CBCT Exam for patient slated for heart surgery - Courtesy ROOTS
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From: Terry Pannkuk
Sent: Thursday, November 26, 2009 2:28 AM
Subject: [roots] CBCT Exam for patient slated for heart surgery
This patient was scheduled for open heart surgery (heart valve replacement)
next week and his dentist and physician wanted clearance that this tooth
did not have recurrent endo disease/infection. The patient presented with
no observable symptoms and the PA was inconclusive. The previous endo was
obviously done poorly and one off-angle radiograph suggested a separated
instrument at the tip of the DB. I explained to the patient that I might
be able to get more information from a CBCT that would help determine whether
the tooth should be treated before his surgery. The value of the CBCT in
this case was obvious and the patient elected to have me scan him.
The previous endo treatment looks incompletely cleaned, shaped,
and filled short. There are two very small PARL's noted at the periapex
of the DB and MB roots on the CT slicing. An MB2 was missed and the DB
may have a very small file separated, at the apical curve (or at least it
looks suspicious on the 3-D constructed image). He also seems to have some
mucocele's/sinus pathosis associated with the pneumatized sinus about the
palatal root (lobulated cloudy radiopacity).
When I mentioned that I thought there might be some sinus path the patient
revealed that he had chronic unilateral sinus symptoms (right side).
I didn't know if the findings would change the plan for the heart surgery
and provided the physician with the findings. The physician was very
pleased to get the info and cancelled the surgery for next week, wanting
to take no chances. The new plan is to retreat the tooth in two steps,
allow time for endodontic disease resolution and have the patient
follow-up with an ENT specialist to assess the sinus status. Once all
these disease entities are eliminate he will have the surgery rescheduled.
The relative value of the CBCT was clearly obvious in this case. If this
had been a different patient presenting with routine health and did not
require surgical clearance, the conversation would have been different.
Without symptoms, without a need to replace the crown, and without PA
radiographic signs of an obvious lesion, I would have presented the
need for a CBCT as being much less but optional if the patient wanted
to see if there was subtle chronic disease associated with the tooth.
I doubt the patient would have elected to pay for a scan and I certainly
wouldn't have tried to sell it - Terry