Advice on this endo patient?

[TSDentSurg]

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Hey guys!

Well, I'm currently on my endodontics rotation. Here's the relevant info on the patient I've been assigned to:

The patient has no general medical conditions, 30 years old, and has moderate periodontitis (average pocket depth 5-6 mm). He presented with a complaint of pain, cold sensitivity and mobility of #32, and a white painful "pimple" on the facial surface of the gingiva.

Upon visual examination, the coronal surface is demineralized, and there is a periodontal abscess. Pocket depth is 8 mm on facial and lingual, 5 mm on mesial and distal.

PA radiography shows extensive caries extending into the root canal, and a periradical abscess.

I then decided to do an IAN block (my patient is very pain sensitive), drain the abscess, and then perform an RCT with 1% sodium hypochlorite. I then filled the canal with GP, took impressions, and fitted a temporary crown. I then splinted the crown to #33 and #31, and referred him to periodontics.

He comes back in a week for the permanent crown to be fitted.

My questions are:

1. If the periradical abscess returns, would you recommend an apicoectomy and LANAP, or extraction, GTR, and implant, since there's a good amount of bone loss?

2. Do you think this was a perio-endo abscess, or an endo-perio one?

Thanks!

 

[oralcare123]

It would have been helpful if you mentioned that you are in Europe and using international numbering system.
Anyway. In my opinion tooth should have been extructed.

 

[DrJeff]

If your endo fails, via the return of the peri-radicular lesion, then its a no brainer to extract, graft and place the implant using evidence based dentistry as your guide.

In reality, if I was betting I'd say you've got an perio-endo lesion. This would also make me a bit more hesitant to have immediately cut the crown post endo treatment instead of waiting 6 or so months for some radiographic evidence of peri-radicular healing and at worst, stabilization of probing depths. Sounds like the patient was esthetically OK with the demineralized appearance of the tooth, and unless your endo access prep was oversized a composite build up of your access point, to which you could incorporate splinting to the adjacent teeth would more than likely suffice until you can be sure that the lesion is indeed healing. Especially considering that this is an anterior tooth and not a molar. Much better then if the lesion doesn't heal to have to just extract a tooth that the patient paid for the endo on rather than both the endo and the crown on. Sometimes a bit of patience, when clinically appropriate, is the best thing that we can do for our patients.

Personally, I'd of just explained to the patient the likely cause of this endo lesion, that the tooth needs an endo, and in a few months, once we can verify that this multiply caused lesion is healing that then we'll need to place a crown on the tooth. I'd also tell them that if we see in a few months that the lesion isn't healing, (and let them know that that is a possibility) that the tooth would need to be extracted and replaced (I'd probably just briefly mention at that point that multiple replacement options exist if the tooth does indeed need to be extracted, and that we'd discuss all of those options *IF* that scenario arises - keeping it both simple and informative tends to work very well with most patients, and often if you overwhelm them with talk of endo-perio lesions and possible failures and detailed replacement options all at once, you end up with both a skeptical and a confused patient, which isn't a good thing!

 

[TSDentSurg]

I did explain to him that if the endo fails, I'd have to extract the tooth, and send him to periodontics to have a bone allograft and implant. He seemed okay with that, as he told me he did not want to have to deal with maintaining a bridge. I agreed with him that bridges are "nasty", and they can make his periodontitis worse.

I also asked the periodontics service to evaluate him for LANAP once his abscess has resolved.

 

[tooth knockn]

Hey guys!

Well, I'm currently on my endodontics rotation. Here's the relevant info on the patient I've been assigned to:

The patient has no general medical conditions, 30 years old, and has moderate periodontitis (average pocket depth 5-6 mm). He presented with a complaint of pain, cold sensitivity and mobility of #32, and a white painful "pimple" on the facial surface of the gingiva.

Upon visual examination, the coronal surface is demineralized, and there is a periodontal abscess. Pocket depth is 8 mm on facial and lingual, 5 mm on mesial and distal.

PA radiography shows extensive caries extending into the root canal, and a periradical abscess.

I then decided to do an IAN block (my patient is very pain sensitive), drain the abscess, and then perform an RCT with 1% sodium hypochlorite. I then filled the canal with GP, took impressions, and fitted a temporary crown. I then splinted the crown to #33 and #31, and referred him to periodontics.

He comes back in a week for the permanent crown to be fitted.

My questions are:

1. If the periradical abscess returns, would you recommend an apicoectomy and LANAP, or extraction, GTR, and implant, since there's a good amount of bone loss?

2. Do you think this was a perio-endo abscess, or an endo-perio one?

Thanks!

1- if the pt wants to save the tooth and is willing to do all that is required to save the the tooth and possibly other teeth in his mouth, you should teach him how to correctly maintain a healthy mouth. Ok, so there fore the pt should get a new abscess, do a retreat. Wait a month if abscess reappears same place do the apico. Apico should definitely do the job of the recurring abscess.

But what ever happens, if he has perio problems then implants won't be the best plan for him, unless he gets new habits of maintaining a healthy mouth.

I think perio-endo, because the loss if bone around the tooth and the deep carie can cause the sensitivity.

For all you know, possible fracture!!

If it was my patient and he had opposing teeth and the 32 was all messed up, bone loss and coronal weakness, implant maybe, if he agrees to bone graft and keeping flossing and brushing 2-3 times a day.

The is patents call.


My opinion with my 10 years of dental assuring experience.

 

[TSDentSurg]

I called the patient, and he's doing quite well. The RCT seems to have worked.

Should he get LANAP to restore his attachment? I really don't want him running around with these deep pockets.

 

[tooth knockn]

I called the patient, and he's doing quite well. The RCT seems to have worked.

Should he get LANAP to restore his attachment? I really don't want him running around with these deep pockets.

Research if lanap is worth it.