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Pimp on the gums

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From: Maarten Meire
To: ROOTS
Sent: Tuesday, May 11, 2010 5:55 AM
Subject: [roots] Your opinion on this one

I was not able to save this one, and honestly, I don't know why.

This 40y old female has had a pimp on her gums ever since her childhood. Her dentist has always
told her just to squeeze it now and then. Recently she took a second opinion with another dentist,
who referred her for retreatment of 21. Two weeks before the first consult, she hit her child's
head with her front teeth: 21 was mobile and painfull.

When I first saw her the crown of 21 was heavily discoloured, there was a buccal fistula with
draining pus. The tooth was (slightly) vertically mobile. Apical lesioin and strange widening of
the PDL space in coronal 1/2. No occlusal interferences. Probings <=3mm, except distopalatal (4mm).

First visit: removal of old RCfilling, disinfection (NaOCl/EDTA, PUI), Ca(OH)2 placement (Ultracall)

Second visit: fistula still present, slight discharge of serous fluid. Again disinfected and placed
a thick mixture of Ca(OH)2 powder.

Third visit: no improvement: fistula not closed, teeth still vertically mobile. I advised her to
have the tooth extracted. I obturated the canal with gutta percha/AH+ (squirt).

Any ideas on why the infection could not be controlled? - Maarten









Hi Maarten, Extraradicular biofilm. I see this frequently on teeth with a longstanding sinus tract.
I would pack and wack! - Marga

The root sure looks split to me.  Are you sure it doesn’t probe deeper?    I wouldn’t perform surgery
and  disrupt the labial plate any more than it is.   It could be an apically originating crack due to
spreader loading if it doesn’t probe.  I’d either do something noninvasive like CBCT or just presume
it’s cracked and pay the piper.   The CBCT will also help you plan the inevitable implant -  Terry

Hi Terry, I did not probe under LA, but I probe rather firm ;-) I did not have the feeling it was a
cracked root. Also, I had a very good view on the canal walls with the microscope, and didn't see any
sign of VRF either. Yet no conclusive evidence of course.

Concerning the spreader loading as a cause for crack, I'm not too worried about that if you consider
the 2 gutta percha cones floating in the canal (preop RX): not too much condensation forces there!
Thx for your comments, - Maarten

Hi Maarten, I could certainly be wrong about the crack, but I am very suspicious of it still.
Good luck with the case, great post, we are all curious to see how it works out! -   Terry

I agree with Terry's comments. My suggestion to perform surgery was based on the assumption that there
are no signs indicating a crack or fracture.

Did you probe under local anesthesia? That's what I do when I suspect a fracture.CBCT for sure! - Marga

Hello Marga, Your point about extraradicular biofilm due to a long standing sinus tract was definitely
interesting! Does this mean that such cases more frequently are treated surgically in your office?

I'm not sure about the crack, as I pointed out in my answer to Terry. I think in thid case the root dentin
is so heavily and thoroughly infected that an intracanal approach is not able to control it.

I consider calling the patient and offer her the CBCT option. Do you think the fact that the tooth is now
root filled is a problem for the diagnostic accurity of the CBCT? -  Maarten

Hi Maarten Does this mean that such cases more frequently are treated surgically in your office?
Yes, for sure I will post an example shortly - Marga

hi terry and marga-  whats more invading therapy: surgery or cbct? so: whats your opinion to doing
first- radiology or surgical access? if you wouldnt see crack on cbct would you do surgery past?
would be  both methods additional or exclusional methods? means: if i cant see crack i wouldnt perform
surgery access or if i cant see a crack while surgery i wouldnt perform cbct? wouldnt it be better
to perform surgical access first ?  or perform first a 3d x-ray?  whats your handling procedures?
very curious...Dennhardt H

Interesting point and a tough decision Holger,

Decision trees, algorithms,  or even just using Bayesian analysis to pick the best of undesirable options
for a patient requires a sense of intuition about Likelihood.

Diagnosis and treatment planning simply starts out as a foggy tapestry of unlinked data entities.   You then-


1. Put all that shit in a box.
2. Pull out the light pieces that are easiest to handle and read them first sorting them into relevant
   or trash boxes
3. If a solution is obvious leave the heavy pieces that require too much energy and time in the shit box
   and move forward with the plan.

but frustration occurs if a solution is not obvious and you have to continue dealing with heavy stressful items .

Your Tooth Fracture Example:

1. Patient presents with a lot of data entities: radiographs, history notes, clinical observations, and other
   items which are light

2. The majority of the time I simply diagnose a crack from their history, symptoms, the radiograph they bring
   with them, and the basic endo exam including perio probing.
   no CBCT,  no exploratory surgery,  you can simply extract the tooth; it’s obvious, no need for CT Scams,
   no need for unnecessary exploratory surgeries; it’s abusing the patient to do otherwise, thus overtreating.
   but  sometimes (which is the minority patient that takes up most of your time)

3. The light evidence is not obvious requiring a heavier exam:  CBCT scan or exploratory endo access
   (or even more rarely surgical exploratory access)

If there is no additional collaborating evidence like a sulcular defect upon probing, a widened PDL on the
PA radiograph, you run the risk of having the CBCT come up as a blank not defining a diagnosis or treatment plan.
This fruitless investment may then lead to the decision to perform exploratory surgery which may very likely
have a poor access vantage point for an interproximally existing vertical root fracture, leading to the even
heavier exam: nonsurgical exploratory access which may, or may not require post removal, etc.
(I rarely perform exploratory surgical flap procedures)

-ultimately an extravagant series of efforts and expense can lead to ultimate discovery of a nontreatable
root fracture and a doomed tooth.

Patients do not like this.

The solution:  The patient is informed of this complex analysis at the initial consultation.  Certainly,
many will not understand the complex impact this fouled tangled mess of philosophical fishing line has on
the acceptance and success of their treatment, but simply communicating this jargon creates a very necessary
shared responsibility.

In summary,  I may perform exploratory nonsurgical access for one patient, take a CBCT scan for another,
simply extract the tooth for patient who refuses to accept any heavy investment, but I find it best to
let the patient guide the investment in heavy data/exam items. -  Terry

P.S.  Did that make sense?

hi terry- you make my day...   at a course i have heard ones saying:  act as a physician not like a mechanic.
you should have the knowledge to decide- than you are a physician- otherwise not. we need ideas no cookbooks.
the point is: we are always hungry for evidence based techniques. the truth is: evidence is even more than
literature. it is self experience, knowledge and patients compliance. and to use all these items we have but
not because we have these items.  story: i had a trial and the expert witness was asked by the patient if it
would be a failure or mistreatment not to perform a 3D vision before. .. it was the same reason of a crack
it has to be extracted past exploratory surgery , no 3d x-ray (cause i havnt one)  and i decided  the same
way you do. ...  yes it makes sense...  greetings  hope we will see us anywhere - Dennhardt H

With a tooth that has been causing problems for so many decades, the tooth should be full of resistant
bacteria and their products. I  would give antibiotics guided by an antibiotic sensitivity test,
extract, graft and put an implant in. - Alexander Hegi

Hi Alexander, I understand your point, but on the other hand I have treated other teeth with long standing
infection successfully, so I think it was worth giving a chance... - Maarten

Dear Maarten, Thank you for your reaction. I fully agree with your initial treatment
of trying to treat this tooth conservatively. However, the outcome is
not what you and the patient hoped it would be and my suggestions were
what to do with it in the present situation.

As dentists we often hope for treatments to last, last and last, where
as realists we know that the outcome is guarded by limitations of
materials, history of pathology and desired longevity. We try and try
and either charge the patient or limit our fees in an effort to be a
good human and a good care provider.

I see many patients that can benefit from expensive top quality
dentistry, but the reality is that this is outside their means an
desires. I still think I should continue to provide care, but accept
that i see these patients more than I should - Alexander