nice case!

[gpg]

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Hey people

thought I'd discuss this case with u all.Lady in early 50's reported with c/c of discoloration of lower centrals.Said Endo was attempted by some one else but could not get the canals.IOPA shows HUGE periapical associated with one of the centrals.The coronal half of the canal is calcified,while the apical half can barely be seen.

The other one has a TOTALLY calcified canal.When she presses her chin both the teeth sort of pain.She has made it clear that she will not undergo an endo surgery.

I have put her on antibiotics(Amoxycillin 250 mg tds) and anti-inflammatory(Rofecoxeib 25 mg tds) and called her on Monday.Will try to locate canals with file # 6 or 8.Then will place EDTA with the help of a lentulo-spiral and place ZoE.

Will call her after 2 days and try to do the BMP.Will be using brand new instruments for profile and hand instruments if needed.

A well done root canal should help in resolution of the lesion.

Any suggestions/comments?

will keep you all posted about the progress of the case.

gpg

 

[organic]

gpg, thanks for sharing the case.
Though you have described it very well, I might not get some of the details. Please correct me if I am wrong, if you could share pre- op X-ray or post op xray, that'd be even better. Here is what I think

--How long has the patient been symptomatic?
-- what was the reason patient had the first root canal attempt ?

-- you mentioned that lower centrals are both discolored but the lesion is only associated with one canal, have you thought that this periapical lesion might have caused pulp necrosis in the other central? what are the clinical findings?

-- if the patient feels sore on pressing the chin, the buccal cortical plate might have been perforated or closed to be perforated, which MIGHT imply that this lesion is not small and has been there for a while.

-- what was the # of your master file? I seem to remember that lentulo-spiral doesn't have mini-size for lower anteriors( maybe they do manufacture it now, but I haven't used it for a while) . I don't like this thing because it is one of the most seen broken instruments and it is very hard to retrieve or bypass.

-- Did you take another X-ray after you put ZoE in? Is your ZoE radio-opaque? Did you compact it to the end? Did your lentulo-Spiral go all the way to the working length?

-- why did you choose to place ZoE?
Eugenol has the effect of " calm the nerve" if you are close to an irritated pulp. But Eugenol is a necrotic agent, not especially biocompatible with tissues, ZoE is not alkaline enough to neutralize the inflammatory environment. I'd opt for pure powder calcium hydroxide mixed with water and compact it all the way to the end of canal. Maybe there are new reports about ZoE that I am not aware of, please educate me if you do see other journal articles about ZoE

-- how did you seal this canal at the end? what kind of material?


thanks again for sharing the case

 

[gpg]

Hi Organic

thanks for replying....am really looking forward to a nice discussion os this and such similar cases.

1)I will try to post the xrays.If not then u cud send me ur email and I will mail them to u.

2)patient is totally asymptomatic.She went to the earlier dentist to treat the discolouration.Also she realized by accident about the pain on pressing the chin.I am sure this lesion is not small.I have described it as HUGE.And I am quite sure there is not much of the buccal plate left.

3)The dentist has not been able to locate the orifices at all.I will first have to look them up.

4)Hence there is no question of master file,working length and apical seal.That comes later.First let me find the orifices.

5)I will be placing EDTA(chelating agent) in the pulp chamber.This will soften the dentin and enable me to locate the orifice and prepare the canal.I will be using the lentulo only to place the EDTA as far as possible.

6)The ZoE is a temporary restoration OVER the EDTA.Not within the canal.I agree that it is necrotic.And hence will not be placing it within the canal till I am assured of a good hermetic seal.

7)Try using the Lentulo on the reduction handpiece(eg Profile,Protaper)The highly reduced speed prevents breaking to a large extent.

8)We get a product called Vitapex(Calcium hydroxide+Iodoform) here in India.I will prepare the canal and place that and wait for a month or so.Then I will fill the canal.

9)The root of the other tooth is distally tilted in the apical third and there is almost 2 mm of bone between the apex and the lesion,although it is sure to get involved.It is possible that the tooth with the lesion developed an endo lesion,which went on to become a perio one.And now the other tooth has got an endo lesion from the perio lesion.

10)The patient is not ready for an Endo surgery but said if the tooth cannot be salvaged she will consider extraction and implant placement.

gpg

 

[drPheta]

I have a question. If all this work is being done to find the canal and pack it with Calcium Hydroxide, why is this patient against endo if it's likely to be a possible treatment? It seems like if you're going to be working int he canals anyway, and there's inflammation within why is Endo not wanted?

Maybe I'm not getting something. I am only a first year.

 

[gpg]

Hi Pheta

The patient is not against Endo Treatment, per se.She is not willing to undergo an Endo surgery!That involves reflecting a flap,curretting the lesion,chopping off the apex and sealing it with say Amalgam.she is not ready for that.

Thats why I said that I HAVE to do a very very good Root Canal so that the lesion will heal on its own.

Got it?Good question,though for a First year student!

 

[Meggs]

2)patient is totally asymptomatic.She went to the earlier dentist to treat the discolouration.Also she realized by accident about the pain on pressing the chin.I am sure this lesion is not small.I have described it as HUGE.And I am quite sure there is not much of the buccal plate left.

Did she suffer some kind of trauma in that area? If she did, make sure you test vitality in all other inferior incisors, or better yet, in all teeth that were involved in the trauma area. What you're describing could possible be a cyst and not merely a periapical lesion. 😕

8)We get a product called Vitapex(Calcium hydroxide+Iodoform) here in India.I will prepare the canal and place that and wait for a month or so.Then I will fill the canal.

Is that the one that comes in a yellow/white box. If it is, and if I remember right, the product indications state that it might be used to fill and endo alone or with gutapercha. So perhaps if you feel that it has sealed properly, you might opt for not removing it.

10)The patient is not ready for an Endo surgery but said if the tooth cannot be salvaged she will consider extraction and implant placement.

But and endo surgery will put her trough wayyy less than an implant. Just by the amount of bone loss that sounds like she has, she would have to at least get bone placed in that area. 😕

 

[organic]

Hi Gpg

thanks for your clarafication, I did misunderstand some of your descriptions.

Just a word of caution, EDTA does soften the dentin, but it soften all dentin, not just the calcifications. Cacification will still be the denser part. What happens sometimes after placing EDTA in the canal is that dentists have a higher tendency of perforation due to overall softened dentin ( for lower anteriors, especially buccal and lingual).

The patient's discoloration might have been caused by calcification of canals, if there is no decay on these teeth, or obvious reason for canal degeneration, I'd want to keep in mind some of the pathological diseases common at the lower anterior area, like Ameloblastoma etc and keep an eye on the radiolucency.

Vitapex is a good material, I prefer using it for Pedo patient because of its lower percentage of Ca(OH)2. For Adult patient, I prefer hard-core Ca (OH)2, but it is personal preference, I haven't heard which one is significantly better.

There are so many details we can talk about with this casce. Nice !