Claudia Hoffman
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35-YEAR-OLD female presented to our office with a history of mild pain
and swelling in her upper left maxilla. She had no significant medical
history, and her dental history included restorations, fixed restorations,
endodontic treatment, and extractions. The patient had no known allergies
and was taking no medications.
The extra-oral exam was within normal limits. The intra-oral exam
showed mild swelling apical to tooth #15. There was an osseo-integrated
implant that had been placed three years earlier in the #14 area.
Tooth #15 was sensitive to palpation and percussion, but no mobility was
noted. The radiographic exam revealed a large periapical radiolucency
surrounding the apex of #15, with previous root canal therapy. The
patient had taken 500 mg of Amoxicillin TID for seven days one week earlier
and stated that she felt much better.
The treatment options for this case were presented to the patient:
retreatment of tooth #15, extraction of #15, or apical surgery on #15.
It was clearly stated to the patient that the periapical lesion surrounding
#15 was very large (see Figure 1) with a guarded prognosis. The implant
in the #14 area was stable, and the main concern was to protect that implant
from future failure.
It is acknowledged that dental implants should not
be placed in infected sites, but the effect of periradicular infections
of natural teeth in adjacent osseointegrated implants is unclear.
In 2004, Shabahang did studies on dogs and found that teeth with periradicular
lesions do not adversely affect adjacent titanium solid root-form implants
(Shabahang, 2004).
The treatment plan for this case was very difficult
to decide. The patient felt very strongly about trying to save #15.
After consultations with oral surgeons, and a clear explanation to the
patient that if non-surgical root canal therapy was attempted on #15, she
might be risking the health of #14, the patient stated that she understood
all the risks involved in the treatment, and she decided to try to retreat
#15. The patient was taken off all antibiotics and the retreatment
was initiated. After initial instrumentation, debridemant, and irrigation,
calcium hydroxide was placed in the two canals. The palatal canal
was blocked, and this made the success of the treatment even more precarious.
The periapical area appeared to be surrounding the buccal apices, so the
patient decided to continue treatment. After the initial visit and
treatment, we waited ten days to see if the symptoms reappeared.
The patient returned and stated that the area felt much better. Tooth
#15 was completed (see Figure 2), and the patient was told to get a core
build-up and temporary crown for three to six months. The patient
is on a three-month recall, and is well aware that this case is trying
heroic measures, but has been asymptomatic for eight weeks. Only
time will tell! I will keep you all posted and show the follow-up
radiographs.
September-October 2006
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FIGURE 1: Showing the large
periapical lesion surrounding tooth #15.
FIGURE 2: After completion
of root canal therapy.
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