Doug Kase
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THING is for sure, it’s great to be the hero! Every once in a while
a patient comes along and you look at the radiograph and the clinical symptoms
and say to yourself, “this is a lost cause.” It’s one of those teeth
that makes you start off saying to the patient that the prognosis is guarded
and soon into the consultation “guarded” turns into poor which quickly
moves over to hopeless. Certainly in this day of implants, why play
around with a tooth that has a low probability of success, when extraction
and implant placement has a much higher success rate?
It is very important to present a patient with
all his treatment options. In this litigious society in which we
all practice, giving a patient all his treatment choices and possible outcomes
is part of proper informed consent. A patient must understand the
potential successes and failures and only then with that consent can a
heroic treatment be initiated. Fortunately for us, a poor outcome,
not a failure, usually results only in loss of tooth and puts us back at
square one, facing replacement with bridge or implant.
Here are two cases in which we gave it the
“old college try” and the patient clearly consented to the treatment and
understood the risks.
Kase’s Case 1
This patient presented with old endodontics,
cast post and core and PFM crown on tooth #30. Clinically, he had
swelling around the mesial root with a periodontal pocket that I was able
to probe to the apex of the mesial root. The radiograph (Figure 1)
confirmed the mesial bone destruction and also showed a possible instrument
separation at the apex. I informed the patient of the possible causes
and that there was a high probability of root fracture. Here is the
big “however”: due to the J shape of the bony lesion, there was a possibility
that this stemmed from the apex, and retreatment of the mesial root was
an option as long as he clearly understood the possible outcomes.
The patient did not want to lose the tooth and wanted to give the retreatment
a try.
I placed the patient on clindamycin to reduce
the localized symptoms and initiated treatment four days later. Conservative
access was made through the mesial aspect of the crown, and I exposed the
old mesial gutta percha fillings. I inspected the exposed pulpal
floor with the microscope and found no evidence of fracture. The
old gutta percha was removed, and the canals were re-instrumented to a
#40 at the apex with a .10 taper. A final rinse of chlorhexidine
was used and allowed to sit for two minutes. The canals were filled
using the EZ-Fill® technique (Figure 2).
I saw the patient two weeks later, and he was
still asymptomatic with no pocketing around the mesial root. The
patient returned two months later and is still asymptomatic and no pocketing
is evident. The radiograph shows that the bone is starting to heal
with a diminished size of the radiolucency particularly on the mesial aspect
of the root (Figure 3).
Kase’s Case 2
This patient presented with minor swelling at
the furcation (buccal side) and ability to probe about 3 to 4 mm apically
and lingually. The radiograph (Figure 4) confirmed a radiolucency
associated with the furcation. The tooth was restored with a carbon
fiber post and composite core and the apices showed no sign of radiographic
pathology. I told the patient that the tooth could be fractured,
the roots could be perforated or resorbed, or a furcation canal could be
the contributing factor. In any case, the prognosis was guarded and
the treatment choices were discussed as well as the possibility of
additional periodontal intervention.
I removed the distal post under the microscope
using ultrasonics and removed the mesial fills to below the level of the
radiolucency. I packed MTA in all the canals down to the level of
existing gutta percha and ultimately packed the floor with sealer and gutta
percha and sealed the access on a subsequent visit (Figure 5). I
saw the patient one month later; he was asymptomatic, and I could no longer
probe the furcation. At his three-month recall (Figure 6), the tooth
was still asymptomatic and there is radiographic evidence of healing in
the furcation. I can only assume that there may have been a small
strip perforation in either root, and the MTA has worked its magic.
Thus, my loyal readers, sometimes making a
heroic effort may be worth the risk.
September - October 2006
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FIGURE 1: Radiograph revealing
mesial bone destruction and possible instrument separation.
FIGURE 2: After filling the
canals with the EZ-Fill technique.
FIGURE 3: Showing that the
bone is starting to heal.
FIGURE 4: Confirming a radiolucency
associated with the furcation.
FIGURE 5: Showing the canals
packed with MTA.
FIGURE 6: At the three-month
recall.
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