From: Terry Pannkuk
To: ROOTS
Sent: Tuesday, September 22, 2009 7:19 AM
Subject: [roots] Another odd consult today

Patient: 66 year old female.
Medical History: unremarkable
Chief Complaint: can't bite on the bicuspid tooth.
Dental History:  I treated an upper bicuspid a few years ago and examined a lower bicuspid
on the opposite side
which was vertically split and needed to be extracted.

Perio: gingiva inflamed, average hygiene, no pockets.

Mobility: Class 2 (adjacent teeth normal)

Percussion: severe (adjacent teeth slight)

What's the plan? What should be considered?  What is odd about this case? - Terry



Hi Terry:
poor C/R ratio? loose misplaced post? ill fitting crown margins?
poor malocclusion needing ortho that patient refused because she liked her 6 front teeth?
just the usual suspects.
Now if the 2nd premolar needs endo, I make sure no one put a tiara on it..))

my plan?
I remove the crown and check for fractures....if no cracks, Post/buildup and ortho until the
occlusion is addressed - ahmad

This is one answer if you don't want to try and move that tilted bicuspid a mile through bone. :)

Other alternatives would be to leave the tilted bicuspid alone and just place one implant. If she wants
to wait indefinitely until she gets tired of the food impaction/difficult cleaning....not a bad idea for
this economy. :):):)

What I didn't say was that the first molar tested negative to cold and the EPT; it's going to be watched,
probably previously pulp capped with a dead or minimally alive pulp.  If stripping back the over contoured
mesial contact of the crown ends up ruining the crown there is a good chance it will need endo.

Ortho up righting and one implant is a nice idea but she isn't interested in ortho. I'd also worry about
EICR trying to aggressively move that one in.  She needs to be worked up by her general dentist, possibly
have an ortho consult before I touch her or proceed.  I don't place implants in maloccluded areas until
the restorative dentist and orthodontist work out a final comprehensive plan.  This may not be a case for
me in my role as an endodontist depending upon the desire to do forensics on the first bicuspid - Terry



Is that a retained deciduous canine? - Craig

No, just extra bone; I don't really see to many cases like this with extra space and no history of teeth.
I really don't know what it is and I'm curious if anyone else has an idea. Usually alveolar bone and teeth
go together. Doesn't seem to be an expanding lesion. The malocclusion has existed her entire life.
If it was due to recent bone expansion I would investigate for something like Paget's Disease.  She has no
other symptoms and the malocclusion is of long-standing origin, so it isn't - Terry