently sealed that I was confident the defective area would not be an issue between appointments and the tooth was ultimately restored.

Coordination of the treatment and good communication with the referring Dentist allowed us to achieve the optimal results with no compromises.

A 6 month recall the pocketing had resolved, the furcal bone appeared to be filling  in and the periapical radiolucency appeared to be resolving. The patient was asymptomatic.

However, much t my dismay, there appeared to be a void under the crown margin ( in the chamber?) that may indicate that the temporary sponges were never removed or that this area remained unfilled. Although an orifice bond was performed by me after the Endo, any open space in the chamber has the potential for coronal leakage that may contribute to long term Endo failure.

Lateral Radiolucency

This 80 year old patient was sent to me with a history of draining buccal sinus associated with a maxillary right cuspid (#13). The tooth had been crowned as one of the abutments  of a three unit bridge from #13 to #15. The patient was asymptomatic other than the draining sinus.  Probings were within normal limits. Pulp tests showed no response in #13 .

Periapical radiography showed a large radiolucent finding associated with the apex of the cuspid as well as a large lateral radiolucent area on the mesial aspect that approximated the adjacent lateral incisor (#12). The radiolucency was quite large and although the lateral incisor appeared to be virgin, I wanted to make sure that the radiolucent finding was entirely associated with the cuspid and not with any pathology associated with the lateral incisor. Pulp tests of #12 showed normal responses .

The other consideration was Periodontal.Maybe this was a Perio lesion masquerading as Endo.  Although there was a bit of bleeding on probing the palatal aspect of the cuspid, there were no deep pockets on the  mesial or palatal  side that suggested a cracked cuspid root or possible Perio issue causing the radiolucency.

I explained to the patient that the pulp in the cuspid had gone non vital and that Endodontic treatment was required . I had some suspicions that there may be a lateral canal on the mesial aspect of the cuspid  that was contributing to the large lateral radiolucency.

Access was made through the Crown and pulpal necrosis was confirmed. The canal was cleaned and shaped and the canal was medicated with calcium hydroxide. The patient was recalled a few weeks later at which time the draining sinus had closed and the tooth was ready for operation. The final operation results showed what we expected, a large filled lateral canal pointing directly to the lateral radiolucency on the mesial aspect of the root. Follow-up imaging at six months postop showed healing and regeneration of the bone associated with the cuspid.

What we can learn from this is that when the pulps of the adjacent teeth are determined to be normal and lateral radiolucencies occur in teeth with suspected necrotic pulps, we should expect some lateral anatomy that is ideally obturated with either gutta percha, sealer or a combination of the two . In any case adequate treatment of the canal system will result in healing of the attachment apparatus and resolution of the problem, as we see in this case .

Salvaging a Cracked Molar

This is a 59 year old male patient who came in with a localized complaint of pain for approximately one week. They had been awakened at night and the pain was increasing. The pain was described as 8 out of 10 and radiated from the posterior right mandible anteriorly.  The ache was described as radiating and throbbing however he did not have lingering pain.  The area was more sensitive to heat than to cold and was increased by pressure and by eating and heat stimulus. Nothing seemed to relieve the pain although the patient did initially have some success with cold water baths and analgesics. There was no swelling in the area . #46 had a large composite (possible MB pulp horn exposure- see BW?). #47 had a very shallow DO composite that was barely through the enamel. But the composite had a crack in it, extending mesially from the distal marginal ridge.   Although #46 was more heavily and deeply restored, the pain seemed to be originating in the  2nd molar, #47.

Mandibular second molar teeth have a high rate of mesial-distal fracture, even in Virgin molars. In this case transillumination showed a mesial-distal crack. Pulp tests were negative to thermal stimulus in #47 (positive in #46)  and #47 was definitely  percussive sensitive. Bitewing radiography showed no associated loss of bone on the proximal surface and periapical radiography showed no evidence of unusual periapical findings (perhaps a bit of thickening at the D root apex of #47?).  I felt reasonably comfortable in proceeding with Endodontic treatment on #47 provided that the tooth had full cuspal coverage immediately after treatment.

I explained to the patient that but the pulp in #47 had become necrotic due to the fracture and that this had resulted in the acute symptoms he was experiencing. The tooth would require Endo treatment followed by immediate full cuspal coverage restoration. Endodontic treatment was performed without incident (pulp was found to be only partially vital) and was sent back to the referring Dentist for immediate restoration . The patient returned for one year postop recall completely asymptomatic with a nicely restored Crown . The proximal bone appears to be normal and the overall prognosis appears to be good.

Mandibular second molar teeth have a high rate of mesial-distal fracture, even in Virgin molars. In this case transillumination showed a mesial-distal crack. Pulp tests were negative to thermal stimulus in #47 (positive in #46)  and #47 was definitely  percussive sensitive. Bitewing radiography showed no associated loss of bone on the proximal surface and periapical radiography showed no evidence of unusual periapical findings (perhaps a bit of thickening at the D root apex of #47?).  I felt reasonably comfortable in proceeding with Endodontic treatment on #47 provided that the tooth had full cuspal coverage immediately after treatment.

I explained to the patient that but the pulp in #47 had become necrotic due to the fracture and that this had resulted in the acute symptoms he was experiencing. The tooth would require Endo treatment followed by immediate full cuspal coverage restoration. Endodontic treatment was performed without incident (pulp was found to be only partially vital) and was sent back to the referring Dentist for immediate restoration . The patient returned for one year postop recall completely asymptomatic with a nicely restored Crown . The proximal bone appears to be normal and the overall prognosis appears to be good.

Over my 35+ year Endodontic career I have transitioned somewhat in my decisions to treat or not treat such cases. The first thing I look for is the opposing tooth, which often is it full Crown restoration. Teeth opposing crowns are frequently associated with higher rates of fracture in restored or even Virgin opposing teeth.

There are two factors that determine whether I recommend that patients proceed with Endodontic treatment and restoration:

#1. If the pulp is testing non-vital and there are periapical areas in the furcation and at the apices, there is a VERY good chance that the crack is extensive. If the crack is either close to the furca or traverses it completely.  (This can only be confirmed with crack visualization) I believe that the tooth is a poor candidate for rehabilitation.

#2.  The depth of the pocketing along the fracture line. If the pocketing is greater than 6 or 7 millimeters, and there is associated vertical bone loss, again the tooth is deemed to be a poor candidate for treatment and I recommend extraction.

There will always be patients who will attempt to salvage teeth like this rather than replacing them with an implant (mostly for financial/insurance reasons) . In those cases I tell patients that it is impossible to determine how long this tooth will last and that somewhere between 2 to 10 years is not uncommon. Retention of these teeth depends on many factors such as response to function, time to final restoration and occlusal factors, many of which cannot be predicted.