From: Valerio Di Grazia To: ROOTS Sent: Thursday, January 10, 2008 4:32 AM Subject: [roots] draining canal tooth 22: - first visit: old GP removed and canal dressed with calcium idroxide, presence of drainage. - second visit: after 1 week the canal was still draining exudate,so again calcium idoxide dressing -third visit: after 3 weeks from the second visit, the canal still drains and make the filling impossible. So again dressing, but this time I've had exudate draining while dressing with calcium idroxide, that's to say I had problems even to dress the canal. What can I do? - Valerio Di Grazia, Bologna,ItalyDear Doctor Grazia, The radiograph is a little hard to read. An angled film with the film placed more parallel with the long axis of the tooth and with about a 15-20 degree angulation from the mesial would be helpful. An instrument placed in the canal for this film would provide a lot of information. The incidence of 1st bicuspids having only one canal is so uncommon, (less than 10%), that I would expect more than one until I had exhausted all means to eliminate that possibility. It appears that there is more than one root outline on your film. Please see the image I've attached - Grant Grant, Perhaps I am confused, I thought international 22 was the upper left lateral incisor, which is unlikely to have two roots? - DanS Valario,Suggestions: 1. Open and reclean, you may find your apex needs to be larger than 50 2. Take a 27 g irrigation needle and seat it to working length, it is about ISO 45 and should seat if you are truely at 50 3. Hook it up to suction ( I use Intravenous infusion tubing) 4. drip NaOCl into the access with another irrigating syringe and let the apical suction pick it up. This will take several minutes. If the needle clogs take it out and put it on the end of your air/water syringe and blow. Some times this has to be done a few times before the needle will suction freely, which means you have removed some debris from the apical area. 5. Follow with liquid EDTA, dry as best you can, and apply Ca(OH)2 mixed with 2% Clorhexidine 6. Very carefully seal the case so no coronal leakage is possible. A post and core temporary leaks alot, find another way. 7. Schedule the appointments a month apart. 8 Consider antibiotics, consider surgery Dan Shalkey How is your perio probing? I had a case like this that eventually was ext'd due to a prominent developmental groove on the disto-palatal aspect. I failed to see this as a potential source for the infex, but later concluded this was indeed the reason for failure. Apical surgey would not have helped. KendelG Why don`t you try using the poliantibiotic paste like intracanal dressing? - Edward Alberto Valerio is there another canal or apical ramification contaminated? - Carlos Murgel Dear Valerio, Some canals have their own timing. We are missing some elements regarding your clinical procedure: apical enlargement, other angulated xR, what about 2.1, are you working with a scope, did you find one or two canals (the qulity of the xR is not very good)? At the next appt, I would enlarge a bit, let it drain for 30 min to an hour and place a MTA apical plug. If you don't feel confortable with that you can place Ca(OH)2 powder directly at the apex and wait again. I would follow-up to make sure it heals nicely, if not surgery - Gaelle Dear Gaelle, I work with Zeiss loupe 4,5x and head lamp, I haven't a scope, but I can say that there aren't 2 canals. The apical size of 22 is 50 ISO,and I was thinking to fill it with GP. About 21, I've already retreated it. One more question: at the next appt, after draining for 30 min or more, could I use MTA even if the canal is still wet?(I tought no). Or just in case the canal is completely dry? - Valerio Dear Gaelle, I work with Zeiss loupe 4,5x and head lamp, I haven't a scope, but I can say that there aren't 2 canals. The apical size of 22 is 50 ISO,and I was thinking to fill it with GP. About 21, I've already retreated it. One more question: at the next appt, after draining for 30 min or more, could I use MTA even if the canal is still wet? (I tought no). Or just in case the canal is completely dry? - Valerio Dear Valerio, Effectively, if you have excessive fluid the MTA can wash out but MTA sets with moisture too, so a little bit of it should not be detrimental. A little trick also to accelerate the removal of fluid, you can press extrorally where the lesion is or ask the patient to blow while pinching the nose. If there is still fluid coming out at the end of the session, I would suggest you to take CaOH2 powder and place a little bit right at the apex, this should stop the fluid from coming inside the canal, then place the MTA plug + moist cotton pellet close and reassess the following week. I agree with Grant, I was asking about more pics as it seems there might be an additional canal, if not you are certainly dealing with a large one so I doubt 50 is enough. Take a 80 file and drop it in the canal to see where it stands, if you are far from, the apex try with a 70...etc... I don't agree with Daniel regarding the CHX and CaOH2 mix as there is no benefit from this mixture, CHX and CaOH2 works differently - Gaelle I don't agree with Gaëlle about trying to fill the apex in the presence of active drainage, and there is benefit from Ca(OH)2 mixed with CHX 2%, but probably not alot more than Ca(OH)2 alone. There is not complete agreement on much in endo, especially when it comes to medicaments. Thank you, Gaëlle, for reminding us all about this. I did agree and like some of the other suggestions you made, hopefully some of them will help the patient - Dan Shalkey On Jan 13, 2008, at 2:10 AM, andreea corlan wrote: > What if this tooth has an abrupt canal curvature in the apical third, > in a plan perpendicular to that of the X-ray film? > > Profesor Merrit, are there any counterarguments against my theory? > > Valerio, how did you get up to the 50 file? > Did you use small diameter precurved files? > Did you ever have a WL longer than the one you have with the 50 file? > > If my theory is corect, than you can have a ledge. And if you'll use > larger diameter files in this stage you will only make the ledge > larger (bigger) and more difficult to bypass. - Andreea Dear Andreea, thank you for reply. I didn't feel a sudden curvature with hand instruments. Anyway at the next appointment I'll try to take some shifted pics to solve any doubt. - Valerio If the tooth has an abrupt canal curvature in the apical third as suggested I would expect the radiograph make the root appear shorter than the central incisor. It might look more like the "Photoshop- doctored" image I've attached. The question brings to mind another situation that might explain the reason for continued drainage from this tooth. This would be as a result of a misinterpretation of the root orientation of a maxillary lateral incisor in relation to the crown. As we all know, the root of this tooth is normally angled to the palatal, (about 25-30º), in relation to the buccal surface of the crown. This contributes to an error being made, when searching for the canal, leading to perforation of the root to the buccal. With a large lesion, such as is seen in the present case, one might mistake the drainage coming from the perforation site as coming from the apical foramen. To determine if this is so, one could use absorbent cones to determine the depth into the canal at which moisture is encountered. If the cones continually are moist short of the approximated length of the canal then one should be very suspicious of a perforation. As another confirmation, one might place a finger on the buccal soft tissues over the root while inserting a gutta percha cone to length. If the cone is felt through the tissue short of length, then perforation is probably confirmed. See attached Buccal perforation.jpg - Grant
