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Endo tips    Better Endo    Endo abstracts    Endo discussions

 "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.  Iíve 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

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. Iíll 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? - Gregori Kurtzman 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. Iím very disappointed in the apathy. WTF is going on around here? - Terry Terry, This could be fun! You've cast your bait into the pond now let's see if I can steal the bait and leave you with an empty hook. :-) I find it quite interesting that you have a case in which you got healing without a separate decompression procedure and I showed a case last week in which I got complete healing with it. It goes to show the wide latitude we sometimes have in treatment decisions yet can still achieve healing. Cyst decompression would have been overtreatment in your case and in my case removing the crown, post and retreating would have been overtreatment. I admit that my case is unique in that I knew the entire history of the endo and restorative treatment and would not expect complete resolution if I hadn't known the endo restorative history. I still think cyst decompression is a valuable treatment especially in cases in which the contents of the cyst are a thick paste which cannot be drained through an open canal and resorption of the contents of the cyst would take a very long time if It could occur at all. Looking to have fun but not looking for an argument.- Randy Hedrick ps: Now let me cast my line in the pond. I know you like to stir the pot on TDO, I have attached my case and the write up if you want to post it and get things going again on TDO on decompression. :-)) Randy, You get healing with our without decompression. My argument is that it is a pointless unnecessary procedure for Lesions of Endodontic origin. I feel there is a rampant scientific hypocrisy amongst those who chastise endodontists who leave teeth temporarily open for emergency drainage, while they have no qualms sticking a rubber poop chute in the mucosa for cyst decompression when it isnít even necessary. Iím not talking about oral surg path like dentigerous cysts, OKC, and foreign bodies that get dropped into extraction sockets, or cellulose fibers that get pumped out into the periapical tissues. Iím talking about garden variety LEOís. These never need to be decompressed regardless of size.- Terry Terry, I agree for the vast majority of LEO decompression is unnecessary. I use it about once every 3-5yrs and can't remember the last time I used it. It is most appropriate in the Maxillary anterior where apical scars tend to develop when the lesion has broken through both the buccal and lingual osseous cortices. Usually I find in these cases where endo is initiated on large lesions, I get a flare up which I'm kinda happy to have because I gives me the opportunity to do an I&D and irrigate the lumen of the lesion. The inflammatory event probably causes a breakdown of the organization of the lesion which I view as "site preparation" for healing. Sometimes a closed curettage helps remove the contents if it is a thick and paste. I take the drain out after a few days, irrigate again and the finish the endo a few weeks later. Haven't seen many scars develop after that regimen. It would be most applicable in the maxillary anterior where the lesion is large and retreatment is not an option, not a common occurrence either. - Randy Hedrick Randy, Iíd just summarize things as this: 1 Thereís no such thing as an apical scar, itís self-denial of a failure 2 Through-and-through defects will heal if you wait long enough and no intervention is necessary. The patient doesnít care if they have soft tissue that takes 5 years to ossify. 3 The patientís host defense is wonderful and doesnít need our help once weíve eliminated the pathosis. 4 In twenty years Iíve never seen a lesion caused by endo not heal that couldnít be explained by either a procedural error, inability to accomplish the objectives of nonsurgical endo, or a was a misdiagnosed nonendo entity to begin with. Decompression of LEOís serves no purpose and is a waste of time. - Terry Terry, You will have to take up #1 with the pathologists who report "dense fiberous connective tissue with an absence of inflammatory cells" in their biopsy reports. - Randy Hedrick 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 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 I agree Terry, my feeble mind can only handle one endo at a time!! I will post one of my cases , no pulp cap involved, just a crack. Finished it today in two visits. - Glenn 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 ďthrough-and-throughĒ 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, LA Holger, I enjoy these arguments even if others donít. JJJ 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 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 I had a case a few years back, where all of the mand incisors became involved, had a huge cyst covering all 4 teeth. Draining it was the only way I got the patient out of pain. - Gary Gary, Thereís a difference between an emergency I and D and decompression. Youíre talking about something different. Iím talking about leaving a rubber anus in someoneís mucosa for weeks thinking it will change the course of healing which would occur anyway after proper endodontic treatment on a LEO. Decompression is a complicated unnecessary procedure that may reduce the observed radiographic size of the lesion more quickly but makes no difference to the patient. Itís an exercise in meaninglessness - Terry Terry , could you tell us how you really feel about decompression? - Glenn

Protaper flaring
6 yr old Empress
Cvek pulpotomy
Middle mesial
Endo misdiagnosis
MTA retrofill
Resin core
BW importance
Bicuspid tooth

Necrotic #8 treatment
Finding MB2 / MB3
Deep in a canal
Broken file retrieval
Molar cases
Pushed over apex
MB2 and palatal canal
Long lower third
Veneer cases
CT Implant surgury

Weird Anatomy
Apical trifurcation
Canal and Ultrasonics
Cotton stuffed chamber
Pulp floor sandblasting
Silver point removal
Difficult acute curve
Marked swelling
5 canaled premolar

Sealer overextension
Complex anatomy
Secondary caries
Zygomatic arch
Confluent mesials
LL 1st molar (#19)
Shaping vs Cleaning
First bicuspid
In Vivo mesial view
Inaccesible canals

Premolar 45
Ortho and implant
Radioluscency
Lateral incisor
Obturation
Churning irrigant
Cold lateral
Tipped to lingual
Acute pulpitis images

Middle distal canal
Silver point
Crown preparation
Epiphany healing
Weird anatomy
Dual Xenon
Looking for MB2
Upper molar resorption
Acute apical abcess
Finding MB2

Gingival inflammation
Irreversible pulpitis
AG BU ortho band
TF Files
using TF files
Broken bur
Warm technique
Restorative prognosis
Tooth # 20 and #30

Apical third
3 canal premolar
Severe curvature
Interesting anatomy
Chamber floor
Zirconia crown
Dycal matrix
Cracked tooth
Tooth structure loss
Multiplanar curves