Patient: 49 year-old female with mild controlled hypertension, rhinitis, and asthma (at time of treatment, 1999). There was a history of tuberculosis a few years before the 2014 recall examination.
Chief Complaint: Tooth pain after recent crown (1999)
Dental History: The patient reported continual pain since a new PFM crown was placed two weeks before her endodontic exam (1999). Her referring dentist has performed an emergency pulpotomy through the crown.
Significant Findings (localized to tooth #4, 1999): Severe percussion sensitivity, slight mobility (less than Class 1), moderate gingival inflammation, and radiographic evidence of periodontal ligament space widening with a lateral radiolucency (distal middle third of the root)
Pulp and Periradicular Diagnosis: Necrotic/Chronic Periradicular Periodontitis (Tooth #4)
Treatment Prognosis: Good
Treatment Plan: Nonsurgical Endodontic Therapy (Tooth #4)
Special Considerations of Performed Treatment:
It is not uncommon for endodontic therapy to be required after the preparation of a tooth for a crown or bridge abutment (15-30% of teeth having a full coronal preparation end up needing endodontic therapy either before, during, or even years later after the restorative procedure.
In this case the patient was referred to the author after pain developed following the placement of a crown. Maxillary and mandibular bicuspids are known to have a high frequency of lateral/accessory canals. Modern emergency management of pulpal disease should employ aseptic isolation with a rubber dam, complete pulp debridement, and placement of a well-sealing temporary. The patient failed to have relief of pain when her general dentist attempted to manage the initial abscessed tooth. Although the patient's pain had subsided after the pretreatment prescription of antibiotics, a single visit endodontic treatment did not result in complete resolution of symptoms and a second visit was required 3 months later to clean, shape, and repack the root canal system. The author has since changed his protocol to treat necrotic pulps and retreat previously treated root canal systems in two visits spaced 1 month apart with intracanal calcium hydroxide.
After the second treatment visit (3 months after the first treatment attempt), the patient's symptoms completely resolved and she was followed up on recall numerous times (7/11/2000, 11/11/2004, and 1/17/2014)
The tooth has been properly restored with a well-fitting crown throughout that period.
Recall Examinations:
3/8/1999 (2 months after initial endodontic treatment): Patient's symptoms continued at a lower, but significant level (endodontic retreatment was performed on 4/12/1999)
7/11/2000 (15 months after endodontic retreatment): all clinical signs and symptoms were within normal limits
11/11/2004 (5 1/2 years after endodontic retreatment): all clinical signs and symptoms were within normal limits
1/17/2014 (15 years after endodontic retreatment): all clinical signs and symptoms were within normal limits and CBCT scan taken
Key Learning Points:
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Single visit endodontic treatment on symptomatic, abscessed teeth can sometimes lead to prolonged unresolved symptoms and fail to completely eliminate disease
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Post-treatment signs of complete osseous regeneration may take years or even a decade to occur when observed with three-dimensional imaging (CBCT)
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Nonsurgical retreatment should be favored as opposed to surgical retreatment whenever possible and/or practical. Surgical retreatment has a lower long-term success rate due to complex root canal system anatomy (especially in teeth like bicuspids having a high frequency of lateral/accessory canals)
- Long term observation of a clinician's own treatment results is an invaluable education that should lead to prudent improved conservative modifications in case management.
All Practicing Dentists Should Employ A Diligent Recall System in Their Practices to Monitor Their Own Treatment Outcomes