If you are interested in an endodontic refresher lecture, come and join me next Thursday at the Pacific Dental Conference (PDC 2019). Two and a half hours lecture filled with pictures and videos demonstrating the initial endodontic treatment.
Patient presents with apparent sinus tract in quadrant 4. According to the patient, the sinus tract had been identified by a hygienist during a hygiene appointment. Subsequently, the endodontic treatment had been initiated in order to resolve the infection. Here is a clinical photo of the sinus tract-like tissue.
The above image shows what appears to be a non-draining sinus tract. If this is indeed the case, it means that there should be a necrotic tooth with a lesion in close proximity to the drainage site and one should be able to express exudate from the site by poking it with a sharp explorer tip. Upon palpation, the tissue felt like a fibrous nodule that can be easily displaced under the non-keratinized tissue and it could not be drained with an explorer. Evaluation of available radiographs confirms lack of apical lesion in this area. Furthermore, the radiographs show significant pulp recession and heavy coronal calcification in all teeth. This could have resulted in false negative pulp vitality test results.
In the absence of periapical radiolucency and pain symptoms, one should not feel pressured to rush into treatment. The diagnosis for the above tooth might have been healthy pulp with normal apical tissues which would have required no treatment. Instead, the overall treatment has resulted in some structural compromise.
Dens evaginatus (a.k.a. Leong’s premolar) is an odontogenic developmental anomaly. This anomaly, an enamel-covered tubercle with an extension of pulp horn in most cases, occurs primarily in premolars. Loss of this tuberculated cusp during natural root maturation and development will result in early pulp exposure, pulpal necrosis, periapical disease, and arrested root development. Early diagnosis and management of dens evaginatus is therefore the key factor in preventing premature loss of tooth vitality.
Heavy bite, specially with less than ideal occlusion or cusp-fossa relationship, can result in cracks and fractures in teeth. Here is an example of a case with heavy occlusal pressure concentrated on the lingual inclinations of the buccal and lingual cusps of tooth #2-4. Two mesial enamel cracks are evident in this case.
Lets imagine the following scenario if we do nothing for this asymptomatic tooth:
With time, the cracks propagate and involve the pulp chamber. Based on the position of the existing restoration, a tooth split may result no matter how innocent (don’t blame the amalgam fillings). Clinical symptoms (pulpitis) appear. Root canal is done and the initial sensitivity symptoms do resolve. A crown is then fabricated for a possibly deeply cracked tooth. The biting tenderness however persists post-endodontic treatment. If the patient is lucky not to go through further unnecessary treatments (i.e. retreatment, apical surgery, etc.), the tooth will eventually be replaced with an implant. And, this is one of the reasons why root canals get their poor reputation. “Root canals don’t work”, “every root canaled tooth fractures”, or the most insulting to my profession that I have ever heard: “root canaled tooth is an eventual space maintainer for an implant.”
So, lets contemplate the above scenario and think about prevention and saving teeth instead.
Excessive root dentin removal during endodontic treatment and use of posts are the predominant risk factors for root fractures. Common clinical findings associate with root fractured teeth have been discussed in a previous post (It is ‘Game Over’!)
Vertical root fractures are usually detected through careful probing around a tooth but sometimes all you need is air-water syringe.
Imagine the following scenario:
A busy day in practice! A patient comes in with tooth #2-6 (upper left first maxillary molar) being extremely sensitive to cold (a.k.a. a “hot tooth”). You notice a very old, large amalgam filling on the tooth which had been done over 2o years ago. No recent restorative changes in the area is reported by the patient. Breathing in air, blowing air on this tooth with an air-water syringe or applying ice to the tooth sends the patient through the roof. All other teeth in this quadrant are responding normally to cold test. Quickly and confidently, a pulpal diagnosis is reached (irreversible pulpitis), endodontic treatment is recommended, and the need for a full coverage crown is also emphasized after root canal treatment. Simple, right?
Well, not so fast!
You may miss a more serious issue with this innocent-looking tooth in need of JUST a root canal and a crown, you may lose the opportunity to properly inform your patient of possible outcomes of your treatment and you may end up performing unnecessary treatments for a tooth with no hope.
Just imagine the final conversation with the patient after a quick exploratory/pulpectomy procedure:
Me – “Ms. Black, unfortunately your tooth cannot be saved as I had suspected and warned you before we started the root canal procedure today.”
Ms. Black – “I am amazed Dr. E! [with a smile] You knew exactly what was wrong with my tooth. You called it.”
Vertical root fractures (VRF):
Etiologies: wedging posts, excessive root-dentin removal (using large tapered files, orifice shapers, gates glidden drills, etc.), obturation forces.
If vertical root fracture is detected in single-rooted tooth, it’s game over. In multi-rooted teeth, other options (such as, root amputation or hemisection) can be considered before extraction.
A patient presented with pain in the lower anterior area. A fairly good-looking and recent root canal (approx. over 2 months old) had been performed on tooth #4.2. Patient’s pain however had been progressively getting worse since the completion of treatment. The pain was not occlusion-related and analgesics had not been helping either. Upon diagnostic testing, all other lower incisors responded normally to cold testing despite showing some evidence of periapical changes. None of these teeth were previously restored either, except for a class V restoration on tooth #3.2.
The pattern of PA lesion associated with tooth #4.2 (mixed radiopaque-radiolucent lesion), lack of previous restorations and bone pattern changes around vital teeth made me suspicious of periapical cemental dysplasia (PCD). To confirm my suspicion and to manage patient’s pain (possibly not related to PDC), apical surgery was performed for tooth #4.2. The biopsy confirmed the final diagnosis of benign fibro-osseous lesion consistent with PCD.
Six-month recall radiograph confirms the complete healing of the surgical site and the patient has remained asymptomatic. I cannot explain the biological process involved in patient’s appearance, persistence and resolution of pain but here are some facts about PCD:
Therefore, vitality testing is the key to diagnosis and radiographic follow-up and frequent observations are the most appropriate treatments for cases like this.