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!

The Blame Game - Root Canal Failure?

CASE #1
I recently completed a diagnostic excavation on this tooth and determined that it was non-restorable due to decay under mesial crown margin and into the pulpal floor of the tooth. The findings of the implant surgeon indicated a "failed root canal" as the cause for extraction.

It is well known that a common reason for endodontic failure is root canal recontamination caused by coronal leakage. If coronal leakage allows bacteria to re-enter the root canal system, then did the root canal fail or did the restoration fail? In this particular case, when rampant caries is found under the crown margin and extending into the pulpal floor, it is more accurate to say that extensive recurrent decay is the reason the tooth is non-restorable requiring extraction.

A review of the root canal history also confirms that endodontic therapy was successful.

This pt presented in 2006 with an prior rct & acute apical abscess. Retx was recommended. A periapical lesion is noted on the distal root.

Retreatment completed in 2006.

In 2010, the patient returns with symptoms. The distal lesion has healed, and the mesial margin of the crown shows leakage. It is recommended to remove crown and excavate decay.

The radiographic history would indicate that the endodontic retreatment performed in 2006 was was successful with healing of distal lesion.

When a tooth is to be extracted, a proper diagnosis should be given.

CASE #2

This patient came to our office today for consultation. Pt reports that RCT was done many years ago without any issues. Last year he traveled to Mexico for some dental work. The crowns were placed on #30 & #31. A periapical lesion has now developed on the mesial root of #30. My diagnosis is: prior RCT w/ symptomatic apical periodontitis. Coronal leakage is identified radiographically on mesial and distal margin. In this case, you could easily say the root canal failed. However, the inadaquate coronal seal on #30, in my opinion, is just as likely the cause for the periapical lesion on the MB root.

In our practice at Superstition Spring Endodontics, we would diagnose #30 as: Prior RCT with SAP (symptomatic apical periodontitis - percussion pain) with coronal leakage. Retreatment would be recommended. We would explain to the patient that for long term success, we need to prevent any leakage from above. (We would also recommend evaluation of mesial margin #31 by general dentist)

A proper diagnosis does not cast blame. It objectively reports current findings and indicates the reasons for recommended treatment.

Clinical Clues for Identifying Cracked/Fracture Roots

Accurate diagnosis of a cracked/fractured root is a difficult task. It is important to get it right, because the treatment for a cracked root is usually extraction. I explain to patients that there are some clinical signs that would indicate a cracked root, but they are not 100% conclusive all the time. These same clinical signs can occur in other situations as well.

The typical signs associated with a cracked/fracture root that we have previously reported:

1. J-shaped lesion or large lateral lesion

2. Deep, narrow periodontal pocket

A couple new clinical signs that I have not previously reported include:

3. Swelling in the in the marginal gingival, adjacent to the fracture

4. Failure of a swelling to resolve despite a course of antibiotics

The more of these clinical signs I see in one patient, the more confident I am that the root is cracked/fractured.

I explain to patients that the only way to know with certainty is to visualize the crack. This is most effectively done with magnification. This can either be done through an endodontic access, or through a small periodontal flap to examine the root surface. I expect that with time, CBCT will be better able to help us in the diagnosis of cracked/fractured roots. At this time, the CBCT does not appear pick up on a cracked/fractured root until the pieces of the root begin to separate.

Here is an example of a case in which several of the described clinical signs were present indicating a cracked/fractured root. Access and visualization confirmed the diagnosis of cracked root.

Pt presents with a swelling in the marginal gingiva adjacent to distal root of #19. The radiograph shows a large, lateral lesion on mesial of distal root. Patient had been taking Penicillin for several days, without resolution of the swelling. Antibiotic was changed to clindamycin to see if swelling would resolve.

Swelling did not resolve after taking clindamycin.

At this point, I am quite certain I will find a cracked root. If this were simply a perio issue or an endo issue, I would have expected it to clear up with the antibiotics.

Access into pulp chamber exposes a vertical crack/fracture on the MB root as well as the DB root.

The tooth is deemed non-restorable and extraction recommended.

If you are unsure if a tooth has a cracked/fractured root, contact your endodontist. Not all teeth can be saved, but endodontists are the specialists for saving teeth and can help you determine which ones to save.

Herodontics? - Revisited

In Aug 2009, an American Academy of Implant Dentistry press release stated, "...times have changed and patients should forego prolonged dental heroics to save failing teeth and replace them with long-lasting dental implants". While it universally accepted that implants are a great way to replace missing teeth, a more controversial topic is when to replace a diseased tooth with an implant. In my opinion, those promoting dental implants have become increasingly more aggressive about replacing natural teeth.

As a specialist, I am occasionally called upon to perform "heroic" procedures. This may be following some iatrogenic damage or by a patient who wishes to retain a natural tooth at any cost. While I would much rather treat a normal, straightforward endodontic case, the use of microscopes, ultrasonics and MTA have allowed us to preserve teeth that many would consider "hopeless". I am often amazed at the success that we have with some of these "heroic" cases.

The following case was previously posted, but the patient returned for a 4 year recall last month. Unfortunately, the patient was returning for another root repair perforation following endodontic access on a different tooth. This case would be considered a "heroic" case by anyone's standard! In this particular case, this patient has been pleased with his decision to retain the tooth.

Original Post
This root canal was done just over four years ago. The patient presented with pain to percussion, and an 8 mm buccal probing was present. The RCT had been completed 2 years previously and recently became symptomatic.
DX: Prior RCT w/ Symptomatic Apical Periodontitis.
Treatment recommended: Non-surgical retreatment, perforation repair with possible need for endodontic surgery. Prognosis: guarded.

As you can see, the MB canal is very calcified. Calcification of this kind would make this case a very high level of difficulty. The MB canal was missed and the furcation was found, instrumented & obturated. Proper case selection can help prevent this type of complication. However, if this does occur, one would expect to find bleeding and the tactile sensation of the pdl/cortical bone is very different from the canal. Length determination films, working films or final films should also identify the perforation. I would recommend immediate referral to an endodontist for treatment of an iatrogenic event such as this.

Retreatment completed. MB canal located and treated. Furcal perforation repaired with MTA. Patient placed on recall to watch the area and see if endodontic surgery will be required.

Recall at 2 years & 3 months. Patient reports complete function and no symptoms. The 8mm periodontal probing has dissappeared. This tooth is considered "healing", and scheduled for a 1 year recall.

You can call it "herodontics", but that tooth is functional, apical bone looks good, periodontal pocket has disappeared. This will be a fun case to watch over time.

4 Year Recall

Asymptomatic & fully functional.

NOTE: I have never said this is pretty. Actually, its pretty ugly. However, retaining the natural tooth has preserved the crestal bone, provided normal function, and cost much less in time and money than any replacement option available.

Endodontic Retreatment & MTA Preserve the Tooth

Here's a tooth that had endodontic treatment over 10 years ago. While the clinician had difficulty finding all the canals, the tooth has been functional for quite some time. A large furcal defect raises suspicion of a root fracture or perforation.

DX: Prior RCT w/ Symptomatic Apical Periodontitis.

There are many who would consider this hopeless and recommend extraction.

Let us consider the cause of this treatment failure:

1. Missed Canals

2. Furcal Perforation or Root Fracture?

Can these issues be addressed to preserve the natural tooth?

In my consultation with the patient, I explain these issues and that endodontic re-treatment may be able to save the tooth (as long as the root is not fractured). I also explain the alternative option of extraction.

Finding missing canals is a simple solution.

A perforated root can be repaired with guarded prognosis.

A fractured root will require extraction.

I tell the patient the only way to know for sure is to open the tooth and investigate. Considering the nice crown on the tooth, the cost of attempting to save the tooth is minimal, compared to the cost of removing and replacing. In this case the patient elected re-treatment.

Pre-operative radiograph.

Upon access, 2 additional canals are located and instrumented. A furcal perforation is also identified. No root fractures are found.

Re-treatment is complete. Canals obturated with gutta percha and furcal perforation repaired with MTA. Glass ionomer base is placed over MTA.

7 month recall shows a tooth that is fully functional with remarkable healing of the furcal defect. Endodontic re-treatment has preserved the natural tooth.

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.

Vertical Root Fracture

This 92 year old patient came into our office for evaluation of #7. She reported no pain, but had a sinus tract between #6 & #7. Probing around #7 appeared normal.

The radiograph appeared to show some lateral radiolucency at the level of the post. The post also appeared slightly off angle with the root canal obturation. Despite the lack of narrow probing depths, I suspected a root fracture.

At this point, we decided to verify that fracture by disassembling the restoration. The patient was informed that if the root was fractured, then she we would not be able to save the tooth.



After simultaneous removal of the post and crown, multiple vertical root fractures were identified. A lingual, and distal fracture are seen in this image.

A mesial root fracture is seen in this angle.

Visualizing a fracture is the only certain way to diagnose a root fracture. This procedure is not well reimbursed, if at all. It will certainly require time that could be used for more productive treatment. However, if it was my tooth, I would want to know it is fractured before extracting it.

I suspect that a possible application of the new cone beam dental CT's will help with diagnosis of vertical root fracture.

Vertical Root Fracture

Vertical root fracture (VRF) can be one of the most challenging parts of endodontic diagnosis. It is often only diagnosed after you have ruled out everything else.

Since treatment of a VRF is extraction, it is important to have an accurate diagnosis. The most certain way to diagnose a vertical root fracture is to see it. This is easily done with a microscope internally. However, that takes significant chair time.

Here are a few tricks that will help you diagnose a VRF.



RADIOGRAPHS:
Look closely at this radiograph. You can see a dark line running parallel to the canal. This dark line will appear if the fracture has caused the root to separate or if you just get lucky with the horizontal angle of your radiograph (just make sure it is not a missed canal).









J-shaped lesions are often indicative of a VRF. **however large, non-fractured, endodontic lesions can also have this appearance

PROBINGS:
Long narrow periodontal probings are often indicative of a VRF. A long, narrow probing develops along the line of a fracture because the pdl cannot attach to the fracture. Looking closely at this image demonstrates the pdl breakdown along the line of the fracture.

**However, a draining sinus tract throught the periodontal ligament can also give you similar probing.**

As you can tell, all of these tips still have some exception to them. Full, accurate diagnosis of VRF sometimes requires a couple of visits to rule out all of the other possibilities. Visualizing the fracture is best done internally with a microscope. However, if you find several of these signs together, you can be fairly confident that you have a VRF.

Time for an Implant

This patient was referred to my office today to finish the RCT on #5. I was obviously a little concerned about the restorability of the tooth. Since she traveled quite far, and her referring dentist had sent her, I went ahead and opened it up to take a peek.





This is what I found. (not surprising)

We discussed the options:

OPTION #1

1. RCT $800

2. Build-up $250

3. Crown Lengthening $700

4. Crown $800

Total $2550 with guarded/poor prognosis



OPTION #2

1. Extract $200

2. Implant $1800

3. Crown $1000

TOTAL $3000 with excellent prognosis

OPTION #3

1. Extract $200

2. Bridge $2400

TOTAL $2600 with excellent prognosis

It is obvious that an implant or bridge will have a better long term prognosis than trying to save this tooth with endodontic therapy, perio therapy & restorative therapy. This is a situation where I made a recommendation for extraction. Since #4 has a nice crown and #6 is a virgin tooth, if it were me, I would personally go with the implant option.

In my practice, I always try to give my patients the same treatment that I would want for myself or my family. I think we owe it to our patients to give them all of the options.