Pimp on the gums
From: Maarten Meire
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
The opinions and photographs within this web page are not ours.
Authors have been credited|
r the individual posts where they are.
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 doesnít probe deeper?
wouldnít 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. Iíd either do something noninvasive like CBCT or just presume
itís 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,
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
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; itís obvious, no need for CT Scams, no need for unnecessary
exploratory surgeries; itís 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