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The opinions within this web page are not ours. Authors have been credited
for the individual posts and photographs where they are. - www.rxroots.com

Ominous Lesion 2 1/2 year recall

From: Terry Pannkuk To: ROOTS Sent: Tuesday, February 28, 2006 7:56 AM Subject: [roots] "Ominous Lesion" 2 1/2 year recall I posted this case initially on ROOTs 2 Ĺ years ago and recalled him today. I recalled this patient today because of all the discussion about decompression. I'íve never performed a decompression procedure and view it as having no value if the etiology is that of endodontic disease. Why decompress through the mucosa when you can decompress through a path that already exists? (i.e. the root canal system). When I first saw this patient I was concerned about the look of the lesion (being extremely large with root resorption) and had a biopsy ordered. It came back negative and was infectious in nature. The healing shown on recall confirms this. I never did get the fistula to close with calcium hydroxide so I just packed it off. It then closed which was evident 2 months later and today, 2 Ĺ years later. The tooth also exhibits complete periapical osseous regeneration on #28 and the suspected involvement of #29 is now obvious. I wanted to see the resolution of #28 before recommending treatment of #29. Today, I scheduled him for post removal, and retreat of #29. We also talked about molar uprighting and implant placement. This is not an unusual case and I followed him from my initial posting on ROOTs in 2003 so that we could discuss it today. Decompression is not necessary for the healing of endodontic lesions. It is of value for other nonendodontic lesions such as large invasive cysts. I suspect it is used primarily as an unnecessary insurance code add-on like the unnecessary grafting of 4-walled extraction sockets by implant surgeons - Terry Ominous lesion recall

Ominous lesion recall Terry, at this point do you think 29 needs to be retreated or surgerized as the lesion seems centered around that root and there seems to be some laterla resorption on that root? or would you advise continuing to monitor since the total lesion has significantly reduced over time? - Gregori Kurtzman Greg, No surgery, I mentioned that I have set the patient up for retreatment of #29. I'íll dismantle the tooth and two-step it with calcium hydroxide. Iím not thrilled with the post and crown on #28. Iíll post the chronology of #29 later on. I never do surgery on retreatment cases like this one. Typically posts are fairly simple to remove and endodontic surgery serves to worsen the crown-root ratio with incomplete cleaning and shaping of an already failed case thatís internally septic. The observed external resorption on the mesial surface of #29 is likely the result of a lateral canal that wasnít addressed or cleaned during the initial treatment. It will be interesting to see the result. An asymmetric laterally skewed radiolucency almost always represents some extra root canal anatomy. Itís been chronically inflamed for quite a while. I never would have dreamt of treating the second bi until the first bi healed enough to reveal its clear contributory involvement. The next step after treatment of the second bi is to get him to an orthodontist for molar uprighting, then Iíll place an implant - Terry Terry, I can see what you mean can almost make out a lateral canal leading to the lesion on the lateral. will you try to get afile into the lateral if its as almost a 90 degree angle or will you mostly try to clean it irrigaiton wise and force caoh thru it to heal it? how long would you let the caoh sit before completing the obturation? - Greg Greg, I place a wet mix of CH for one month then replace with a dry mix for another 1 or 2 months if necessary. I didnít think of that myself..thanks Fred. - Terry Greg, Iím amazed everyone is calm about this case on ROOTís. It caused a huge ruckus on TDOChat when I said decompression is unnecessary. I thought for sure this would cause a fight on ROOTís - Terry I think if the lesion is due to whats coming from in the canals and you clean the canals decompression shouldnt be needed but IMHO if you have a lesion that is expanding even thou you cleaned the canals then creating an artifacial fistula may be whats indicated it relieves the pressure makign the pt more comfortable and changes the micro enviorment of the lesion. in a case like this so close to the mental nerve i would assum there are some risks to decompression near the nerve - Greg Great case Terry........neat to see and now you know the 2nd premolar was involved to a lesser degree. Thanks for posting. - Glenn Thanks Glenn, I rarely treat two teeth in the same period of time. - Terry Its always great to see signs of good healing. Gives me confidence to take up cases with ominous lesions. thanks for sharing terry. with your permission I will save this case in my patient education presentation to convey the message.......... disease elimination results in healing. - Venkat Just be sure to block out the patientís name that I forgot to take off - Terry Wow, I wish I could see the same on all my patients. - Thomas P.S The only thing I do differently is wait for the S. Tract to close with Ca(OH)2, am I wrong ? Thomas, I will typically wait 3 months and change CH once to see if the fistula will close. If it doesnít I assume that the final pack and obturation has a good chance of more effectively sealing off the remaining space and blocking the influx of clinically significant pathogens. I have a hybrid philosophy believing that it is arrogant to believe that one so perfectly cleans and shapes a root canal system that a necrotic case can be predictably treated in one visit with the same degree of success as a vital case, BUT I know from these numerous experiences that a fistula doesnít have to close prior to a case being finished. I also believe that those who perform through-and-through procedures (i.e. nonsurgical and surgical endo the same visit) on these types of cases are usually performing an unnecessary surgical procedure on the patient. Basically I believe decompression and through and-through procedures are popular unnecessary endodontic procedures performed without truly understanding the biology and the potential for the patient to heal without exotic intervention. Endodontic healing is simply related to meticulous attention given to addressing septic internal root anatomy. Except in the most rare zebra cases, it doesnítí matter if you treat the periapical environment. In fact it would be advised to leave well enough alone. You can always do the surgery later and more easily if necessary. Unnecessary treatment is a cardinal sin in health care - Terry hi terry, thanks for t he clear statements- like everytime. I love knives- as I come from the dark side as a perio freak. so I have often seen cases with undoubtable wrong diagnosis and unnecessarily surgical treatment . my decision for doing through and through is independent if the fistula is closed or not- when I cant see any development in the cyst, or more worse- a growing of it. this in my eyes is the only reason to set a cut. but in most - I would say all cases there are perio and endo lesions coupled. so you have to do more a perio than a endo surgical procedure. my.02 cents - Holger Dennhardt Holger, I enjoy these arguments even if others donít. I feel that with extremely rare exceptions primary endo lesions can be treated predictably without surgery. I rarely perform endodontic surgery and only in cases where the root has been severely resorbed or mutilated by a previous treatment making access to the root canal system impossible. Host repair is the most powerful treatment tool we have and it isnít ours. All we have to do is get out of the patientís way and not interfere with their healing process. - Terry Beautiful result #28! When contemplating the hx and the resorption of #29, would this not be an appropriate time to extract and place implants both #29 and #30, integrating while #31 is uprighted? Opinions, please. - Peter A Thomas,DMD No, I figure #29 is treatable and a better planned implant can be performed after #31 is uprighted. - Terry terry I think it was my initial presentation which set this off,this was of a foreign soldier in Israel who sought treatment,the problem here was that he is remaining in an area where first world treatments(if you look back at his x-rays you will see very poor rcts)for another 2 months, would you go for 1 month calcium hydroxide and final rct ? - solly Hi Solly, Yes, I routinely place CH for at least a month and sometimes replace it leaving it in for another two months if I feel it could be a benefit and there was a chance that the original placement washed out due to excessive purulence. If I feel that Iíve exhausted a conscientious effort to clean and place CH over an extended period of time, Iíll just pack the case off and frequently the case will heal. If it doesnít heal after an observation period Iíll perform surgery. Ten years ago I used to perform surgery more often trying to treat more heroic cases with poor-to-guarded prognoses if there was significant strategic value to saving the tooth. With implantology, those indications are much more rare and I today I probably only perform and endo surgery case 3-4 times a year at most. The vast majority of these necrotic cases with large lesions heal without surgery. Jim Simon is completely off-base clinically with his assessment of Bay versus True cysts. There probably are no True Cysts of endodontic origin, at least none that Iíve ever seen. Any histological section that seems to show a True Cyst is probably a misleading two-dimensional section that fails to show the convoluted portion that is contiguous with the expanded PDL. These heal without surgery and if you donít perform meticulous nonsurgical endo with a skilled technique or if you immediately perform surgery/decompression you would never know that the follow-up procedure was pointless, which it is. - Terry

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