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  Retreatment of tooth #16


The opinions within this web page are not ours
Authors have been credited for the individual posts where they are. - ROOTS
From: Marga Ree
To: ROOTS
Sent: Sunday, April 03, 2011 7:09 PM
Subject: [roots] Diagnosis?

Looking forward to hearing your suggestions! - Marga

Mmmh, I would suggest: Take an ConeBeam. ;)) 16 AP, maybe paro-endo and/or VRF. 15 hard to tell by the PA. I would go for access cavity without anesthesia to justify sensitivity. Same with 17. (Or first take a cbct) Sinusitis as DD, so a CBCT or maybe a panorama x-ray will show. Curious for the solution, because I left my sunny place in my garden to answer. ;)) - Jörg Suppose you had no CBCT, what would you do to identify the tooth causing the complaints? Bur access cavities in both 17 and 15 without LA? - Marga If Antibiotics do not change anything, the pulp(s) have to be more or less vital, if they are the reason for the complaint & if there is a dental origin. What about percussion, palpation, swelling on 17 and 15? PD's? If occlusion & articulation is fine, no pockets beside 16 and no cbct or panorama is available, I would first check the opposing teeth (sensitivity etc, see above) Next step , if complaints are not massive, and there are no hints for a sinusitis (ear-nose-throat-doc says everthing is fine) would be retreatment on 16 and wait what happens. If nothing changes I would take rubberdam and create a nice access on 15 and if positive on 17. So what did you do? - Jörg Jörg, You hit the nail on the head, given the complaints of the patient (pain is hard to localize) it is very likely that the pain is of pulpal origin, coming from a tooth with vital pulp tissue. Percussion and palpation: 17 ++. 16:-, 15:-. No swelling. Now what is your next step? - Marga test with warm water. diffuse pain is likely c fibers firing. warm water will identify offending tooth. - Rodrick Nice discussion what about cold test on this teeth.. does the pain increase at night..does anything increase the pain like bitting or cold water etc..does bitting in a certain way increase the pain.. when were the treatments done for teeth 15,16,17. did the patient have this pain before treatment.. i think the tooth that gives a spontanous pain on cold test is the source.. maybe i am wrong.. - Subhi Alnahas Marga, The thickening of the periapice in the tooth 15 is an indication that something is not right. I bet all my chips on the tooth 15 is the source of pain. - Marcel Caetano 15 didn't respond to EPT, nor did 17. Percussion and palpation: 17: ++, 16: -, 15:- Marga Marga, So far I can see is the radiolucent area bigger on the apex of the mesiaal root of the 16 than of the 15.So I would think of a mb2 not treated But the furcation involvement could also suggest a fracture of the mesial root of the 16 . Without CBCT I would treat the 16 and tell the RD that the 15 needs a root treatment too .For the 17 I will wait after the treatment of the two other elements . This diagnosis is based only on one rad ,So this conclusion can’t be the definitive one. Bite Wings, Xray under an another angle ? The point here is that both the 16 and 15 have pathology . I’m sure the CBCT would give an answer. May be I’m wrong ? - Paul NOYER Paul, You are right, there was an untreated mb2 in 16. However, the patient complained about a diffuse pain that was hard to localize. This type of pain is usually of pulpal origin, if it were of peri-apical origin, the patient can ususally identify the tooth in question very accurately. Therefore, I was pretty confident that 16 was not causing the complaints. I will post part II shortly. - Marga I believe the source of such a complain will be a result of vital tooth. IMO 17 is the most susceptible source of the pain as I can see a deep carious lesion related to mesial buccal root. Thank you for sharing - Mohammed Thanks to everybody that came up with suggestions and questions. The offending tooth was 17. First indication was the type of pain, indeed of pulpal origin. Second indication was that 17 was extremely sensitive to percussion, in contrast to 16 and 15, indicating peri-apical pathosis. Third indication was that the AB failed to give any relief. I opened 17, and found necrotic and vital tissue in the canals, so there was apical periodontitis and pulpitis, hence the confusing complaints. The rest of the slides speak for themselves. - Marga

Beautiful - Pierre Morin Splendid! That's why Emilios always speaks very high of you! Thank you for sharing!!! - Konstantinos Hi Marga Thank you for sharing this really interesting case, beautiful! - Imran Marga , Very good documentation. I don’t agree with your second and third argument because you did not mention that 17 was sensible to percussion In your first presentation. But anyway it is was a nice case to think about and a nice picture with the extra root distal. Thank you for your time - Paul Noyer Hi Paul, Thanks for your comments. I did mention the fact that there was no relief from AB in my first slide. There were a few takers, and then I mentioned in one of my replies that: 15 didn't respond to EPT, nor did 17. Percussion and palpation: 17: ++, 16: -, 15:- Sorry if this didn't come through. - Marga Great case Marga... WOW!!! It´s always a pleasure to see your cases. May I ask you just a few questions? How do you manage to do electric pulp test in teeth with crowns? In this particular case did you consider negative response to the EPT in 1.7 and 1.5 reliable? any periapical findings in 1.5 with the scan? - Javier Thanks Javier. EPT on crowned teeth is done under the microscope: push the gingiva in an apical direction with a plastic spatula to expose the crown margin, make sure your crown tip is properly placed against the root surface, see picture. If you don't have a special crown tip, then you can use any instrument (e.g. endodontic explorer) as a bridging instrument, just bring the bridging instrument in contact with your usual EPT probe - Marga

Thank you Marga. Great tip.- Javier Hi Marga, Brilliant endodontic diagnostic and treatment skills as usual! One key question regarding your case: What was the cause for the pulpal necrosis in this case? Was it a deficient or carious crown margin...I noticed in your photos that your access cavity was a traditional conservative one in this case... I often find that in such cases I need to 'over-enlarge' the access to some degree, to assess for secondary caries, 'open' crown margins, etc. If this was the reason for pupal necrosis, is there an indication for removal and remake of the crown, even though from your radiographs, the crown margins appear 'sound'. Or, do you simply accept a slightly deficient crown margin, and seal it internally as best you can, and then monitor the case carefully periodically. My experiences with similar cases to yours are that most crowned teeth with pulpal pathology have poor/leaking/deficient/carious crown margins (or deep internal cracks), which led to the pulpal pathology in the first place, and often there is a need to remake the crown or accept a compromised prognosis mainly for restorative/structural reasons. And, sometimes, by the time I have removed ALL of the underlying core material +/- caries, I find that I have 'shelled-out' the existing crown (and tooth) quite considerably, which sometimes compromises or weakens the crown or tooth. What are your thoughts on this issue, because I rarely find it discussed on this forum. - Peter Spili Hi Peter, Thanks for kind words! Your comments make fully sense to me. This patient was referred by a very good restorative dentist, his crowns are of superior quality. Therefore, I could make a conservative access opening through the crown, there were no signs of caries or poorly fitting crown margins. If that was the case, I usually remove the crown and make what I call a pre-endodontic build-up, I have attached an example, and you can read the original post below. I do all build-ups and post placements myself, so this is very common in my practice. My AAE presentation "the endo-restorative interface", will address restorative procedures in detail. - Marga ----- Original Message ----- From: Marga Ree To: Clinical TDO Sent: Thursday, October 02, 2008 9:31 PM Subject: [TDO Clinical] Leaking crown margins This patient was referred after the dentist had tried to access 16, and perforated under the mesial margin of the crown of the 16. The patient was in severe pain, and there was a swelling at the buccal aspect of 16. 15 appeared to have a deep carious lesion under a poorly fitting crown. To determine the restorability, I first removed the crowns of 16 and 15, and made pre-endo BUs of composite. After that, the endos were routine. - Marga

Hi Marga , Nice cases . I suppose that the crown are useless after your treatment. When do you make the decision to advise the RD to make new one’s And by the way how many pair of shoes do you take with you this time to San Antonio. - Paul NOYER

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