From: Terry Pannkuk
To: ROOTS
Sent: Saturday, November 21, 2009 7:54 AM
Subject: [roots] First Scan

This patient is a 26 year old woman who started off having an amalgam replaced with a composite on #14.
She also had been told she had an abscess on #4 which was treated by a local endodontist in February.
She began to have sensitivity with #14 and was referred to a different endodontist as #4 took a long
time to resolve.  This endodontist treated #14 and she still had pain.  That endodontist retreated
the tooth about 5 months later because she still couldn't bite on the tooth. She changed dentists who
referred her to a third local endodontist.  He recommended apical surgery on #14 and #4.  She went
back to the first endodontist to see if she really needed surgery on #4, it was feeling fine.
She then changed dentists for the third time.  This one told her to have #14 extracted because root
canal treatment doesn't work.  This dentist also told her not to have an implant because they are
made out of metal and to have ozone treatment of the bone.  She then traveled to Scottsdale, AZ and
saw a fourth endodontist who took a CBCT on a Galileos; he told her to do what the 3rd endodontist
advised.  At this point her orthodontist was concerned and figure he'd call me to see if I had and
words of wisdom; he then sent her over today.

#4 had no signs or symptoms of endo disease (I didn't' bother to post a radiograph because it wasn't
as interesting as #14), you can just take my word for it that it looked like an average endo, not great,
not bad with no signs of path.

#14 had moderate percussion sensitivity,  no palpation sensitivity, and she couldn't bite on it.
Perio was fine although a little sensitive on probing, no bleeding.

She came with extensive records, two CBCT disks (one from a Galileos, one from a J Morita).
The woman is extremely knowledgeable having learned a tremendous amount about dentistry the last year
and is very philosophical about her dilemma simply wanting to do the best thing.

What do you think? - Terry




Remove the restoration and look for a crack or missed canal - Dan Shalkey

Yeah, "ping-pong" patients :-)
Terry, is there a temp crown on that tooth? What's her occlusion/parafunction status?
Judging by the access shape i think i can guess where are you aiming - Dmitri

LOL...yep, I just posted the algorithm.  She has some malocclusion that is being treated by
the orthodontist. #14 has very light occlusion and has been adjusted.  No known parafunction.
I got the info from the orthodontist.  He doesn't want her to lose this tooth and needs it
for support, that's why he preempted the planned extraction on Thursday wanting my opinion
first.  I think extraction would be a mistake as well especially given the patient's dental
motivation and temperament - Terry

Horizontal Fracture on palatal canal? I think there might be lesions around this root mid canal.
- Jose

That's what I was looking at that no one else mentioned. It could be a scatter artifact because
it doesn't really show on the J. Morita scan only the Galileos which happens to be the only scan
I could capture images from.  The J. Morita viewing software is extremely limited and doesn't
allow you to fully rotate skulls around the way you would like, but given the fixed dimensions
I viewed, it didn't show anything like the horizontal entity you are referring to. It also shows
no evidence of that suspicious entity on the PA.

I measured the length of the palatal core, know I can easily drill it out.  Surgery recommended
as a first option always raises my eyebrows, especially in this case where it was also recommended
for an asymptomatic recently treated tooth that seems to be healing.  As always, I won't mention
specific names on this case, but it only fuels my disgust for the motivation behind some people's
recommendations.  This case represents all the problems with ethics and competency we have in
the profession.  Dentists are being taught to be stupid and greedy.

This is my plan (it may not be the ideal or perfect one, but it's what I feel gives me the best
odds of 1. Revealing the true etiology of pain and 2. Having the best chance of disease resolution
saving this strategically valuable tooth if possible:

1.  Leave #4 alone.

2.  Access, remove the core, explore #14 for fracture, perfs, purulence, and restorability.
    a.   If not treatable --->extract
    b.   If judged treatable--->place CH and re-evaluate in one month

3.  Evaluation in one month
    a. If asymptomatic in one month, finish likely obturating the DB and P with MTA due to blown
       out apices, Possible MTA in MB root if ledged or false path perf (looks suspicious that a
       curve was blown through)

    b. If symptomatic, irrigate, clean shape more, place dry mix of CH possibly with Ledermix and
    re-evaluate in another month, not filling for at least 2 months.  The more stubborn the
    resolution is the longer I wait to make sure the tooth is asymptomatic before finishing.
4   If the tooth does not settle down and become asymptomatic I will discuss proceeding with further
    options with the patient (patient's choice):
    a.  extract
    b.  pack it and evaluate for improvement of symptoms

5. Evaluate one month later
    a.  If symptoms resolve after packing (I see this happening frequently yet unpredictably),
    then wait at least 2 months (arbitrary term that might be change depending upon discussion
    with patient and dentist)  while provisionalized to make sure signs of disease do not recur,
    then place final restoration.
    b.  If symptoms do not resolve, perform apical endo surgery on all roots, given the CBCT data
    I might use to flaps in this case due to the palatal inclination of the p root (palatal and
    buccal flaps instead of trans-sinus, but that would depend more on the surgical access when
    performing the buccal approach first)

6.  Re-evaluate after surgery, giving even more time (6 months before final restoration).
    Usually surgery gives you immediate resolution of symptoms due to direct curettage of all
    causative elements.  If a surgical case like this fails it might take a while.  6 months
    would be the minimum amount of time

I would consider having a tooth like this finally restored after going down the line this far on
the treatment algorithm.

This patient is extremely intelligent, highly motivated and wants to do the best thing.
I'm amazed she trusts me as much as she does after all the bullshit she's been through.
She still has faith in dentistry, feels that all the people she's been to had her best
interests at heart, but feels that her situation was unique and challenged the intellect
and skills of all the practitioners she's seen.  I don't see it that way but it's not my
job to judge.....I only do that online. :):):)  In my practice I very honestly present the
problems, give my rationale for treatment, and leave the opinion commentary about ethics
and competency to those not part of the treatment team.  I view that as the most professional
way to behave with patients.  When I have issues with ethics and competency it's presented
here or to representative organizations designated to fight those battles.  Unfortunately
those organizations have pretty much had their balls cut off and are run by eunuchs,
so I tend to bitch more here. :( - Terry

Good to know we were looking in the right direction, good luck with the case. - Jose

terry: quick tip:
install a program call snagit on the system you evaluate your cbcts on.  www.snagit.com.
you can do quick easy image captures right off the screen.  even though we want to scan
through the volumes, you generally want to save, or put into a document or ppt,
specific stills.  i find this to be faster and more efficient than the captures and
exports provided by the manufacturers, particularly if i'm working with more than one
software, as i often do - gary

Thanks for the tips, you are definitely the king of online app advice! :) - Terry

Microsoft like the idea so much they incorporated snip it or some such thing into
windows 7 that does much the same.  At least it seems to for the 4 days I’ve had it
installed - gary