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My failing case - Courtesy ROOTS |
| The opinions within this web page are not ours. Authors have been credited for the individual posts where they are. Photos courtesy John A Khademy- ROOTS |
From: John A. Khademi, DDS MS Sent: Wednesday, April 20, 2005 12:56 AM To: ROOTS Subject: [roots] My failing case I retreated yesterday Marty came in 8/2004 CC constant dull ache and hot/cold sensitivity. Crowns LLQ placed some years back. Pulp and periapical tests on LLQ and ULQ revealed irreversible pulpitis and subacute apical periodontists (more on this if people are interested) on #18. Perio WNL. A single visit 2:00 hr RCT thru the FGC was performed. Total tx time was 1:45. Marty came back several times complaining of a continued dull ache, sensation of "metal" or cold, pressure, "feels different" over the next six months. Occlusion and adjacent and opposing teeth were evaluated and found to be WNL. She has a high stress job and admits (as if I couldn't tell!) to clenching and grinding. In 3/2005 we agreed to retreat the tooth (at N/C). I removed the amalgam, GP (no odor) and given that this was a fixit- or-extract-it case, removed all of the dentin between the mesial and distal canals with an ultrasonic. What I found surprised me. I had always though that these fused-root, single POE teeth were a slam-dunk. I almost felt bad about charging a molar fee. After ultrasonically, removing the dentin between the mesial and distal canals, I found two fins of tissue, still "reddish" where the "MB" and "ML" "canals" were. I troughed away with the BUC-1 at first, then the BUC-3 and CPR-4. Length and original prep size were verified and CH place for 1 mo. As of yesterday, symptoms relieved to the point of finishing the case w/o anesthestic! Take home #1: I shoulda seen this one coming. 40-60 yo female, high stress, high acheiver, T2.5, lower second molar, was hitting in CR. I never should have done a single visit. Take home #2: 1:45 tx time with full strength NaOCl did NOT get rid of the tissue. Maybe I should have heated it. Yeah. Right. Take home #3: It was not about the file. You could have prepped this with rotary/reciprocating/stress relieved/radially landed/safe sided/partially active tip/blessed with holy water/kissed by virgins GodFiles in sizes #2-6 and it still would have failed. Take home #4: I just needed to spend the time. 1:45 wasn't it. 15 minutes? Yeah. Right. Take home #5: Will you have success with 15minute molars? Some, perhaps a lot depending on your case selection. With Marty? Uuummmm, No. Will you see those failures? Probably not, unless you are the only endodontist in town. A very small town. Then you get them all. Including your own. Very humbling - -jNice case presentation John. You’ve eloquently presented the argument against the mentality of “race against the clock/mechanical consideration-only” approach to endodontics. I recently had a very similar case….c-shaped lower molar…vital case no less, which I had treated initially and it failed and developed a large lesion. I went back in and spent more time troughing out isthmus space which somehow I had missed the first time (maybe Gary Carr is right about finding anatomy on the 2nd visit)…all sorts of purulent drainage. After a couple visits with caoh, the canals were finally dry, the patient comfortable, and finally I finished it - Mark Take home #3 still has me laughing my rear end off! - Gary Thanks John, very eloquently put. The frustration for me is that I spend as long as I need to, I generally do multi visit as Gary was right or at least us slow guys need a second look. When you spend the time and make sure it's clean dry and asympt before you fill, look at the PA and it looks good, it does hurt when you have to start again. The only people who have success with 15 min molars are the guys selling the courses but you left Take home #6 off your list.. - tim It does happen, but should be a rare occurence. It really should happen to GP's LESS than us because they should be getting these high risk cases out of the office. - -j
