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Pericemental dentin ; Long time recall - Courtesy ROOTS

The opinions and photographs within this web page are not ours. Authors have been
credited for the individual posts where they are - www.rxroots.com
From: Terry Pannkuk
To: ROOTS
Sent: Tuesday, July 13, 2010 10:30 AM
Subject: [roots] Today's First Long Term Recall

I treated this cracked tooth with compromised pericemental dentin in 1998.  Two strikes against it.
It still there, functional and healthy with a well-made gold crown.   Notice how the straight angle
from 1998 shows the narrow diameter of the ribbon-shaped root canal system.  The slightly off-angle
one today makes it look wider.  Depending upon the angle I take Iím sure I could get a different
opinion on whether itís hogged-out.  Clinical opinions are like a-holes, everyone has one,
right Glenn? - Terry

Yep yeo! Did Ben Johnson know you were using rotaries in 1998? Other than the light-to-moderate GG use in the coronal, the endo on this case could be straight out of a FastTrack course. The access is large, and gouged. Strike #1. The saving grace on this case is that the PCD has not been violated by the endodontic shape, and the case has full gold which minimizes the axial reduction. Also of note is what appears to be an amalgam core, and a fairly flat occlusion further protected by a third molar.- Textbook Clark&Khademi Sure the PCD looks perfect, gouged by the guy who placed the amalgam, deep distal post with a post prep drill, extensive caries wipe out of the distal and complete distal amalgam margin. I build this type of case up with bonded amalgam myself these days with no post and wouldnít have let the referral do the build-up. . This is purely a fortuitous anecdote and an unlikely success. I was using rotaries too much during that period, my later results and earlier results were better. Below is an attached 14 year recall on the same patient I saw today with a missed DB because I was trying to be Khademi-like in my distal extension. There had been distal periodontal surgery with an amalgam repair of root caries. I didnít want to pop it out. I wasnít as aggressive then as I am now and would have extended the access to make sure I could see the distal better removing all restorations that might restrict my access and cause me to miss something (like this confluent deep loop of a DB canal. (I took a CBCT of this one because Iím treating #14 which is more broken down than any of the other previous teeth I treated (#15, 2, and 18). Definitely a suspicious recurrent lesion on #15 and if there was any clinical evidence/symptomology Iíd take it apart and retreat it. Re-entering it now will likely render it nonrestorable. Iím letting sleeping dogs lie. Check out the transverse section series. Starts off as a single buccal orifice branches off to a distinct DB loop a few mmís down, then joins back. There is no doubt in my mind I wouldnít be looking at that light diffuse PA radiolucency and wondering what I left percolating down the DB track if I had extended the access and not wimped out trying the please the perio guy. Definitive endo first, eliminate disease, then the other clowns can do their dirty work. My job is not to leave loose ends. The more difficult the access and the more complex the anatomy, the more a important it is to perform a SEE access. Iím simply ďlucky so farĒ this patient hasnít manifested clinical disease with this tooth. - Terry

Hereís the third tooth I treated on this woman that I recalled today. I treated #2 in 2003. (7 year recall), much better shaping and I had pretty much given up on the rotary bullshit at this point. Notice the apical internal resorption defect in the palatal system. The obturation replicates Hess anatomy more than a skinny Tulsa shape. The CT exam is much more appealing and didnít give me reason to worry about future bone loss/disease progression or equivocal subclinical signs and symptoms typically pawned off as hypochondria or simply a fussy continually complaining patient. Interestingly this patient decided not to have the crown and still has the amalgam build up that was placed 7 years ago. Fused, unfavorable root form, deep distal root caries, unprotected cusps, in occlusion Tell me how this pericemental dentin is so protected. Tell me how this tooth survived the Khademi-Clark Dogma of Dentinal Destruction? It even survived my own current dogma of not filling a necrotic tooth in one visit.or did it?.....maybe that PDL space widening at the distal root apex wouldnít be there if I had placed CH for a month. Barnettís full influence hadnít kicked in to make me a total 2 visit Nazi until about 2004 ( a year later) - Terry

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