root canal failure

[ajsa]

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Hi,

I had a root canal retreatment at the end of last year on tooth #3. About 2-3 weeks after that, a bump (fistula) developed on the gum above the treated tooth (there was no bump pre-op). The endodontist suspects the MB root is cracked and suggests root amputation. He said there is chance it is not cracked and only apicoectomy will be needed. There is deep pocket on the gum in question, so i was told by my periodontist it is crack. Here is the x-ray image:
http://img132.imageshack.us/img132/8374/xrayb.jpg


My questions:
1. Did I really need the root canal retreatment? The endodontist intially told me he did not think retreatment was necessary, but after talking to my general dentist he got convinced there was some infection. And he insisted he saw infection during the procedure.
2. Did the RC retreatment make the root crack? The roots' diameters have become much wider than pre-op. Was the RC retreatment too aggressive?
3. I am not happy with the outcome of the RC retreatment. I wonder if it makes sense to pursue peer review at local dental society?

My periodontist suggest I should go straight for extraction/implant. Even if i choose root amputation, he told me socket graft should be used in the resulting socket to preserve the bone in the likely event the tooth needs implant in the future. Since bone graft in not covered by my dental insurance anyway, i think i'd better to choose implant than root amputation.

Any inputs will be highly appreciated. Have been very confused and anxious in the last a coupon months..

Thanks!

 

[1992Corolla]

In before the close!

 

[DocJL]

without higher quality radiographs, and the treating endodontists written notes on findings prior to recommending and initiating retreatment, I can only give an opinion of limited scope.

I will say that the initial endodontic therapy appears to be fairly well done, although not textbook perfect. Fills appear to be dense, tapered, and to length, but perhaps not as flared and completely instrumented as ideal, and maybe 1mm short on the palatal root, and I do not believe that the MB2 was located and instrumented. While I see no obvious periapical pathology present on the preoperative film (although films are not of the best quality as seen on my computer, and are of limited diagnostic value), I would not be surprised if it was failing secondary to a noninstrumented MB2, a very common reason for failure on max 1st molars. It does appear there might be a lesion lateral to the MB root on initial film, but is too cloudy to be sure.

Why were you initially referred to the endodontist? how long ago had the first endo been done? was it symptomatic? a complete history would be helpful.

As far as the retreatment goes, I will say that it does appear to be the most aggressive canal preparation I have ever seen on a molar, with exception being the palatal canal, which was instrumented and filled to length, but doesn't appear to be sized any larger than initial treatment, which I find odd based on the appearance of the buccal canals. By that I mean I have literally never seen so much removal of internal root structure on an endodontically treated tooth, even a retreatment. Those canals appear to be sized to an 80, 90 or even larger MAF. I have only seen such large fills on teeth where endo was initiated secondary to trauma, on young teeth with large canal spaces. This was obviously not the case on your tooth, based on the preoperative film alone. With that said, strangely enough, the film tracking the sinus tract with a GP point doesn't appear to show as aggressive a preparation? did the endodontist go back in the tooth a 2nd time and retreat the buccal canals at this point? could you tell me the dates taken on all 4 films?

At this point I would say cut your losses and go with the implant. It appears highly likely that the tooth is vertically fractured. A root amp is a compromise at best, and I believe as a treatment modality has fallen out of favor with the advent of, and high success rate of implants.

 

[ajsa]

Thank you so much Dr. JL!

The RCT was done about 9 or 10 years ago.. My general dentist referred me to the endodontist after my regular checkup, as there was some minor sensation when i brushed my teeth in that area. yes they think there was an untreated RC.

yes, i decided to go for the implant as you advised.. I just feel very very unfortunate for my experience, as i did not have issue before the retreatement..

Do you think if i can make a case on peer review?

Thanks!

 

[tinman831]

without higher quality radiographs, and the treating endodontists written notes on findings prior to recommending and initiating retreatment, I can only give an opinion of limited scope.

I will say that the initial endodontic therapy appears to be fairly well done, although not textbook perfect. Fills appear to be dense, tapered, and to length, but perhaps not as flared and completely instrumented as ideal, and maybe 1mm short on the palatal root, and I do not believe that the MB2 was located and instrumented. While I see no obvious periapical pathology present on the preoperative film (although films are not of the best quality as seen on my computer, and are of limited diagnostic value), I would not be surprised if it was failing secondary to a noninstrumented MB2, a very common reason for failure on max 1st molars. It does appear there might be a lesion lateral to the MB root on initial film, but is too cloudy to be sure.

Why were you initially referred to the endodontist? how long ago had the first endo been done? was it symptomatic? a complete history would be helpful.

As far as the retreatment goes, I will say that it does appear to be the most aggressive canal preparation I have ever seen on a molar, with exception being the palatal canal, which was instrumented and filled to length, but doesn't appear to be sized any larger than initial treatment, which I find odd based on the appearance of the buccal canals. By that I mean I have literally never seen so much removal of internal root structure on an endodontically treated tooth, even a retreatment. Those canals appear to be sized to an 80, 90 or even larger MAF. I have only seen such large fills on teeth where endo was initiated secondary to trauma, on young teeth with large canal spaces. This was obviously not the case on your tooth, based on the preoperative film alone. With that said, strangely enough, the film tracking the sinus tract with a GP point doesn't appear to show as aggressive a preparation? did the endodontist go back in the tooth a 2nd time and retreat the buccal canals at this point? could you tell me the dates taken on all 4 films?

At this point I would say cut your losses and go with the implant. It appears highly likely that the tooth is vertically fractured. A root amp is a compromise at best, and I believe as a treatment modality has fallen out of favor with the advent of, and high success rate of implants.

Just curious to know if you're an endodontist? Even so, it's against the code of ethics to criticize another dentists work unless there's gross negligence involved,
because then this happens...

Do you think if i can make a case on peer review?

Would you be willing to sit in front of a advisory committee providing testimony for the patient? If and when the patient loses the case, would you be willing to risk the possibility for a slander lawsuit from the other dentist? If this patient walked into your office for a second opinion, you state facts, never opinions about the work.

As far as this thread is concerned, an exam has not been performed and we do not have all the facts. This is why soliciting medical advice on SDN is not permitted. In the best interests of our members, it would be better advised that you consult with your own dentist, or another dentist on any questions you may have. Closing thread.