Patient: 58 year-old female in good health (2010)
Chief Complaint: biting sensitivity and swelling of the lower front tooth
Dental History: The patient had received root canal therapy on the mandibular right lateral incisor (tooth #26) 8-10 years prior to the consultation with the author in 2010. A PFM crown was placed after the root canal treatment. A historical diagnosis of bruxism had been made. The patient’s dentist had noticed a periapical radiolucency on a routine radiograph and referred the patient for endodontic consultation.
Significant Findings (tooth #26): the patient presented with moderate percussion and palpation sensitivity. The periodontal probing depths were within normal limits but gross calculus accumulation was noted. A periapical radiolucency measuring 4 mm in greatest diameter was noted with external inflammatory root end resorption.
Pulp and Periradicular Diagnosis (tooth #26): Previous root filling with acute periradicular periodontitis and external root end inflammatory resorption
Treatment Prognosis (tooth #26): Good
Treatment Plan: Nonsurgical endodontic retreatment (tooth #26)
Special Considerations of Performed Treatment:
This case demonstrates the perplexing decision to complete treatment when the initial endodontic access, cleaning, shaping, and placement of intracanal calcium hydroxide suggests inadequate resolution of the abscess and a possible treatment resistant infection. Deep microscopic inspection of the canal wall showed a small subtle line that may have been an apically propagated root fracture which is known to occur with spreader loading (Pitts et al 1983, Holcomb et al 1987, Lertchirakarn et al 1999, Dulaimi et al 2005, and Soros et al 2008)
The patient presented with what seemed to be a routine retreatment possibly complicated by root end resorption which occasionally may require combined periapical surgery to achieve a definitely successful treatment result. The following chronology of patient visits highlight the steps required to confidently complete treatment and save her tooth:
1/27/2010: Initial consultation and diagnosis
1/28/2010: Endodontic access, removed previous root canal filling, cleaned, shaped, filled with calcium hydroxide, and then temporized the access with a Cavit filling. Deep inspection with the microscope revealed a line on the wall of the canal in the middle and apical third of the root. The patient reported initial post-treatment discomfort and swelling which had resolved after a few days. The patient was informed that the root may be split and that extraction would be necessary. A check visit was scheduled at one month to clinical exam the tooth and surrounding tissues.
3/1/2010: Gross calculus accumulation was removed yet the periodontal probing depths were within normal limits. It was decided to leave the calcium hydroxide in place for 3 months and schedule another check visit (no radiograph taken).
5/18/2010: A clinical and radiographic exam was performed. The findings were unremarkable with the radiolucency appearing slightly reduced in size. A change of calcium hydroxide was planned.
6/4/2010: The patient was asymptomatic, the Cavit temporary was removed, the calcium hydroxide replaced and a Geristore temporary surface placed over the new layer of Cavit filling.
12/14/2010: The patient was asymptomatic. A clinical and radiographic examination was performed. Tooth #26 showed little change in the size of the periapical radiolucency. Continued monitoring was advised with leaving the tooth as is indefinitely until signs of healing were noted. A recall visit was scheduled for 6 months.
6/1/2011: Calcium hydroxide was changed and a new core filling was placed (Geristore). The patient was asymptomatic and all findings were within normal limits.
10/4/2011: A clinical examination with radiograph was performed. The patient was asymptomatic, yet smaller periapical radiolucency was still present. Continued indefinite monitoring was advised.
4/26/2012: A clinical examination without a radiograph was performed. Severe bleeding upon probing at the distolingual line angle was noted and there was severe calculus accumulation. Periodontal maintenance was emphasized. The periodontal probing depths were within normal limits. The patient was asymptomatic and a 1 year recall examination was scheduled.
4/15/2013: A clinical examination with radiograph was performed. The patient was asymptomatic, all findings were within normal limits and the periapical radiolucency was significantly reduced in size. The patient wished to continue monitoring and a one year recall visit was planned to consider finishing treatment. The patient was continuing to have trouble with her oral hygiene and calculus accumulation was still occurring. The periodontal probing depths continued to remain within normal limits.
7/29/2014: The patient returned for recall evaluation. The clinical and radiographic findings were within normal limits and the patient planned an appointment to finish endodontic treatment.
12/16/2014: Endodontic treatment was completed and the root canal system was obturated via the vertical compaction of warmed gutta percha technique with Kerr Sealer. A DT Light post was bonded to provide fracture resistance and a Filtek surface paced.
Key Learning Points:
Long-term indefinite placement of intracanal calcium hydroxide is a reasonable strategy for teeth with a questionable prognosis as in this case.
- When long-term periodontal stability and evidence of periradicular osseous regeneration is observed, endodontic treatment can be completed with confidence.