First case , be gentle - Courtesy ROOTS

From: Yong Kim
To: ROOTS
Sent: Tuesday, May 29, 2007 4:06 PM
Subject: [roots] First case --- be gentle

This is my first Roots case posting.  I'm nowhere near as good as the people posting here, but I would like critiques
and suggestions on how to improve.  Here's the history:

30 y.o. female, CC: "my back tooth hurts so bad".  #28-31 evaluated.  Probing 6mm on distal #31, WNL all others.  Perc
+++ only on #31, - on others.  Palp +++ distal #31, others normal.  Cold +++ #31, WNL others.

Dx:  IP/AAP
Pre-op:
Glide path to #15, ProTaper S1-->F2.  Gauge apices.  MB=#30, ML=#25, D=#35.  Lateral condensation (stuck in the stone
age for a few more days).
Post-op:
Discussion:
The distal is long.  When I used the apex locator (Root ZX), the reading was erratic.  Went from no reading, to apex,
and back to no reading when moving the file just a tiny, tiny bit.  So I took a WL film, and the file was long.  For
some reason, I went back to the apex locator, which said it was short, and I went with the apex locator instead of the
WL film.  That was stupid.  I admit it.  As for the other two apices, I can't tell from the x-rays.

Comments, criticisms, and suggestions appreciated! - Jay





Nice endo ! Is that cervical caries or resorption? - Marga

Dear Dr. Kim,

In my experience, most of the time when the EAL is eratic, changing to a file size that is
closer to the size of the foramen will remedy the problem. I don't have an explanation but it seems to
work.

This is a great case for demonstrating several diagnostic and procedural, (both endo and
restorative), questions.  In addition to the length control question.  I took the liberty
of using Photoshop to increase the  contrast of your first image and then annotated it with arrows to mark an
important  landmark and a few diagnostic features you might want to consider.

First from a diagnosis standpoint, in your endodontic residency you will be asked to
document the patient's symptoms very precisely, (maybe so that 5 years from now in response to an
attorney's questioning you can review the patient's responses to methodical questioning in such detail that
any expert witness will have to agree those answers point to the pre-operative diagnosis you've offered and
justifies the treatment you undertook). Much of your residency will be spent in learning how to discern
reliable literature with which to justify why you say or do every minute detail of what you say or do. "Tooth
Hurts", won't cut it.  Attorneys  take journals like DentalTown with articles entitled, "How to sue a dentist after
your client has a root canal".

Before I get clobbered for an ethical slip, let me enter this disclaimer. The major reason you
want to go to the extent of adequate information gathering and documentation is so that you
can DO GOOD.  It's just that in today's culture, threats of lawsuits seem to be more motivational.

While we are discussing diagnosis, on the enhanced image attachment there are some light
gray arrows that outline a diagnostic feature that should raise a red flag. This is a nearly
classic picture of external cervical invasive resorption.  It very often is asymptomatic. The double black arrow
points to its entrance into the dentin of the tooth.  Root canal therapy alone may not stop the progression of the
resorption.  It's been discussed at length in the past on Roots. Most Classic Literature Reviews on the subject
will probably start with the study by Geoffrey Heithersay.

The second diagnostic feature apparent on the radiograph is outlined with white arrows and
very often is found in combination with a tooth that has had a chronic inflammatory response in
the pulp.  Teeth showing this type of bone response should always have pulpal disease RULED OUT.



The third feature on the radiograph, (this one denoted by the black arrows),is of particular
note with second molars in that it very often is found directly under the path of an
overextended root canal filling which creates an extra hazard to inadequate length control.
It's one thing to overextendbut quite another to lacerate or puncture the inferior alveolar nerve.

Returning to the double black arrows.  This is the restorative dilemma.What steps must you
take to assure the crown margin covers this area?  It is an opening through the cementum and
dentin as much as is caries.

This may be more than you wanted or needed but it gave an old man a chance to think about
how your case could be put to use in the teaching environment.  May I have your permission
to use it in my book review for our graduate students, The Dental Pulp.

Thanks you,- Grant

Dr. Merritt beats me to the punch. One of the first things that jumped out at me was the possibility of invasive
cervical resorption. It is in the classic location and (judging from the lack of  Cl V restorations of the adjacent
molar) it is likely not caries. If that is the etiology, then endo treatment considerations are secondary.

In any case, I reaffirm Grant's excellent comments with a  giant "Ditto!".

Just because we CAN do endodontic treatment on a tooth, that does not mean that it should have treatment. In this
situation the resorbed should be excavated to sound dentin and the area evaluated for restorability.  By the time you
remove bone to create proper biologic width for the buccal crown margin, you might  have an area that is either not
easily cleanable,  has inadequate attached gingiva, or that may involve the furca. The time to find out is now, not
after the endo has been done.

I also agree with Grant about it being a great teaching case.  Lots of thought has to go into the assessment - and
those are the kinds of cases we learn from best.- Rob

Grant and rob:
This is FABULOUS stuff.  Grant, what a great explanation of the diagnostic
clues included in that pa.  I learned quite a bit from your explanations.
Keep it up guys.  You totally rock!!!!! - gary


Drs. Merritt and Kaufman,

Thank you for the educational responses.  By all means please feel free to use it in any way you see fit.  I didn't
post the case thinking it was a shining example of endodontics.  I was hoping someone would critique it in the way you
did.  Marga actually beat both of you to the punch when she asked if it was caries or resorption.  Quite honestly, I
don't know for sure.  Since she had come in as an emergency, I was focused on getting her out of pain.  As I understand
it now, it would have been ok to perform a pulpectomy, but then evaluate restorability before completing the RCT.
Gimme a slap on the wrist for that one.

As for the apex locator, I tried all the usual tricks.  I measured during WL, after coronal flaring, and after a set of
rotaries, but still got fluctuations.  I tried drying out the chamber and canal, as that sometimes seems to help, but
to no avail.  It also was doing that on another RCT so it's quite possible it's my apex locator, the probe, or some
other component.

I am aware of the "white mass", which is a condensing osteitis.

I did not spot how close the IA was.  I need to evaluate pre-op x-rays a lot closer.

I did a search on ICS.  I had not heard of it before you mentioned it.  The reports advise thorough curretage of
resorptive tissue, trichloroacetic acid, followed by glass ionomer base and composite fill, though some skip the acid.

Well, this has been quite an educational experience, and it's not over yet.   - Jay