From: Terry Pannkuk
To: ROOTS
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