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Puzzle Case: Draining Fistula Associated with a Vital Pulp

Terry Pannkuk, DDS, MScDDiagnostic Puzzles, Instructional, Clinical Endodontic Technique Instruction, Diagnosis, All by Date

Description

Preoperative periapical radiograph showing anomalous root anatomy of the mandibular right first molar (#30)

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What is the reason for a vital pulp and a draining fistula?

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Retained root primary tooth with necrotic pulp

Interesting idea that I didn't think of! Bicuspids come in to replace the deciduous molars do you think a primary molar root could have drifted that far mesially? I'll add that idea to my differential diagnosis. Thanks Jim!

I'll add the remaining data I have on this case by the end of the day giving people a chance to guess what's going on. I'm not sure I really have the answer to this puzzle and it should generate some excellent comments!

Hi Terry,
Interesting case. Perplexing. Where do you find these things?!

I initially thought this was perio based on your sensitivity tests, and the location of the fistula. Basic question - were you able to track the fistula?

2 questions: Have you thought of getting an OMF radiologist to read the scan to see what they think? I was also thinking that another possible ddx could be an enostosis - however - in the sagittal view, it does appear to have some sort of PDL like structure.
Thanks for posting.
A

Answers to your questions:

1. I could not get a gutta percha cone to go into the sinus tract it might have been healing, so no radiograph of the tracing

2. I have thought of getting and OMF radiologist to read the scan but figured it was a bit premature at this point wanting to wait and see if the fistula heals and comes back. If it comes back then that might be the next step, although I'm a bit more personally inclined to simply flap and debride which might definitively eliminate the etiology even though we me never find out what it really was. A biopsy submission would be possible with the flap procedure which would be very simple to perform.

The enostosis idea is another good intellectual stab at what this might be. I liked Tinnin's retained primary root idea except it just happened to be the wrong area! It's fun to try and figure these out. Once in a while amidst our constant daily routine of endo after endo we get thrown a few curve balls. My point in presenting this one is to show that not every case presentation has an obvious answer. Quite frankly I still don't know what the Hell this is and won't pretend that I do. It's food for thought. Maybe some clever person will figure it out. If the sinus tract heals and never comes back, we'll never have a definitive answer to this puzzle. That's a good thing for the patient, but ironically not a good thing for our intellectual curiosity and educational growth. I'll keep you posted if I get more information with an update. Thanks again for your engagement and participation on the PDL site. I appreciate your support Ashley!

Answers to your questions:

1. I could not get a gutta percha cone to go into the sinus tract it might have been healing, so no radiograph of the tracing

2. I have thought of getting and OMF radiologist to read the scan but figured it was a bit premature at this point wanting to wait and see if the fistula heals and comes back. If it comes back then that might be the next step, although I'm a bit more personally inclined to simply flap and debride which might definitively eliminate the etiology even though we me never find out what it really was. A biopsy submission would be possible with the flap procedure which would be very simple to perform.

The enostosis idea is another good intellectual stab at what this might be. I liked Tinnin's retained primary root idea except it just happened to be the wrong area! It's fun to try and figure these out. Once in a while amidst our constant daily routine of endo after endo we get thrown a few curve balls. My point in presenting this one is to show that not every case presentation has an obvious answer. Quite frankly I still don't know what the Hell this is and won't pretend that I do. It's food for thought. Maybe some clever person will figure it out. If the sinus tract heals and never comes back, we'll never have a definitive answer to this puzzle. That's a good thing for the patient, but ironically not a good thing for our intellectual curiosity and educational growth. I'll keep you posted if I get more information with an update. Thanks again for your engagement and participation on the PDL site. I appreciate your support Ashley!

A great friend of mine in my residency is an OMF radiologist. If it's ok with you, I will send him some images and get his thoughts.
A

sure!

Any further development here? Sinus tract resolve? I agree with comment above that noted the entity appears to have PDL space. Possible retained primary root, unrelated to occurrence of fistula. Which of course begs the question -why the fistula? Interesting Thanks

The patient never came back and I got no follow-up report. Thanks for the prompting! I'll email the referring dentist and find out what the current status is.

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