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Deep distal perio pocket
From: Terry Pannkuk
Sent: Wednesday, March 14, 2012 8:50 AM
Subject: [roots] 2 1/2 hour consultation
I donít think itís a good idea to offer a CBCT exam as a free service. This is the report
I stayed late this evening to finish as it was a full mouth reconstruction case. Iíll probably
just do the endo on #3 and thatís it The patientís appointment was 2 Ĺ hours, the report was
extra time this evening after work looking at the two stitched CBCT scanned arches
(luckily I can type fast):
1. Patient arrived didnít do the online medical history, but he was healthy.
2. Assistant took blood pressure, dental history, pain history, etc. etc. and then did clinical
3. I reviewed the assistantís findings in my office to sort out a strategy for my exam with the
notes below in rough draft.
4. I introduced myself to the patient clarified aspects of the medical/dental history.
Next I asked the patient about his expectations to see if they jived with the referring dentistís
(the dentist is excellent and one of the best in town). Performed an oral exam, repeated all
significant relevant clinical tests for redundant accuracy adjusting chart if necessary..
5. I corrected and updated all my rough draft notes and decided whether it was possible to sequence
and prioritize and endodontic treatment order (it wasnít necessary because the #3 tooth was the
only definitive recommended endo treatment).
6. I discussed all the significant endodontic related findings with the patient (i.e. the list below)
and answered all his questions (there were many). I mentioned that I may adjust some of my findings
based upon my review of the CBCT data (later after reviewing the scans I defined #3 as clearly needing
endo and #24/25 as not being reasonable to treat) .
7. I sent the following report to the referral. He will call me back and weíll discuss the next step
which will likely be scheduling him for #3. I fully expect to see this patient again in a month
or two when he is in provisionals for re-evaluation of teeth that will likely need an endo evaluation
after the crowns are removed and pulps are exposed.
8. This referral likes me to do implants for him but if this ends up being a largely edentulous case,
Iíll decline because itís well beyond the scope of my specialty boundaries and this one wonít be
within my implantology niche.
I saw xxxx in 2008 for the right posterior lower sextant. I examined all areas today.
The following are the summarized notes with the multitooth chart information below.
Attached are images of the teeth having significant findings or of specific interest.
#2: deep distal perio pocket may improve with wisdom tooth extraction. Endo retreatment with post
removal advised if a new restoration. (guarded to fair prognosis primarily due to perio if not
#3: necrotic pulp, CBCT shows a radiolucency/lesion over the MB root apex Endodontic treatment advised.
#7: previous endo a little short but no evidence of recurrent endo pathosis. Tough call to redo endo
if a new crown is planned. Iím not sure what the weakly radiopaque material is cementing the post
which seems to be injected well past the apical extent of the post. If itís nonresorbable it may be
problematic to retreat/remove without apical surgery. CBCT shows no periradicular radiolucencies
suggesting recurrent endo disease.
#9: Filled grossly short, possible paste or MTA root filling material. I strongly suspect previous
pulp obliteration with an attempt to negotiate a nonnegotiable system was filled short. Iíd recommend
leaving it alone and doing surgery later if necessary. CBCT suggests no evidence of recurrent
#10:Previous endodontic treatment looks adequate with no suggestion of recurrent endodontic disease.
#14:Possible exposure, distal pulp horn, cold thermal response was normal. CBCT scan showed no
suggestion of endodontic disease.
#15:Previous silver point endo, with poorly filled palatal root terminus (no observable material).
Likely missed MB2 (impacted #16 should be taken out). CBCT showed no evidence of recurrent
#19:Failing previous endodontic treatment, retreatment with bicuspidization would likely fail due
to root fracture and would be extremely heroic/impractical. Extraction advised.
#24:Type II Heithersay resorption mapped on the CBCT as limited to the lingual surface.
Considering the advanced labial abrasion and cervical weakening, the prognosis is poor and
extraction is advised.
#25:Type III Heithersay resorption, worse prognosis than #24, the defect was also mapped on the
lingual and is larger. Extraction is advised.
#30:Previous endo with unsuccessful management of root external lateral inflammatory root resorption.
Chronic furcation lesion. The status does not look a lot different from when I examined him in 2008.
It still has a poor prognosis with a chronic furcation lesion. Advanced inflammatory root resorption.
#31:Advanced root inflammatory root resorption with failing previous endodontic therapy, very poor
prognosis, extraction advised.
Thanks for your trust and support, - Terry