Patient: 82-year-old female with controlled hypertension

Chief Complaint: Asymptomatic (2005)

Dental History: The patient’s dentist noticed localized periodontal bone loss involving the furcation on a routine dental radiograph. The crown had been placed an unknown number of years earlier (2005)

Significant Findings: 6mm pocket at the MB line angle area with bleeding upon probing, no response to cold thermal stimulation, and a wide-banded radiolucency encompassing both roots and the furcation presenting on the radiograph (2005).

Diagnosis: Necrotic Pulp/Combination Endo-Perio lesion, chronic periradicular periodontitis (2005)
Prognosis: Guarded (2005)

Treatment Plan: Nonsurgical Endodontic Treatment (two steps with calcium hydroxide) with a Decision Point before completing treatment to assess the periodontal status for initial healing (2005)

Treatment Description and Special Considerations:

This patient presented with the classic signs of a cracked tooth, but the differential diagnosis definitively included a combination primary endo/secondary perio lesion due to lateral or furcation accessory canal acting as a route of disease transmission to the surrounding periodontium. If the pulp had been vital, the prognosis would have been poor. One month after cleaning, shaping, and filling the root canal system with calcium hydroxide, the periodontal defect healed and the prognosis was re-assessed as favorable. The 7-year recall exam and radiographs with a CBCT scan demonstrated clear osseous regeneration and healing. There was no crown-root fracture detectable during the initial access appointment when the pulp chamber was inspected with the aid of the microscope.

Key Learning Points:

1. Furcation accessory canals are very common and have been reported to exist with as high a frequency as 30% in lower molars

2. Never make a radiographic diagnosis without clinical testing

3. Creating a strategic decision point before finishing a combined endo-perio lesion case, allows validation of initial periodontal healing and a good prognosis before proceeding with definitive therapy (i.e. completion of endodontic treatment)