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tjdentist

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Hi,

I was doing the recall exam today and found out that there's a round, well-defined radiolucency at the apex of #25. nothing positive clinically, no caries or existing filling, not cold sensitive, percussion is negative. slight to moderate bone loss, but pocket depth is WNL. pt has no discomfort with this tooth before.

I was not sure to do or not do the RCT. I talked to my boss and hoping that she can help. She said there's pathology present. then you should do RCT. You don't have to figure out the etiology.

I don't recall if there's any anatomical presence of radiolucency there. Maybe I should do the RCT?

Thanks in advance!
 
Check history: Trauma? it's color and compare to adjacent teeth, electrical pulp test.
Make sure the teeth is not vital, there are many pathologies present as radiolucency. Key is to get correct diagnostics. If you aren't sure please refer patient or better let your boss treats!!!!!, because wrong diagnostics is very common and can be sued.
 
tjdentist said:
Hi,

I was doing the recall exam today and found out that there's a round, well-defined radiolucency at the apex of #25. nothing positive clinically, no caries or existing filling, not cold sensitive, percussion is negative. slight to moderate bone loss, but pocket depth is WNL. pt has no discomfort with this tooth before.

I was not sure to do or not do the RCT. I talked to my boss and hoping that she can help. She said there's pathology present. then you should do RCT. You don't have to figure out the etiology.

I don't recall if there's any anatomical presence of radiolucency there. Maybe I should do the RCT?

Thanks in advance!
Click to expand...
I'm assuming the tooth is vital? If so I wouldn't do root canal therapy, it's like shooting in the dark and hoping you hit something. That radiolucency can be a host of things. Obviously we can't see the radiograph, but I wouldn't jump to do an RCT.

What's the size of the radiolucency, shape, completely radiolucent?
Were any teeth extracted around the area of the #25?
Is the Lamina Dura intact? If it is you're probably dealing with something that's not related to the tooth.
 
African American female?
tjdentist said:
Hi,

I was doing the recall exam today and found out that there's a round, well-defined radiolucency at the apex of #25. nothing positive clinically, no caries or existing filling, not cold sensitive, percussion is negative. slight to moderate bone loss, but pocket depth is WNL. pt has no discomfort with this tooth before.

I was not sure to do or not do the RCT. I talked to my boss and hoping that she can help. She said there's pathology present. then you should do RCT. You don't have to figure out the etiology.

I don't recall if there's any anatomical presence of radiolucency there. Maybe I should do the RCT?

Thanks in advance!
Click to expand...
 
She's Hispanic Female, around 40yr.

The tooth color looks very close to the neighboring teeth. No recall of any trauma. and she's shocked when I pointed to her the radiolucency. the shadow is small, well-defined, round or pear-shaped, little off-centered to the apex of #25 but looks like has a very close relation with #25. The shadow doesn't seem to be dark, dark, pitch-black. it looks like a periapical infection from the density. The neighboring teeth are present and all looks healthy from perio and restorative aspect.

I absolutely agree with all of you. Before I start any RCT, I will make sure the x-ray, clinical exam, and symptoms all correlate. However, for the past month, I have had the chance to talk to a couple of very experienced dentists, who have practiced for more than 20 years. They are telling me that if the pathology is present, then go ahead and do the RCT. One of the dentist told me that no cold test or EPT is necessary because that shock and hurts patients. here's the example: I was checking the recall pt and saw a radiolucency at the apex of #29, but simple ignored it. I had the concept that it's probably mental foramen. the X-ray was spotted by this senior dentist coincidently. He looked at the PAN and told me that it's an infection at the #29. So, I did the cold test and pt doesn't have response. i reported to him the result of cold test. To my surprise, he was asking me why I should do the cold test. Of course, I told him it's one of the most reliable way to tell the vitality of tooth. He said "I don't do cold test. Just by looking at X-ray, I have decided that the tooth need RCT."

I guess because of the influences of the talk with the senior dentist, when I was seeing this #25 pt, I just didn't do the cold test because I was almost certain that there are some infection going on.😕
 
just study PCD. it's quite suspicious! I will do the vitality test to differentiate when she comes in.
 
Test the vitality of the tooth. If it responds normally you have no rationale for performing rct.
 
Remember not all dentists are the same. Do you know some body in your class that you don't want to touch your teeth? Be careful when listen to the "experienced dentists"
You can consult with your pathologist or better your former faculty at your school, read text book...
I worked in some general dentist offices before and there are no EPT machine to test vitality of the teeth. That why they said no need....
Next step may be access without anesthesia ..... If pt has pain it is vital.. stop RCT....I haven't ever done this but it is in the text book "Pathways to the pulp 9th edition"
 
tjdentist said:
She's Hispanic Female, around 40yr.

The tooth color looks very close to the neighboring teeth. No recall of any trauma. and she's shocked when I pointed to her the radiolucency. the shadow is small, well-defined, round or pear-shaped, little off-centered to the apex of #25 but looks like has a very close relation with #25. The shadow doesn't seem to be dark, dark, pitch-black. it looks like a periapical infection from the density. The neighboring teeth are present and all looks healthy from perio and restorative aspect.

I absolutely agree with all of you. Before I start any RCT, I will make sure the x-ray, clinical exam, and symptoms all correlate. However, for the past month, I have had the chance to talk to a couple of very experienced dentists, who have practiced for more than 20 years. They are telling me that if the pathology is present, then go ahead and do the RCT. One of the dentist told me that no cold test or EPT is necessary because that shock and hurts patients. here's the example: I was checking the recall pt and saw a radiolucency at the apex of #29, but simple ignored it. I had the concept that it's probably mental foramen. the X-ray was spotted by this senior dentist coincidently. He looked at the PAN and told me that it's an infection at the #29. So, I did the cold test and pt doesn't have response. i reported to him the result of cold test. To my surprise, he was asking me why I should do the cold test. Of course, I told him it's one of the most reliable way to tell the vitality of tooth. He said "I don't do cold test. Just by looking at X-ray, I have decided that the tooth need RCT."

I guess because of the influences of the talk with the senior dentist, when I was seeing this #25 pt, I just didn't do the cold test because I was almost certain that there are some infection going on.😕
Click to expand...
What if it turns out to be something like a browns tumor or a fibroosseous lesion?

It appears your senior dentists might be leading you down a wrong path; I dont mean to sound rude.

Of course if I see a discolored , semi mobile tooth with a periapical radiolucency and a broken lamina dura i'm 99.9% sure the tooth requires RCT but I would never 'not' do a cold test.

You where probably right to assume it's the mental nerve, (My notation is different, but I'm assuming #29 is a first or second mandibular premolar?), and sometimes it's better to delay treatment until you're pretty sure about what you're doing.

There was a case I saw recently where a private dentist filled every tooth in one arch for a patient, even did a few root canals for posterity, because the patient was constantly complaining of pain. Turned out to be Trigeminal Nueralgia.Had he/she done a proper history, and followed correct diagnostics this patient would of saved tons of money.

While I was a student a Root filled central came in 3 months after the initial obturation complaining of tenderness. The senior dentist with over 30 years experience was positive it was a traumatic occlusion. I disagreed believing we needed to retreat the tooth.
Long story short, and 2 endo consults later we retreated the tooth and the patient has been asymtomatic for over a year now.

Just because someone is senior to you doesn't mean you need to rush into their treatment; being an associate complicates things but I'll never do a procedure that I dont think is in the best interest of my patient even if my boss tells me to do it.
 
Streetwolf said:
First thought that popped into my mind after reading only the first post and I'm not even out of school yet 😛
Click to expand...

In his/her defense, we did just take part 2 of the boards 🙂

Hup
 
tjdentist said:
Hi,

I was doing the recall exam today and found out that there's a round, well-defined radiolucency at the apex of #25. nothing positive clinically, no caries or existing filling, not cold sensitive, percussion is negative. slight to moderate bone loss, but pocket depth is WNL. pt has no discomfort with this tooth before.

I was not sure to do or not do the RCT. I talked to my boss and hoping that she can help. She said there's pathology present. then you should do RCT. You don't have to figure out the etiology.

I don't recall if there's any anatomical presence of radiolucency there. Maybe I should do the RCT?

Thanks in advance!
Click to expand...

ummmm, neither you nor your boss thought to perform pulpal vitality tests?🙄

any symptoms, palpation/percussion sensitivity? as this was a recall examination did you compare your radiographic findings with prior radiographs?
 
cresophene said:
I'm still trying to figure out what #25 means. For me it means Maxillary left second premolar :laugh::laugh::laugh::laugh:
Click to expand...

Was this a joke?


OP, if a tooth is asymptomatic and there's no definitive diagnosis, why would you do a RCT? That's just a shot in the dark as to the solution to your problem.

Always cold test. Cold testing is not always a sure bet. + response means pulpitis, but a - response doesn't always mean nectrotic. There could be factors affecting the patient's response to the cold (thickness of tooth structure for one). Any dentist who automatically does a RCT every time they see a PARL is just lazy or trying to make money. If a lawsuit comes your way and you didn't have cold testing down on your records, that's one strike against you. Use your own best judgment.

Take another PA at a different angle to see if the RL moves to rule out mental foramen. Do the array of testing to determine vitality. If you can't tell, you can observe the tooth. If the patients history suggests cancer, you can get a consult with path.
 
excellent points!

I did find out that there are similar PA radiolucency at exactly the same tooth in the film taken in 2006. My boss will see her in a couple of days and I will find out more!
 
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