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Endo tips    Better Endo    Endo abstracts    Endo discussions

Acute Occlusal Trauma - Courtesy ROOTS

The opinions and photographs within this web page are not ours. Authors have been
credited for the individual posts where they are - www.rxroots.com
From: Terry Pannkuk
To: ROOTS
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

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