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Aching right posterior area - Courtesy ROOTS

The opinions and photographs within this web page are not ours. Authors have been
credited for the individual posts where they are -
From: Terry Pannkuk
Sent: Friday, October 15, 2010 3:22 AM
Subject: [roots] Today's Puzzle Case

Hereís a patient who is a PhD Chinese Literature professor at UCSB. 
(heís Chinese).  Presented with aching in the right posterior area 
and was referred to have #30 treated which was said to be abscessed  
Interestingly the cold thermal test was positive as was the EPT.  
Perio findings were normal.  No swelling, no palpation
sensitivity, no percussion sensitivity.

What do you do?  CBCT? - Terry

I definitely took a CBCT on this one.  Wild case, no buccal bone.  
Here's my note to the referring dentist. I'm going to get a second 
opinion from an oral surgeon who is an MD, DDS.  Definite COD on 
this one!

Hereís the email to the referral, explaining my thoughts.  Very odd 
pattern of bone loss I thought a referral to an oral surgeon was 
in order for a second opinion.   Any ideas?

Hi xxxxt,

Dr. xxxxxs presentation was very interesting. He responded normally 
to cold thermal stimulation on #30, 29 and other anterior teeth.  
I took an EPT believing it was a false positive but he responded 
to the EPT as well. I then took a CBCT scan and found he has gross 
dehiscenceís on all teeth in this quadrant with very little
buccal bone coverage.  The bicuspids show periapical bone loss as 
well but there is little chance it is due to endodontic disease.  
His periodontal findings are unremarkable with no real pockets to 
speak of. He also reported no history of orthodontics to account 
for the teeth being pushed out of the bone. I suggested that a 
second opinion with an oral surgeon would be a good idea to see if 
there is any chance of a metabolic/systemic cause for the odd bone 
presentation.  Do you want me to contact xxxxxxx and see what he thinks?
His symptoms are probably related to the stress and possible fracture 
of the hemisected root functioning as a distal abutment for the bridge.  
The gingival tissue looked a bit inflamed and irritated in that area.
I donít think itís related to #30, there was no swelling, no percussion 
sensitivity, no palpation sensitivity, no biting sensitivity, and no
pain on chewing.   Note these interesting 3-D CBCT renderings; there is 
essentially no buccal plate covering all these roots! - Terry

Protaper flaring
6 yr old Empress
Cvek pulpotomy
Middle mesial
Endo misdiagnosis
MTA retrofill
Resin core
BW importance
Bicuspid tooth

Necrotic #8 treatment
Finding MB2 / MB3
Deep in a canal
Broken file retrieval
Molar cases
Pushed over apex
MB2 and palatal canal
Long lower third
Veneer cases
CT Implant surgury

Weird Anatomy
Apical trifurcation
Canal and Ultrasonics
Cotton stuffed chamber
Pulp floor sandblasting
Silver point removal
Difficult acute curve
Marked swelling
5 canaled premolar

Sealer overextension
Complex anatomy
Secondary caries
Zygomatic arch
Confluent mesials
LL 1st molar (#19)
Shaping vs Cleaning
First bicuspid
In Vivo mesial view
Inaccesible canals

Premolar 45
Ortho and implant
Lateral incisor
Churning irrigant
Cold lateral
Tipped to lingual
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Middle distal canal
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Weird anatomy
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Upper molar resorption
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Finding MB2

Gingival inflammation
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AG BU ortho band
TF Files
using TF files
Broken bur
Warm technique
Restorative prognosis
Tooth # 20 and #30

Apical third
3 canal premolar
Severe curvature
Interesting anatomy
Chamber floor
Zirconia crown
Dycal matrix
Cracked tooth
Tooth structure loss
Multiplanar curves