Doug Kase
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 IAGNOSIS
of an endodontic problem can sometimes be obvious. You take a look at a
particular tooth that a patient is complaining about, and you see clinical
caries that has created a hole so large you can park a Mack truck inside
it. Or if it is not that obvious, usually on a radiograph there is some
sign of pathology, either caries or a periapical radiolucency, that points
you in the right treatment direction and thus you say to yourself that
this is a “no brainer.” Well my loyal readers, not everything is what it
seems!
The case I am going to present to you was somewhat
of an initial “no brainer.” A patient was referred to our office with an
obvious need for endodontic treatment on tooth number 3. The X-ray showed
a clear radiolucency associated with the apicies of tooth #3 and a relatively
large restoration (Figures 1 and 2).
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| FIGURES 1 AND
2: X-rays showing a clear radiolucency associated with the apicies of tooth
#3 and a relatively large restoration. |
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Upon conducting a clinical exam, I also found a fistula
on the buccal gingival, where I placed a gutta percha point to trace its
origin (Figures 3 and 4).
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| FIGURES 3 AND
4: X-rays showing a fistula on the buccal gingival, traced to its origin. |
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The diagnosis seemed pretty clear-cut in my opinion. Feeling
pretty cocky, I informed the patient that this would be a simple root canal,
there should be very few post-operative complications due to the fistula,
and we would be able to complete it in one visit. I was a hero and everyone
was happy!
I administered buccal infiltration local anesthesia
and gave a small palatal injection at the gingival margin also to numb
for the rubber dam clamp. Because this was a non-vital case, I felt that
there was no need to give a deep palatal injection, which can be uncomfortable
for the patient. Actually, due to the non-vitality, I could have done the
treatment with very little to no anesthesia. No symptoms + dead nerve +
fistula = no pain. I started a conservative access opening through the
onlay, and as soon as my bur touched dentin the patient gave me a sign
that he was feeling something—he jumped! Impossible, I thought, so I tried
again and got the same response from the patient. Now I had to start up
the diagnosis machine. I looked back at the radiographs. Perhaps due to
internal calcification in the pulp chamber, the palatal root was still
vital and walled off and all the pathology was associated with the non-vital
buccal roots. Or perhaps was this a bony lesion that was not even associated
with an endodontic problem at all. I removed the rubber dam and placed
Endo-Ice on the palatal aspect of tooth #3 and got a clear vital response.
Using the logic that if there was not enough palatal anesthesia to anesthetize
tooth #3, there certainly was not enough to anesthetize #2 as well, I pulp-tested
tooth #2 with Endo-Ice, and believe it or not there was no response. How
could this be? Everything preoperatively pointed to #3, but there was obvious
vitality. Instead of numbing further and proceeding to complete a root
canal on #3, which would have looked like a winner on an x-ray, I closed
up shop for the day so that I could bring the patient back to retest the
area without the presence of local anesthesia.
The patient returned the following day, and upon
a pulp test of tooth #3, I found that I was able to elicit a vital response
from the buccal and palatal surfaces. However, #2 gave no vital response
at all. The patient was informed that perhaps tooth #2 was the actual culprit
and the radiographic pathology was just presenting mesially. Since
this was the only reasonable explanation, endodontic therapy was performed
on tooth #2 and the radiographic result on the final films gave me the
final answer to this very interesting diagnostic case (Figure 5).
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| FIGURE 5: Showing the lateral
canal off the mesial aspect of the mesiobuccal root and the corresponding
puff of sealer into the periapical radiolucency. |
Note the lateral canal off the mesial aspect of the mesiobuccal
root and the corresponding puff of sealer into the periapical radiolucency.
The patient returned one week later without any postoperative symptoms,
and the fistula was closed.
So remember, don’t always believe what you see.
It is OK to do a little second-guessing.
November-December 2005
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