Every now and then you get a case that makes your heart sink into your stomach. You know that feeling that I am talking about. All is going well, but then you see something in the radiograph you wish you could erase. (Talk about close to the nerve! You could say this case HIT a nerve with me.) Yes, this was one of those situations.
Luckily, this tooth story has a happy ending, but we need to be prepared for these things when and if they do happen.
So, here we go. This case was pretty simple, it was your average endodontic case.
Let’s take a look at the radiographs.
Caries into the pulp, and the canals look wide open, which is always a holiday for me!!
This patient had no real pain, just some slight tenderness to percussion. He felt cold, but the cold didn’t bother him so much. I diagnosed this tooth with Asymptomatic Irreversible Pulpitis and Symptomatic Apical Periodontitis.
The case was going smoothly, I was at a good working length, my cones fit to working length—all was well.
So I obturated… and this happened…
My patient didn’t jump. Fortunately, he never felt a thing. So that gave me some hope that this would all be okay. But, to be honest, I wasn’t going to know the true outcome until I did my postop call the next day.
I knew I needed to take a CBCT before he left to see what was really going on. Remember, we are looking at the tooth in 2D here, so viewing it in 3D is best. You never know what’s superimposed.
Luckily the sealer was actually lateral to the nerve. Now, it’s still pretty close, and so I still was a bit nervous. Luckily, when I called him the next day, he was fine and had no abnormal discomfort or numbness.
This is my question to you: how are you going to prevent things like this from happening? Do you use a different sealer when you are close to the nerve? Are you using a CBCT to let you know how close you are to the nerve? Do you instrument differently at the apex if you are close to the nerve? Those are definitely questions I ask myself in a case like this.
Let’s take a look at the protocol in cases like this.
What if it actually did cause a problem in this case? What is your protocol?
My first instinct would be to get an oral surgeon involved. They will then assess the severity and see what treatment is necessary. My understanding is that they would start out with a prescription for Neurontin and Medrol (but don’t take my word for it; this is an oral surgeon’s wheelhouse and not a formal recommendation on my part as an endodontist). Based on the response to the medication they would evaluate if the patient would need any further intervention like surgery.
I called my OMFS just to pick his brain about treatment options if a case like this were to remain symptomatic. Surgery would require an incision in the neck, but it seemed that he was more comfortable doing it that way. Apparently, it’s hard to access intraorally, but if needed, he would enter at the point of the mental nerve. Then he would slowly pull the whole nerve out of bone to get to it and essentially clean it off. My surgeon friend said that, if there is no resolution within 6 months, then surgery is indicated, and you really shouldn’t wait at all beyond that.
Some may think that removing the tooth at this point will solve the problem, but I am not so sure it would have any impact at this point, because you would still need to remove the material.
So, as always, be careful when doing endo. Just when you think you get good, you will get a case that humbles you and keeps you grounded.
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