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Fistula in lower right quadrant
From: "Tommie Van de Velde"
To: "ROOTS"
Sent: Tuesday, January 23, 2007 12:03 AM
Subject: [roots] treatment decision
Being a periodontist I have not a lot of experience with endo.
Started knowing more about this forum through rximplants... This is
Referral from my endo guy. 40-year old woman presented with fistula
in lower right quadrant. First RX is with gutta point showing
involvement of lower canine (43).
Endo did RCT on 43, no relieve of symptoms (apparently second canal
caused some problems). Incisor started being painful also, so he did
a rct on that.
Fistula persisted. Antibiotics made the fistula disappear.
Now my question is:
- what is your diagnosis?
- what would you do to help this patient? - Tommie VAn de Velde
Diagnosis? can't say without results of testing. I'm not impressed by
the tracing---in other words, I would not have done endo on 43 with
only the g.p. tracing result. I would want to know results of
sensitivity tests for 41, 42,43,44. This is a difficult case.
I'd also be interested in the endodontists findings upon entry to
these teeth - Kendel
Tommie, This is very difficult diagnosis. I applaud the endodontist
for finding 2 canals on the one tooth...but I don't think he got to
the terminous in one (the one that looks shorter) canal.
Ideally, BEFORE the endodontics was done, your endodontist should
have done pulp testing, preferably with cold and if needed Electric
pulp testing. This would have helped make the decision on what
caused this entitiy
Now I'm afraid, it's time to surgery for biopsy, but the lingual
canal that's shorter then the buccal on the canine is gonna be very
difficult to tx surgically. - Joey D
I'd retreat the canine trying to get to the end of the root that's
filled short. If no joy, surgery as Joey mentioned. If I was able
to get an acceptable result with re-tx, I'd do no further tx pending
future recalls.
I'd be curious to know what the vitality testing results where on the
incisor. My bet is it might not have needed tx based on no evidence
of caries or deep pre-existing restoration - Mark
Well, no carious leasion on the canine neither. My guess it was
perio- endo. So lateral got involved. There was definetely a reason
to treat the lateral. I can say that since I know the end of the
story. Let's say vitality was negative on the lateral, so it was
a good decision to treat this tooth - Tommie
It would help if you presented us with a full dx workup, then there
would be a lot less "guessing" Otherwise, your guess is as good
as mine or anyone else's. I seriously doubt that lesion is primary
perio judging it radiographically, but as I said, without the full
story on dx workup, that's just my guess - Mark
Tommie,
The fact that RCT did not result in improvement could
be attributed to:
- inadequate cleaning & shaping (especially the apical few mm of
unfilled canal space in the second root of 43 can harbour enough
micro organisms to cause failure)
or:
- this wasn't an endodontic lesion in the first place. Therefore
it would indeed be interesting to know the pre-treatment result
of sensitivity test, probing, mobility, ...
- maybe we should not overlook the possibility of a
non-odontogenic cause? - Maarten
Hi Maarten, Pain symptoms disappeared by doing the rct's on both
teeth. But fistula remained...We're getting there...Tommie
Surgery pics given below
So when opening the gingival tissues, buccal bone was almost
intact except for a small fenestration under the apex of the
lateral. Widened this with a small round burr and realised the
defect was much bigger than I expected.
SO decided to open up the whole thing and saw a cyst.
My diagnosis: peri-apical "radicular" cyst. I suspect canine
to be origin, but lateral was defintely involved too.
So my question is rooters: would this diagnosis been missed
when you tried to retreat the canine? For the record, both
teeth didn't react on vitality testing. Who would not continue
doing surgery after both endo's (imagine the canine filled to
the apex) and fistula disappearance?
Can a cyst like this resolve without surgery?
My opinion is no... (?)
So I removed the thing, put some Bio-oss in it and sealed with
a collagen membrane. As you can also see I managed to remove
both the apices of the canine :-) - Tommie
Just being curious... Any trauma hx or non-carious cervical lesions?
- Edward T Hsu
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