Monday, September 29, 2008

Root Perforation causing Tooth Loss

This patient came to our office for evaluation of tooth #3. He reported having a recent root canal and crown done by a general dentist. Since the time the work was completed, he was experiencing "burning & itching in the gums around that tooth". The patient was concerned that he was having an allergic reaction to the cement or materials of the crown.

Our examination found #3 sensitive to palpation, moderately sensitive to percussion. (Adjacent teeth WNL) The radiopacent material in the furcation area of the tooth was noted.

Retreatment was initiated to evaluate the area.

The crown was first removed. Upon first look, there appears to be mesial decay still present and an obvious void between the tooth and the post/core material.

Additional removal of the buildup material shows a surprise underneath.

It become obvious that the distal wall of the MB canal has been perforated.

At this point, we can understand where the symptoms have been coming from. An attempt could be made to try and repair this defect (with MTA), however, the long term prognosis would be guarded to poor. Considering the the cost of initial treatment, the cost of retreatment which would then require post & build-up and new crown, this patient elected to extract the tooth.

This then becomes an appropriate time to replace this missing tooth with an implant or bridge. I recommended an implant consultation.

Endodontic treatment did not fail on this patient. The treating doctor failed to put his patient's best interest first and failed to inform the patient of the treatment complication (perforation) that occurred during treatment.

In a case like this, the patient referred himself to our office for evaluation. Had his dentist properly evaluated the case difficulty and referred him to an endodontist for treatment, this tooth would likely not have been lost.

This is not endodontic failure. This is failure to do good endodontics. This failure to do quality endodontics may be part of the reason that some clinicians are questioning the success of endodontic treatment.

Tuesday, September 16, 2008

Root Canal or Implant?

The latest version of Inside Dentistry (July/August 2008, volume 4, number 7) has a very interesting cover story by Allison M. DiMatteo BA, MPS. As an endodontist, I have been watching this debate develop for quite some time. I think it is important to determine what is behind this effort to pit one dental specialty against another.

This particular article seeks the opinion of endodontists and periodontists alike. All sides agree that implants are a great way to replace missing teeth. There is consensus that there is value to retaining natural teeth. The disagreement seems to come from the debate about when to remove a tooth in order to place an implant.

There are some who argue that implants are more successful than endodontically treated teeth. This is despite the evidence that shows that implants and endodontically treated teeth have similar, almost identical success rates.

Richard Mounce DDS, an endodontist, points out that the only controversy between endodontics and implants is "primarily economic and more artificially manufactured than exists in reality...There are clear indications for endodontic therapy and clear indications for implant therapy. Rarely are these treatment options so evenly weighted that when considered side by side (as to their advantages and disadvantages) that there should be a 'competition' or 'controversy', most especially when the patient's interest is put first".

According to Gregori M. Kurtzman DDS, "as a general rule, it is better to save a tooth...if you can". Restorability is the key factor in determining when a tooth needs to be removed. Ability to get a good margin, not violate biological width, cracks, strength of furcation, crown:root ratio etc. are all important factors in determining the restorability of the tooth. An endodontically treated tooth with a poor restoration, will generally not have long term success.

However in the same article, Dr. Kurtzman goes on to questions the success rates of endodontic surgery, and even the value of endodontic retreatment. Dr. Kurtzman points out that the financial investment into retreatment, like all treatment options which does not have 100% success rate, may be better made in a more predictable treatment of an implant.
That argument shows lack of understanding and appreciation for modern microscopic endodontic therapy.

I routinely recommend implant therapy for patients. What concerns me as a specialist is to see the marketing techniques and lack of proper endodontic evaluation during the treatment planning of implant cases. All of our mailboxes are full of marketing journals filled with clinical cases of implant placement.

Here is an example of two cases in the same issue of Inside Dentistry p.104-108.

This case is described as a "peri-apically involved maxillary incisor resulting from a failed root canal." Treatment options were reviewed and informed consent was obtained. Based on the patient's desire to reduce trauma and treatment time, it was decided to perform immediate implant placement. First of all, failed root canal is not an accurate diagnosis. The radiograph does not show the peri-apex. As best as we can tell the periodontal ligament looks fairly normal at the periapex. Was retreatment an option discussed? If it was, would it not be considered "less truamatic" than extraction and immediate implant placement? Not to mention the ability of a natural tooth to retain the crestal bone levels. Unless this tooth has a vertical fracture, of which there is no evidence, endodontic retreatment is a better option.

Another case from the same article shows a 27 year old female with a "symptomatic maxillary left lateral incisor with a history of endotherapy with a core build-up and crown". Active infection was noted with perilous fistula and exudate at the gingival margin. The prognosis of this tooth was deemed "hopeless".

Again, the endodontic evaluation of this tooth is incomplete. The anterior "bite-wing" type film certainly shows a normal crestal bone level, however, it is impossible to evaluate the endodontic therapy and is not a sufficient pretreatment radiograph. The conclusion that this tooth has a "hopeless" is premature.

Inadequate endodontic evaluation seems to be commonplace in many of the published clinical cases and those marketing dental implants. As mentioned above, there should be little controversy regarding endodontics and implants. Our specialties should not be pitted against one another, but should work together to meet the needs of our patients.


DiMatteo, A. "Making the Right Move: Planning Your Clinical Strategy", Inside Dentistry, July/August 2008. p122-133.

Malek, M. "Done in a Day: Immediate Tooth Replacement with Definitive Prosthesis", Inside Dentistry, July/August 2008. p104-108.