Management of Dens Evaginatus

This 17 year old Asian female patient was sent to me for consideration of a Virgin mandibular second molar on the right side. The patient had a history of pain in this tooth but was not sore on presentation. the patient had been placed on antibiotic medication for the previous six days.

Radiographic examination showed classic Dens Evaginatus. Apical development was incomplete and there was a diffuse radiolucent area associated with a blunderbuss apex . There was an associated draining buccal sinus and the gingiva was slightly swollen and discolored. Palpation of this area was minimally positive. All other findings were normal. Periodontal probings were within the range of normal.Pulp tests were non-responsive. A Diagnosis of Dens Evaginatus, incomplete apical development and chronic periapical periodontitis was made.

A rubber dam was placed in the tooth was accessed without local anesthetic. The access was rinsed with NaOCl 5.25% and attempts were made to ascertain the level of any vital tissue in the canal. Paper points were used to test the area and established the rough estimate as to where the necrotic pulp ended and the apical tissue started. I used a custom rolled gutta Percha cone to radiographically check where this level terminated. Calcium Hydroxide medication was inserted into the canal and gently packed with large paper points and Schilder Pluggers.  The patient was instructed to return at three month intervals to assess symptoms and the periapical area. The sinus closed and the apical radiolucency began to resolve.

Approximately 6 months later, the area has resolved sufficiently to allow me to obturate the canal and the patient was totally comfortable . Obturation  was completed by filling the apical section with MTA, followed by gutta percha filling in the coronal part of the canal. A composite and fillingwas used  to close off the access.

The most critical part of managing the case is to determine the level at which we wished to terminate the cleaning and shaping procedures and being able to control the obturation materials to the point where no excess is extruded.  No barrier techniques were used in this case. This is a slow process and patients have to understand the slow pace at which the pathology resolves

Molar Disassembly Retreat

This 41 year old female patient was referred to me for endodontic consideration of tooth #37. The patient had a history of endodontic treatment with post and amalgam core/Crown restoration . The patient’s current complaint was sensitivity to chewing and percussion. Periodontal findings were within the range of normal. Palpation was normal and chewing and percussion were slightly positive.

Radiographic examination showed a very large diffuse radiolucent area associated with both apices of this tooth. The size of the lesion was of some concern as well as the extensiveness on the mesial, distal and lingual aspects. I was concerned that the tooth may have been cracked but no Periodontal findings supported this diagnosis. The Crown appeared to be at least 20 years old and was due for replacement. the referring dentist wished me to perform disassembly retreatment on the tooth before replacing the Crown. cbCT radiographic examination showed loss of lingual bone and extensive Periradicular breakdown.

The Crown was cut off the tooth and the post was removed from the distal canal. It appeared to be very loosely placed and I was not sure how much retention it was providing for the core. All canals were negotiated and cleaned and shaped. During disassembly it appears that a small portion of the core amalgam fell into one of the canals and we can see this as a radio-opaque mass in the apical area of the canals.
The case was medicated with calcium hydroxide for one month . The patient returned asymptomatic at which time percussion sensitivity was gone and the tooth was much more comfortable.

Obturation was completed with vertial compaction of warm gutta percha and Kerr sealer. The dentist was given instructions to re-restore the Crown and the patient was seen at 6 month intervals to monitor healing.

Recall radiographs showed slow but steady healing and the 18 month mark, virtually all of the radiolucent area had resolved and the patient was totally comfortable.

I was less than happy with the mesial margin of the Crown, which appears to be short but all in all I think but the results are excellent considering the size of the original radiolucent lesion and what appeared to be a significantly involved tooth.

 You may wish to note that the tooth was restored quite adequately without a post , so we can say that the post placement for the original Crown was probably not necessary.

Perio or Endo?

This case was referred by a local periodontist for Endodontic consideration of this mandibular right second molar. The patient presented with gross labial gingival swelling along the gingival Crest and what appeared to be a periodontal Abscess.

A large MO amalgam restoration was placed in the tooth that appeared to be approximating the pulp. The Periodontist was not sure whether the furcal breakdown was of Endodontic or pure Periodontal origin. The patient exhibited some mesio-angular bone loss in this tooth bone loss but no other evidence of bone loss associated with chronic Periodontal disease. The findings in this tooth could be consistent with furcation involvement of this tooth due to periodontal and not endodontic reasons.

Radiographic examination showed a deep amalgam restoration and a small radiolucent finding in the the furcation. The root apices showed no such radiolucencies. The Crown/Root ratio was noted to be fairly short and the furcation level appeared to be close to that of the bone crest. There  certainly was gross evidence of periodontal disease.   The sensed that the tooth was probably NOT a good candidate for regenerative or other Perio surgery.

Localized gingival swelling is apparent at the gingival margin. Probing of the furcation was Class 2 positive and the area was quite tender to palpation along the gingival margin. The tooth was slightly percussion and chewing sensitive.

Pulp tests were performed, and the pulp was normally responsive to cold.  This was inconsistent with periapical breakdown of Endodontic origin. A diagnosis of acute Periodontal Abscess was made. I explained to the Periodontist that the tooth was not Endodontically involved and that any periodical radiolucent findings that were associated with this tooth were not  Endo related . The diagram I used is above and I find such notations very helpful when discussing cases with patients. It is also a very good way to record your discussions with the patient when sending reports to referrals and to properly document the case. I explained that  Endodontic treatment of this tooth would not be of benefit to the patient. I felt that the periodontal prognosis for this tooth was hopeless and that the tooth should be extracted. The patient was returned to the referring Periodontist for discussions regarding extraction and prosthetic replacement.

Pulp tests were performed, and the pulp was normally responsive to cold.  This was inconsistent with periapical breakdown of Endodontic origin. A diagnosis of acute Periodontal Abscess was made. I explained to the Periodontist that the tooth was not Endodontically involved and that any periodical radiolucent findings that were associated with this tooth were not  Endo related . The diagram I used is above and I find such notations very helpful when discussing cases with patients. It is also a very good way to record your discussions with the patient when sending reports to referrals and to properly document the case. I explained that  Endodontic treatment of this tooth would not be of benefit to the patient. I felt that the periodontal prognosis for this tooth was hopeless and that the tooth should be extracted. The patient was returned to the referring Periodontist for discussions regarding extraction and prosthetic replacement.

Handling an Ugly Perforation

This 29 year old male patient was referred to me in mid treatment. The patient had complained of slight discoloration of this lower incisor and the referring dentist wished to perform an internal bleaching procedure after Endodontic treatment had been performed. Access was made and during the initial entrance into the tooth a labial perforation of the root was made. This remained undetected during the entire instrumentation procedure and eventually the dentist realized that the cone fit was not proceeding normally.  The Dentist removed the rubber dam and was alarmed to find a large area of ulceration along the labial gingiva where the instrument had perforated and the irrigation with NaOCl into the gingiva had resulted in tissue necrosis due to what essentially was a chemical burn.

The Dentist explained the procedural error to the patient and referred the patient to me for continuation of the endodontics. I noted that the tooth was virgin prior to access but had slight discoloration . The lingual access had been closed with IRM.

The patient arrived with a large ulcerated area on the labial aspect of the root . Cone beam tomography revealed the perforation site quite clearly . Interestingly, there was no periapical pathology associated with the apex of the tooth in the PA image. So I assumed that this tooth had been electively treated because of lack of pulp responses to pulp tests or perhaps only to allow for placement o internal bleach. The cbCT revealed only a small thickening of the PDL and a bit of resorption at the apex. The tooth was otherwise asymptomatic  prior to treatment, as far as the patient had been concerned .

I explained to the patient that there had been a perforation on the labial aspect of the root and that I would attempt to repair this area. I could not guarantee that we could continue with completion of endodontic treatment of the rest of the canal, which I felt may not actually be necessary . It was possible that we could merely fill the perforated coronal section and leave the apical section alone, as long as the patient had no postop symptoms or evidence of periapical radiolucent findings.

The perforation site was sealed with MTA and the lingual access was closed with flowable composite. The patient was seen three weeks later at which time the entire soft tissue area had healed normally and there was no evidence of a problem. Both the patient and the referral were very glad that the case had worked out so well and that the patient was asymptomatic.

If cosmetic improvement was desired,  I recommended that only external bleaching procedures be performed on this tooth, perhaps with a single tooth bleaching tray . I told the patient that results could be unpredictable but at this point, considering all the complications that had occurred during the initial attempts to treat the tooth endodontically , the patient  was more inclined to leave the tooth as is.

This is an excellent example of the importance of working length control and the need to monitor Endo access in three dimensions with cone beam tomography. Labial perforation of such teeth is common where severe calcification is present and it is essential that you are able to monitor your 3 dimensional progress into the tooth before such procedural accidents occur.

Furthermore if your working length (as measured by the apex locator) is not coincidental with the approximate root length, STOP the procedure immediately. Under no circumstances should you continue to use irrigants such as sodium hypochlorite in the suspect area until you are confident you are in the canal. In this case, the Dentist was fortunate that the patient was young and the tissues healed quite nicely.

Iatrogenic Oral Surgery Fixation Complicates Case

This 27 year old male patient was referred to me after having had a traumatic incident which resulted in the fracture of his right mandible . The patient had been seen by an Oral Surgeon for repair, which involved surgical fixation of the segments with screws and bars. Patient was having continuing symptoms which are described a

I asked the referring dentist to contact the Oral Surgeon and send any pertinent information he felt was important. I received a photo of a panoramic image that apparently was taken with an iPhone by the referring Dentist.

cbCT examination of the area showed an oblique fracture of the mandible that had been repaired with fixation. Unfortunately the oral surgeon placed the screws of the upper level fixation directly into the roots of the canine and second premolar. Apparently, he realized he realized the error in the second premolar and the screw was removed, leaving a void and the root as visible on the cone beam tomograph. The cuspid screw had been placed right through the cuspid root and out the lingual plate!!! The case was certainly unusual and something I had never seen before.

I explained to the referring dentist that our options were quite limited. Both the cuspid and the premolar would require Endodontic treatment due to the iatrogenic perforation of the roots by the screws.

1. We could attempt Endo  treatment of tooth #45 using conventional methods but the perforation would essentially make the case an open apex situation. Because there was no pulpal pathology prior to the iatrogenic perforation, (I assumed that these teeth were virgin and pulps vital) it may be possible to place MTA to the level of the screw hole and then simply fill the rest of the canal and access. We would have to determine how well the area healed once the Endodontic treatment had been completed on this case.
2. However, in order to treat the problem, the fixation would have to be removed so the screw could be removed from the apex of the cuspid. Once the fixation hardware was removed, we could visualize the apices more clearly with radiographs. We would then treat the cuspid similarly to the premolar, attempting an open apex type of treatment with MTA as necessary.

I may have considered performing Endodontic surgical procedures on these teeth myself but I did not want to take the responsibility of removing the screws and plate because I did not place them originally. We also did not want to have the patient undergo separate surgical procedures for (1) hardware removal and (2) Endo surgery, if necessary.

If subsequent Endo  surgery was required , it could be performed on the damaged apical segments without interference from the hardware. This would necessitate a second surgical procedure, which is something I’m sure the patient wanted to avoid, considering what he had already endured, dealing with his fractured mandible. Also, with each subsequent surgical procedure we run the risk of paraesthesia when working in the area close to the mental foramen.

In the era of digital imaging, this kind of iatrogenic error is surprising and totally unnecessary. Prior to the surgical procedure the surgeon should have examined the anatomical position of the roots of these teeth, scanned the case,  and calculated screw positioning to avoid any possible iatrogenic damage. Surgical stents could have been fabricated, ensuring precise, accurate proper screw position and depth.

I suggested that the patient return to the oral surgeon to have the hardware removed. Once there was evidence of healing of the fracture we would attempt endodontic treatment. As the patient did not return for follow up, I have no knowledge of how this case eventually was resolved.

 Where is YOUR Treatment Plan?

The 64 year old female patient was referred to me for possible continuation of Endodontic treatment of a mandibular 2nd premolar. The patient was referred with a note that said “Endo tx #35 – Tooth has been prepped crown ready to cement. Unable to penetrate canal.” The tooth presented with evidence of temporary Crown and prior endodontic access. The tooth was very heavily tilted, which contributed to difficulties in accessing the chamber and canal.

The patient was asymptomatic. Examination of the tooth showed that the access had been perforated the mesial part of the root.  The referral documents did not indicate that the Dentist had mentioned this procedural error to the patient prior to referral.

Radiographic examination showed extensive decay on the distal aspect of the tooth and access perforation on the mesial aspect of the tooth. Periapical radiography revealed extensive loss of tooth structure to the level approximating the bone Crest. As with all cases, we took a bitewing radiograph to further assess the occlusal scheme. I noted extensive decay on the mesial aspect of tooth #27 under the Crown margin and decay underneath the distal Crown margin of tooth #26. The decay in #27 appeared to be encroaching the pulp and was threatening endodontic involvement. There was no notation in the referral as to whether this had been discussed with the patient prior to referral for the mandibular premolar.

The question remains: What do we do with this information obtained from the bitewing radiography and what do we tell the patient?
Do we explain the procedural error to the and do we  merely mention it in the report to the referring dentist without discussing it with the patient?
Do we mention it to the patient at the time of examination?
The referring dentist may not have discussed this with the patient prior to referral for the premolar so revealing this may be embarrassing to the referral.
Do we have a professional end ethical obligation have to discuss our findings with patients at the time they present?

The patient was referred back to their dentist for further discussions regarding a treatment plan for this  area. The treatment plan implications for have these two other maxillary molars are significant. Ideally, both Crowns should be removed, the decay explored and endodontic treatment, if necessary, should be initiated.
It is my opinion that tooth #27 will probably require elective Endodontics due to the proximity of the decay to the pulp. Tooth #26 may not require Endododntics, however radiographs only show 60 to 70% of the decay that may be present in the mouth and the patient may require  treatment of #26 as well, depending upon the response of the pulp to further Crown preparation.

So we can see from this that the initial Endodontic consultation for the premolar may go from a treatment plan that costs roughly $4-5000 (Extraction and implant or bridge replacement) to  which may include a further $6,00-7000, depending upon whether or not these Maxillary Molars require Endodontic treatment prior to  re-restoration. Since most patients do not have an unlimited budget, I believe that all of these factors must be considered before formulating a treatment plan for the left side of the mouth. (For most, the fact their insurance benefits may cover at least PART or the bridge replacement of #35 will play an important role in the decision.)

In this case that may involve initial extraction of the premolar and then temporization of both #26 and 27 until the patient can decide whether either or both of these teeth will be rehabilitated and how #35 will be replaced.

it is my opinion that the Endodontist is not only responsible for Endodontic treatment on the referred case but also for being part of the overall treatment plan and reinforcing the referring dentists treatment plan in the eyes of the patient.

This can only happen when a treatment plan is sent along with the referral, so that the patient and the referral specialist understand what the general dentist has in mind. The specialist can reinforce that message and treatment plan in the mind of the patient, ensuring that there is no possibility of saying something to the patient that maybe inconsistent, contradictory or embarrassing  to the referring Dentist dentist.

The question remains: What do we do with this information obtained from the bitewing radiography and what do we tell the patient?
Do we explain the procedural error to the and do we  merely mention it in the report to the referring dentist without discussing it with the patient?
Do we mention it to the patient at the time of examination?
The referring dentist may not have discussed this with the patient prior to referral for the premolar so revealing this may be embarrassing to the referral.
Do we have a professional end ethical obligation have to discuss our findings with patients at the time they present?

In this case, the premolar was deemed unrestorable and continuation of Endodontic treatment was not indicated. At that point the patient inquired as to options and we discussed both fixed bridge replacement as well as implant replacement of the premolar.

The patient was referred back to their dentist for further discussions regarding a treatment plan for this  area. The treatment plan implications for have these two other maxillary molars are significant. Ideally, both Crowns should be removed, the decay explored and endodontic treatment, if necessary, should be initiated.
It is my opinion that tooth #27 will probably require elective Endodontics due to the proximity of the decay to the pulp. Tooth #26 may not require Endododntics, however radiographs only show 60 to 70% of the decay that may be present in the mouth and the patient may require  treatment of #26 as well, depending upon the response of the pulp to further Crown preparation.

So we can see from this that the initial Endodontic consultation for the premolar may go from a treatment plan that costs roughly $4-5000 (Extraction and implant or bridge replacement) to  which may include a further $6,00-7000, depending upon whether or not these Maxillary Molars require Endodontic treatment prior to  re-restoration. Since most patients do not have an unlimited budget, I believe that all of these factors must be considered before formulating a treatment plan for the left side of the mouth. (For most, the fact their insurance benefits may cover at least PART or the bridge replacement of #35 will play an important role in the decision.)

In this case that may involve initial extraction of the premolar and then temporization of both #26 and 27 until the patient can decide whether either or both of these teeth will be rehabilitated and how #35 will be replaced.

it is my opinion that the Endodontist is not only responsible for Endodontic treatment on the referred case but also for being part of the overall treatment plan and reinforcing the referring dentists treatment plan in the eyes of the patient.

This can only happen when a treatment plan is sent along with the referral, so that the patient and the referral specialist understand what the general dentist has in mind. The specialist can reinforce that message and treatment plan in the mind of the patient, ensuring that there is no possibility of saying something to the patient that maybe inconsistent, contradictory or embarrassing  to the referring Dentist dentist.

 Where is YOUR Treatment Plan?

The 64 year old female patient was referred to me for possible continuation of Endodontic treatment of a mandibular 2nd premolar. The patient was referred with a note that said “Endo tx #35 – Tooth has been prepped crown ready to cement. Unable to penetrate canal.” The tooth presented with evidence of temporary Crown and prior endodontic access. The tooth was very heavily tilted, which contributed to difficulties in accessing the chamber and canal.

The patient was asymptomatic. Examination of the tooth showed that the access had been perforated the mesial part of the root.  The referral documents did not indicate that the Dentist had mentioned this procedural error to the patient prior to referral.

Radiographic examination showed extensive decay on the distal aspect of the tooth and access perforation on the mesial aspect of the tooth. Periapical radiography revealed extensive loss of tooth structure to the level approximating the bone Crest. As with all cases, we took a bitewing radiograph to further assess the occlusal scheme. I noted extensive decay on the mesial aspect of tooth #27 under the Crown margin and decay underneath the distal Crown margin of tooth #26. The decay in #27 appeared to be encroaching the pulp and was threatening endodontic involvement. There was no notation in the referral as to whether this had been discussed with the patient prior to referral for the mandibular premolar.

The question remains: What do we do with this information obtained from the bitewing radiography and what do we tell the patient?
Do we explain the procedural error to the and do we  merely mention it in the report to the referring dentist without discussing it with the patient?
Do we mention it to the patient at the time of examination?
The referring dentist may not have discussed this with the patient prior to referral for the premolar so revealing this may be embarrassing to the referral.
Do we have a professional end ethical obligation have to discuss our findings with patients at the time they present?

In this case, the premolar was deemed unrestorable and continuation of Endodontic treatment was not indicated. At that point the patient inquired as to options and we discussed both fixed bridge replacement as well as implant replacement of the premolar.

The patient was referred back to their dentist for further discussions regarding a treatment plan for this  area. The treatment plan implications for have these two other maxillary molars are significant. Ideally, both Crowns should be removed, the decay explored and endodontic treatment, if necessary, should be initiated.
It is my opinion that tooth #27 will probably require elective Endodontics due to the proximity of the decay to the pulp. Tooth #26 may not require Endododntics, however radiographs only show 60 to 70% of the decay that may be present in the mouth and the patient may require  treatment of #26 as well, depending upon the response of the pulp to further Crown preparation.

So we can see from this that the initial Endodontic consultation for the premolar may go from a treatment plan that costs roughly $4-5000 (Extraction and implant or bridge replacement) to  which may include a further $6,00-7000, depending upon whether or not these Maxillary Molars require Endodontic treatment prior to  re-restoration. Since most patients do not have an unlimited budget, I believe that all of these factors must be considered before formulating a treatment plan for the left side of the mouth. (For most, the fact their insurance benefits may cover at least PART or the bridge replacement of #35 will play an important role in the decision.)

In this case that may involve initial extraction of the premolar and then temporization of both #26 and 27 until the patient can decide whether either or both of these teeth will be rehabilitated and how #35 will be replaced.

it is my opinion that the Endodontist is not only responsible for Endodontic treatment on the referred case but also for being part of the overall treatment plan and reinforcing the referring dentists treatment plan in the eyes of the patient.

This can only happen when a treatment plan is sent along with the referral, so that the patient and the referral specialist understand what the general dentist has in mind. The specialist can reinforce that message and treatment plan in the mind of the patient, ensuring that there is no possibility of saying something to the patient that maybe inconsistent, contradictory or embarrassing  to the referring Dentist dentist.

 Where is YOUR Treatment Plan?

The 64 year old female patient was referred to me for possible continuation of Endodontic treatment of a mandibular 2nd premolar. The patient was referred with a note that said “Endo tx #35 – Tooth has been prepped crown ready to cement. Unable to penetrate canal.” The tooth presented with evidence of temporary Crown and prior endodontic access. The tooth was very heavily tilted, which contributed to difficulties in accessing the chamber and canal.

The patient was asymptomatic. Examination of the tooth showed that the access had been perforated the mesial part of the root.  The referral documents did not indicate that the Dentist had mentioned this procedural error to the patient prior to referral.

Radiographic examination showed extensive decay on the distal aspect of the tooth and access perforation on the mesial aspect of the tooth. Periapical radiography revealed extensive loss of tooth structure to the level approximating the bone Crest. As with all cases, we took a bitewing radiograph to further assess the occlusal scheme. I noted extensive decay on the mesial aspect of tooth #27 under the Crown margin and decay underneath the distal Crown margin of tooth #26. The decay in #27 appeared to be encroaching the pulp and was threatening endodontic involvement. There was no notation in the referral as to whether this had been discussed with the patient prior to referral for the mandibular premolar.

The question remains: What do we do with this information obtained from the bitewing radiography and what do we tell the patient?
Do we explain the procedural error to the and do we  merely mention it in the report to the referring dentist without discussing it with the patient?
Do we mention it to the patient at the time of examination?
The referring dentist may not have discussed this with the patient prior to referral for the premolar so revealing this may be embarrassing to the referral.
Do we have a professional end ethical obligation have to discuss our findings with patients at the time they present?

In this case, the premolar was deemed unrestorable and continuation of Endodontic treatment was not indicated. At that point the patient inquired as to options and we discussed both fixed bridge replacement as well as implant replacement of the premolar.

The patient was referred back to their dentist for further discussions regarding a treatment plan for this  area. The treatment plan implications for have these two other maxillary molars are significant. Ideally, both Crowns should be removed, the decay explored and endodontic treatment, if necessary, should be initiated.
It is my opinion that tooth #27 will probably require elective Endodontics due to the proximity of the decay to the pulp. Tooth #26 may not require Endododntics, however radiographs only show 60 to 70% of the decay that may be present in the mouth and the patient may require  treatment of #26 as well, depending upon the response of the pulp to further Crown preparation.

So we can see from this that the initial Endodontic consultation for the premolar may go from a treatment plan that costs roughly $4-5000 (Extraction and implant or bridge replacement) to  which may include a further $6,00-7000, depending upon whether or not these Maxillary Molars require Endodontic treatment prior to  re-restoration. Since most patients do not have an unlimited budget, I believe that all of these factors must be considered before formulating a treatment plan for the left side of the mouth. (For most, the fact their insurance benefits may cover at least PART or the bridge replacement of #35 will play an important role in the decision.)

In this case that may involve initial extraction of the premolar and then temporization of both #26 and 27 until the patient can decide whether either or both of these teeth will be rehabilitated and how #35 will be replaced.

it is my opinion that the Endodontist is not only responsible for Endodontic treatment on the referred case but also for being part of the overall treatment plan and reinforcing the referring dentists treatment plan in the eyes of the patient.

This can only happen when a treatment plan is sent along with the referral, so that the patient and the referral specialist understand what the general dentist has in mind. The specialist can reinforce that message and treatment plan in the mind of the patient, ensuring that there is no possibility of saying something to the patient that maybe inconsistent, contradictory or embarrassing  to the referring Dentist dentist.

Will Endo Help This Case?

A 65 year old male patient was seen for exam and consultation regarding teeth #s 31 and 32. Tooth #31 had a history of regenerative periodontal surgery by a local periodontist. There was a persistent 9 mm lingual pocket associated #31 after the Perio surgery.  Because the radiographs showed a periapical radiolucency associated with #3, the periodontist wanted to rule out an endodontic component to possibly explain the failing regenerative surgery. The patient did not recall any traumatic incidents in the area . There was no history of Ortho treatment.

Pulp tests (thermal) were inconclusive. The patient was not very responsive to thermal stimulus in any of his anterior teeth. I performed a test cavity on #31 to confirm vitality. Once dentin was encountered, the pulp was found to be responsive and vital and the test cavity was restored with composite. Therefore the pocketing and radiolucency appeared to be entirely  unrelated to any Endo problem . 

Pre-Perio Surgery Image at left.                                   Postop and distal view at right

In my opinion, the tooth had a poor long term periodontal prognosis, especially if it already had attempted regenerative surgery treatment by a specialist. But I told him that as long as he was asymptomatic I saw no reason for immediate extraction or replacement. I recommended that he be monitored by the Periodontist and that they initiate discussions as to how “interceptive” they wished to be with what would likely be an eventual implant replacement.

Interestingly, the cbCT revealed an asymptomatic lingual external resorptive lesion in the adjacent lateral incisor #32. Again since we do not know how long this has been there, and because the patient is asymptomatic, I recommended that we monitor the area and perform no Endo treatment.

Patients are often referred with radiolucent areas that referrals suspect are endodontically involved.  Periodontists especially, envy the way a healing  endodontic case can regenerate a healthy attachment apparatus back to its original contours and density, IF the problem is purely Endodontic in etiology.

It is incumbent upon every clinician who is contemplating performing Endodontic treatment on a tooth to perform definitive pulp tests and confirm that the pathology is in fact associated with an endodontic problem. Incorrect Endo treatment of such teeth may, at best,  result in unnecessary treatment and no resolution of the area. At worst,  it can decrease the strength of the tooth, hasten tooth loss and result in unnecessary ineffective treatment for the patient.

When in doubt, do no harm….. and consider referral to a Specialist.

Overzealous Access Causes Loss of Tooth

Lateral perforation during attempted endodontic access is a particularly difficult problem to deal with because of the associated destruction of coronal tooth structure that usually occurs at the same time.

Interestingly, a lot of the perforations occur in the maxillary premolar area are errors in positioning of the patient rather than misdirection of the Bur. It is important to have the patient’s head positioned in such a way that your hand piece is not drilling down toward the floor, frequently resulting in perforation of the distal aspect of the premolar. Conversely tilting the chair or the patient’s head too far back can result in deviation to the mesial which is a fairly common occurrence in the maxillary first premolar because of the narrow cervical width and mesial concavity.

Whenever we make access into premolars, we must always pay special attention to guiding the direction of the Bur down the axis of the tooth.  Access can be extremely challenging in situations where crowns are present because the Crown may reorient, tip or realign the crown axis in such a way which makes initial access prone to misdirection.  Deep calcification can also make orientation difficult. This  may mean occasionally stopping and examining the direction of penetration.

Before making access, always check with the PA image first to see (1) if the axis of the crown and axis of the root are dramatically different, and (2) note the level of canal calcification and relative position of pulp i.e./ How far into the tooth do you have to go before you expect to encounter the pulp and (3) in which direction that may be.  When in doubt STOP, take a bitewing or cbCT and check to make sure that you are heading in the right direction.

Further indiscriminate dentin removal until bleeding occurs can only lead to gross perforation and further complications. When perforations are small, sometimes Crown lengthening can be performed to alleviate the problem. However, this always requires some sort of Periodontal surgical procedure and perf repair of the root, subgingival crown margin and a less than desirable chronic periodontally inflamed area.

Unfortunately, in this case, the tooth was grossly perforated and tooth structure so compromised that it could not be saved. The tooth was iatrogenically lost and would need to be replaced by an implant.

Endo works magic on Furca

Predicting outcomes in cases with furcation involvement can be some of the most challenging situations Endodontists can face.  When it comes to deciding on Endodontically treating or not treating a tooth and the patient has previous full cuspal coverage restoration, it is often difficult to get a history of the tooth. Often the history is unknown or unavailable. We frequently do not know whether the tooth required the Crown because of a crack . We know that teeth with cracks have a much poorer prognosis which, would probably lean us away from recommending treatment. But the patient has already payed for the crown and may not want to see their “investment” lost in favor or a more expensive implant.  The only thing we can do in that case is to present options to the patient and let them decide.

This first tooth had crown with gross furcal breakdown, class 2 furcation involvement and a draining buccal sinus. The rest of the mouth look good periodontally and there seemed no other evidence of parafunction or previous teeth that had a history of fracture. So, I was more optimistic than normal that this pathology was entirely endodontically related. But you can never be sure until the canals have been cleaned and shaped and medicated and we see if and how the supporting attachment apparatus responds to treatment.

The patient elected for us to try to save the tooth and I explained that treatment would be performed in two stages . Firstly, the tooth would be accessed and the canals cleaned and shaped and medicated with calcium hydroxide . If we saw improvement in the pocketing, furcation and draining sinus, we could fill the canals and complete the case. If there was some improvement but not enough to warrant completion of the case, we would re medicate the case until such time as all symptoms were gone , pocketing returned to normal and we could be reasonably assured that all associated pathology had been dealt with.  If symptoms did not resolve, we could fairly safely say that either the tooth was fractured or that the periodontal condition of the tooth did not warrant continuation of treatment.

In this cases the results were spectacular. Cleaning of the canal resulted in immediate closure of the sinus and returning of pocketing to normal. Follow up radiographs showed complete healing of the furcation and I was extremely pleased that we could take a tooth that appeared to be hopeless and and return the supporting attachment Apparatus  to normal health. 

 Cases such as these are extremely gratifying and show the power of good endodontic treatment when the source of the pathology is primary Endo.

Cracked Virgin Maxillary Premolar

This case is a comedy of errors. The case was initially referred to me as a Virgin maxillary first premolar tooth with a mesial-distal fracture running through the central developmental groove. Transillumination clearly showed that there was a crack in this tooth running M-D through the center.  The pulp tested vital. There was a 6 mm pocket on the mesial side of the tooth. I wasn’t happy about the prognosis and told this to the patient.

I explained to the patient that the tooth had a fracture and that the prognosis was somewhat variable. While there was some evidence of bone loss on the mesial aspect of the tooth, where we would normally expect,  I was not sure it was severe enough (NOW) to warrant extraction. Because the tooth was virgin and the patient did not want to lose the tooth, she asked that I Endodontically treat it  and try to save it. I completed the case (vital pulp) with a PermaFlo purple orifice bond and small Rebilda DC light cured composite filling in the access. I tried to keep the access as conservative as possible.  I recommended that the patient proceed immediately to their dentist to have the tooth prepared for a Crown and emphasized that the long term prognosis was uncertain. We were taking a “flier” on this one.

I assumed that the tooth would be immediately prepared and a Crown cemented STAT. Instead, it appears that my initial access filling was removed , the tooth was prepared for a large post space and a large cast post was inserted into the canal space.

Approximately a year later the patient was seen for follow up and there was complete loss of mesial bone to the point where the tooth would now require extraction. We cannot say for certain that preparation of the tooth for post space contributed to eventual failure of the root. But I was mystified as to why the dentist felt it was necessary to use a post in this tooth considering that the access was very conservative and all they had to do was minimally prepare the tooth and cement a Crown on top of my treatment.

It is truly unfortunate that improper use of a post may have contributed to the loss of this tooth, even though the patient had accepted the risks. We had done everything endodontically possible to ensure the best possible outcome.

This again points out that while Endodontists may have control over the endodontic aspects of the case, once the tooth leaves our office, we have absolutely NO control of all subsequent procedures which sometimes can contribute to frustrating loss of the patient’s tooth.