Patient: 42 years old male. Medical history non contributory

Chief Complaint: Asymptomatic. (The general dentist found decay on the distal aspect of tooth #16 on a regular check up and diagnosed the pulp as being necrotic)

Dental History: dentition relatively stable with restorations in multiple areas. There was no history of pain associated with the referred tooth (#16). The existing amalgam filling on the referred tooth was reported to be older than 20 years and had been placed by his former dentist.

Significant Findings:

Clinical Tests:

Palpation: normal
Percussion: normal
Biting: normal
Chewing (cotton roll): normal
Periodontal Probings: within normal limits (2 and 3 mm)
Mobility: normal
Cold: negative
EPT: negative

Diagnosis: Necrotic Pulp with Periradicular Structures within Normal Limits

Treatment prognosis: Good (before caries control on the distal which may questionably change the prognosis)

Treatment plan: Nonsurgical endodontic treatment of Tooth #16 followed by a crown/ onlay (possibly delayed due to the patient’s insurance)

Special Considerations of Performed Treatment:

The first step was caries control and assessment of restorability. The caries on the distolingual aspect of the tooth was excavated and a gingivectomy was performed via electrosurgery to establish a supragingival restorable crown margin..

Next a build up was placed prior to beginning the planned endodontic treatment.
Endodontic therapy was performed in a single visit and four main canals were identified, shaped, irrigated, and obturated. Particular care was necessary when treating the two mesiobuccal canals as both were long and curved.

At the end of endodontic treatment, the tooth was restored with a glass fiber post which was placed with adhesive cement and composite resin. The patient was instructed regarding care for the area where the gingivectomy was performed.

The patient returned for recall at 5 years (planned earlier but the patient had been out of the country). The patient reported no symptoms and revealed no recurrent caries. There had been no follow-up with a cusp-protected restoration. There was also no evidence or recurrent endodontic disease.

Key Learning points:

1. It is important to start with assessing the restorability of the tooth by removing all caries

2. It is best to restore the tooth immediately after endodontic treatment because there is no guarantee that the patient will see his own dentist for a proper long term restoration. It is well established that failure to properly restore and endodontically treated tooth might lead to the failure of the endodontic treatment if leakage or cracks appear.