Acute Occlusal Trauma - Courtesy ROOTS
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From: Terry Pannkuk
Sent: Thursday, April 01, 2010 6:54 AM
Subject: [roots] Puzzle 2
Hereís another patient I examined yesterday. Male, 58 years old.
I'íve been watching #18 for a while. #19 was extracted 4 months
ago due to a root fracture and an implant surgically placed by
his general dentist 4 weeks ago (NeOss). When he presented to
me one week ago he reported that there was no discomfort
after the implant placement until one week. He remembers some
pain when the implant was torqued to final placement but that
it was only momentary. His orthodontist called me and explained
that the pain developed when he fit the new Invisalign appliance
one week after implant placement. Apparently there was a
miscommunication between the orthodontist and general dentist
so that when his new appliance was delivered it didnítí fit properly.
I couldn'ít specifically find out if it was hitting the implant but
it didnít fit on the second molar properly either and had to be
severely adjusted. The next day after wearing the appliance
the patient started having severe pain. When I examined and tested
the area there was no sensitivity on the implant when lightly percussed.
It seemed solid and with no inflammation. Tooth #18 was moderately
percussion sensitive with moderate buccal palpation sensitivity with
sensitivity to perio probing although no sulcular defects.
The patient was dental phobic and has been noted to react in a
slightly exaggerated way to probing, dental injections,
etc. Last weekís CTís attached. Implant seems to be placed in
proper alignment. Osteotomy was slightly over
prepped apically. Widened PDL noted circumferentially on #18.
My differential diagnosis in order of suspicion was:
1. Acute Occlusal Trauma
2. Cracked tooth with associated periradicular periodontitis
3. Coincidental recurrent endodontic disease.
4 Nondental etiology.
After having him leave his Invisalign appliance out for over a week
he returned yesterday in even more reported pain.
Clinical tests and findings were the same as a week ago.
What do you think I did? or what do you think I should have done?
and what do you think this is? - Terry
What happens with the bite challenge?
I can't think of any info or changes to add to your differential.
What do you mean by "I've been watching #18 for awhile"---did you
have prior suspicions of recurrent endo disease? - KendelG
I mean this poor guy has been an ongoing science project dating
back to 2005 when I first saw him. Weíve been picking
and choosing our battles. #31 looked suspicious as did numerous
other teeth. #30became symptomatic, I stepped into
retreating it heroically and it failed due to a root fracture
likely propagating from the apical third coronally
(the worst kind to prognosticate). The upper arch is no different.
He iís now looking at a big comprehensive care
project and weíre trying to find out which teeth we can count onÖ..
obviously not many after the dust settles. Below you can see how
his lower posteriors presented in 2005. #30 was the lone
symptomatic one. #31 had the small distal root periapical
rarefaction that we decided to ride. I decided to take action
yesterday and after a week of not having his Invisalign appliance
in but still having the same level of localized pain I accessed
and placed CH in #31. Attached are the access photos and post
drill out (cast core-nonprecious!).
Iím not the quarterback and cannot speak for the play called to
place the NeOss Implant before the ortho was finished.
I was called in help with the pain Dx and perform emg tx.
There was a long discussion regarding the decision to enter #31.
Iím still not convinced the pain is a pure endo failure.
As in the previous puzzle case the timeline is perplexing:
No pain-ŗImplant-ŗNo Painŗ1 Week later invisalign appliance
placedŗmoderate to severe pain localized to #31.
What I find bizarre is the fact that the appliance was mostly
resting on the implant before it was adjusted. If anything you
would think the implant primary stability would have been
compromised. The first point of concern I had was the implant
but it seemed to be ruled out. Heís been going through the
Invisalign treatment for months with numerous sequential
appliances placed. If #31 was the sole problem one would think
it would have been acting up after the extraction of #30 and
tooth movement was instituted creating more trauma on #31.
Even more perplexing was the fact that removal of the cast core
on #31 yesterday revealed no root fracture or anything that
looked like a crack. You can see that #30 had the classic look
of a widened PDL associated with a cracked root. #31 does not
and failed to reveal one upon access.
These are the types of cases I get sent all week long.
I think the patient psychology is certainly a factor here.
He has an extremely low pain threshold and winces even
when I pretend that Iím giving him the injection. J If there
hadnít been some radiographic suspicion of failing endo on #31
I would have never accessed it yesterday. Unnecessarily
drilling through a deep nonprecious cast core isnít what
I like doing starting at 5:30pm. J