The winning entry for the Young Dentist Endodontic Award by Jamie Nelson
This article is an account of a patient I performed an endodontic treatment on in General practice, it gives an account of the examination findings, demonstrates the thought process behind the treatment planning for this case and a description of the treatment done as well as the results.
DOB: 12/05/1989 (24 yrs. old)
Medical History: Asthma (never been hospitalised for it)
Dental History: has been an irregular attender at a different practice
Social History: Smoker (10 a day) light drinker (socially 4-5 units a week).
CY attended the practice initially for a second opinion, as had been informed that the tooth was unable to be saved and would require extraction. The patient was also getting pain from her LRQ, the pain itself was characterised by the pain history below:
Site: LRQ – posterior region
Onset: Worse when eating but usually spontaneous
Character: Dull ache, sometimes feels like the tooth is throbbing
Radiation: Has on occasion radiated up to her ear
Exacerbating/relieving factors: Pain killers take the edge off the pain but don’t eliminate it
Severity: A constant 5/10 but can jump up to a 9/10 at times
HPC: The patient initially had pain from the tooth 1 month ago, but the pain then subsided for a bit, to return much worse 1 week prior to the initial examination.
Patient wishes and expectations: I always like to gauge what the patient wishes to gain from the experience and make a habit of sitting with them for 5 to 10 minutes trying to gain the information required to help with any difficult decisions. This Pt. was very concerned about losing the tooth, as had a minimally restored dentition – only two existing fillings on the LR6 and UL6. However came in with the mindset that she would most likely require XLA, therefore anything we could do would be a bonus
EO: – Right Submandibular Lymphadenopathy, with mild tenderness
- Soft tissues – Tenderness to buccal palpation LR6
- Hard Tissues – LR6 TTP and grade 1 mobile, Occlusal caries seen LL6, LL7 and LR6
- Perio – BPE – 222, 422 (9mm pocket mesial LR6), OH – poor, 50% plaque score
- Vitality (sensibility) – LR6 non-responsive to Endofrost (-50oC)
- Radiographs requested: RBW, LBW, PA LR6
Justification for Radiographs: Caries detection and periapical pathology analysis of LR6
Right and Left Bitewings
Figures 1 and 2
- SITE: Right and Left, Upper and Lower, distal of 7’s to mesial of 4’s
- JUSTIFICATION: Caries detection
- EXPOSURE: 0.25ms, 6mA, 60kV
- GRADE: 1
- Caries - Occlusal radiolucency's LR6, LL6 and LL7
- Path - Furcation obliteration LR6
- Perio – good bone levels, no sub-gingival calculus
Long Cone Periapical Radiograph (LCPA) LRQ
- SITE: LR6
- EXPOSURE: 0.2ms, 6mA, 60kV
- GRADE: 1
Caries: Occlusal radiolucency LR6
Path: Large PA area with furcation obliteration LR6
Perio: good bone levels, no sub- gingival calculus, PDL space widening around mesial portion of the tooth
To summarise the findings, the patient attended with a grade 1 mobile LR6, which was TTP, had a 9mm pocket mesially and was negative to sensibility testing. The LCPA radiograph of the LR6 showed a very large periapical radiolucency surrounding the root of the LR6, external root resorbtion around the mesial root, widening of the periodontal ligament (PDL) space mesially and furcation obliteration. With all of this in mind it leads us to a differential diagnosis of:
(As originally outlined by Simon et al 1)
- Purely endodontic lesion
- Perio-endo lesion: - Primary perio
- Primary endo
- True Perio-endo
- Radicular cyst
With all the symptoms taken into account I came to a provisional diagnosis of an acute flare up of chronic periapical periodontitis, in which sinus drainage had been established through the mesial pocket.
Due to size of periapical (PA) area, mobility, 9mm pocket, communication with oral cavity and mesial external root resorbtion, the prognosis for this tooth is relatively poor, especially as MTA was not available to me at the practice. All options were discussed with the patient and she wished for the RCT to be done here at the practice and completed by me, whom has a very keen interest in endodontitcs but no specialist training.
So a treatment plan was drawn up and the patient happy for treatment to begin
Acute Phase: extirpate the LR6, course of antibiotics: 500mg Amoxicillin TDS 5 days (due to systemic involvement of the lymph nodes)
Stabilization phase: Treat the periodontal issues, avoiding root scale debridement (RSD) on the LR6, incase of a perio-endo origin, in which cell damage caused by the RSD can limit the regeneration potential for the endodontic treatment (2), OHI, diet advice, fluoride application, Smoking cessation and a fluoride toothpaste prescription (5000ppm).
Restorative phase: Restore carious lesions in LL6 and LL7, Complete root treatment on LR6, due to degree of tooth tissue remaining if a conservative access can be cut, restore with GIC and composite.
Maintenance Phase: Review RCT and perio at three, six and 12 months
Recall phase: Caries risk - High, Perio Risk - High, Oral cancer risk – medium, three monthly CE
First visit: - LR6 extirpation
A minimally invasive access was cut into the LR6 – by preserving as much tooth tissue as possible it greatly improves the chances of a long term successful endodontic treatment. Ideally all four sides of the tooth need to remain intact, this allows for better isolation and a stronger external tooth structure. Four canals were located and cleaned to the EWL at an ISO size 20 hand file with copious amounts of two per cent sodium hypochlorite; then dressed with ledermix and restored with GIC. A good access is key to locating canals quickly and by spending slightly longer making it as neat as possible it can really help.
Photos of the access can be seen in figures 4 and 5:
Figure 4 Figure 5
Second visit: - The patient reported she was out of pain after the extirpation was completed, which meant we could proceed to stabilize all other active disease. A supra and sub gingival scale was completed on all teeth except LR6 (incase of perio-endo lesion (2)), smoking cessation given, amalgam restorations placed on LL6 and LL7 occlusally and fluoride applied to all teeth.
Third visit: RCT stage 1 LR6
The temporary restoration was removed and all four canals re-located using hand files, once relocated the access to each canal was improved using Gates Glidden burs, a size 2 to 1/3 estimated working length (EWL), size 4 to 3mm short of that and finally a size 6 counter sunk into each canal by no more than half the depth of the bur around 3mm, (by doing this it also makes creating Nayyar cores much easier as once the bulk of the GP has been removed the size 6 Gates Glidden bur can be counter sunk once again providing a space for the nayyar core to be placed.
Each canal was then prepared to 2/3’s EWL using protaper rotary instruments sizes S1, S2, F1 and F2 (3)
Handfiles were then placed into each canal measured to the EWL and a diagnostic radiograph was taken. When taking a diagnostic radiograph on multi-rooted teeth, I use a mesial swing on the tube head in order to ensure each file is in a separate canal. This can be seen in the diagnostic radiograph figure 6. Once the diagnostic radiograph has been taken the tooth is dressed with non-setting calcum hydroxide and again sealed with GIC.
Figure 6 - working length radiograph with size 15 hand files
The radiograph then confirmed the working lengths for each canal as:
- MB – 18mm (OA)
- ML – 18mm (OA)
- DB – 21mm
- DL – 21mm
(OA) indicates open apex
Fourth visit: RCT stage 2 LR6
The obturation stage for this tooth brings its own challenges as there is no guarantee that a seal can be achieved with an open apex present, which is why conventionally MTA is used to close the open area and allow for an effective seal and this is what I would have done had MTA been available. Instead, I adopted a technique that had never been formally taught to me and prepared the mesial canals 1mm past the radiographic apex in order to ensure effective cleaning at the open apex. Once all of the canals had been prepared to their EWL’s to size F2 protaper (3) with thorough irrigation of two per cent sodium hypochlorite (the Irrigant used is warmed to increase effectiveness (4) and after placement a handfile is used to ensure the irrigant reaches the apex) the total time the irrigant spends in the canals accumulatively was 10 + minutes, this combined with the time of the procedure is in excess of 40 minutes (5)
Figure 7 - apical removal of GP
Obturation – a single point obturation techniqure was used, using an eight per cent ISO 25 F2 Protaper point, using again a technique never taught to me. I placed the GP point beyond the apex until an apical twist back/tug back could be achieved (resistance to rotational or vertical displacement of the point once in place). Once that was achieved the point was marked at the coronal end, this leaves the point long, essentially overshooting beyond the apex, but giving an apical seal. This “overshoot” is then removed by once again measuring the GP and simply snipping off the excess from the apical end (figure 7). The shortened GP has essentially a custom thickness at the apex now and fits snuggly into the canal, hopefully, achieving an apical seal.
The canals were then lined with Tubliseal and the GP cemented into each canal. GIC was used to line the GP as this provides a dynamic bond with the tooth, reducing the risk of GP contamination (6). The restoration can be seen in figure 8.
Figure 8 - composite restoration
Once the restoration was complete, the post operative radiograph was taken (figure 9)
Figure 9 - post operative radiograph of the RCT on the LR6
The radiograph shows that the GP is to length, has a good taper, good density and doesn’t show any voids.
The patient attended her three, six and nine month review appointments and has demonstrated a huge improvement as summarised by the table below:
Also during the nine month review, the nine month post-op endodontic radiograph was taken (figure 10). The radiograph showed an almost complete resolution of the pathology and has demonstrated a successful endodontic treatment.
Figure 10 - nine month post-op RCT LR6
Taking into account all of the above, the table below shows a clinical breakdown of the LR6 comparing the pre and post treatment results, as well as both pre-operative and nine month post operative radiographs.
This case demonstrates that no matter how bleak the outlook there’s always a possibility for success. I myself treat difficult cases with an attitude summed up very nicely by Henry Ford “Obstacles are those frightful things you see when you take your eyes off your goal”