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Puzzle Case: Why the Fistula?

Sep 16, 2019

How do you explain the fistula?

This patient was referred to me after being looked at by his periodontist and restorative dentist. They were confused and so was I by the initial presentation.

Patient: 62 year-old male with atrial fibrillation managed with Digoxin

Chief Complaint: ”Bump on gums”

Dental History: The patient presented with a history of a noticeable lesion at the marginal labial gingival between the maxillary right lateral incisor (#7) and canine (#6). It was first noticed 3 weeks before the consultation visit with the author. Both a periodontist and general dentist had examined the tooth and referred the patient for a third opinion. Level 2/10 pain was described as being intermittent.

Significant Findings: The referring restorative dentist provided a radiograph showing a fistula tracing to the cervical interproximal area most near the canine root surface. Clinical examination revealed slight bleeding upon probing at the mid-labial area with normal circumferential probing depths. There was slight sensitivity upon percussion with Class 1 mobility. Cold thermal testing was within normal limits and the electric pulp test yielded a normal response as it did with all neighboring teeth.

Radiographic and CBCT findings suggested a lingual anomaly on #7.

What is the diagnosis, prognosis and treatment plan?

Gemnation: Complicated Endodontic Treatment Management

Aug 5, 2019

Gemnation presents unusual endodontic treatment challenges

Patient: 19 year old female with noncontributory medical history

Chief Complaint: Biting sensitivity

Dental History: The patient presented with occlusal caries in a groove of an anomalous molar (Tooth #15). The general dentist noted bleeding and a pulp exposure and referred the patient for endodontic evaluation and treatment. The patient reported having mild pain after the temporary pulp cap procedure, especially to biting.

Significant Findings (Tooth #15): The patient presented with an anomalous maxillary left second molar with a resin bonded filling in the mesiobuccal anomalous portion. The patient experienced moderate sensitivity to percussion, a normal response to cold thermal stimulation, normal mobility, and no palpation sensitivity. There was slight bleeding upon probing of the mesiolingual area but all probing depths were within normal limits. Access to the tooth was very limited due to a prominent coronoid process. A CBCT exam revealed a contiguous root canal system space in the anomaly extending near the coronal surface. The anomalous root canal system merged with the mesiobuccal root canal system and a very narrow mesiolingual fin seemed to merge with a single apical portal of exit. The DB and P systems did not appear to be anomalous.

Hidden Split in a Mandibular Central Incisor

Jul 15, 2019

hidden split in a tooth

Patient: 61year-old female with a history of colitis and hypothyroidism

Chief Complaint: biting and cold sensitivity

Dental History: The patient reported no recent dental procedures and started experiencing discomfort 5 days prior to the endodontic examination

Significant Findings: Severe localized percussion sensitivity was associated with the mandibular left central incisor (tooth #24). Sharp transient sensitivity was also noted with tooth #24 with the adjacent teeth responding within normal limits. Periodontal findings as well as all other clinical tests and findings were within normal limits. Fiberoptic transillumination of the tooth demonstrated a break of the beam through the incisal edge with the labial half of the crown remaining dark.