I recently worked on a case almost a decade in the making. While the patient’s story had lots of twists and turns, this is ultimately a tale of getting people out of pain, the importance of diagnosis, and treating periapical lesions in endo effectively.
Ready to take a journey across 9 years of radiographs with me? Let’s go!
Endodontic Periapical Lesions: A Tooth Story
I love this case that I am about to share with you.
Long-term recalls can tell you so much about root canal therapy and what it can do to preserve those pearly whites that you were born with. I love this tooth story and other cases like it because they help us understand the etiology of dental disease and infections.
It is really easy to assume the worst when it comes to endodontic periapical lesions and other varieties of infections, but we need to be careful because these assumptions can create whole belief systems that actually don’t serve our patients in any way.
If you have been following me for some time, you know that I am pretty passionate about saving teeth, but I am even more passionate (if you can believe it!) about changing beliefs around saving teeth among dentists and their patients.
I invite you to read this case study with an open mind and a willingness to question your beliefs about which teeth are savable.
Let’s Dive In
This 38-year-old patient came to see me as an emergency case several years ago.
She had intense pain, and her chief complaint was that she was very sensitive to cold. She was really anxious, and I could tell her personality was being impacted by the severe pain she had been dealing with. My heart really went out to her.
Do you ever have patients like that? Where you know you aren’t meeting the “real them” because they are just in so much pain? It’s heartbreaking.
I know the trauma of that experience firsthand, because I have been one of those patients before. As a result, I’m super very sensitive and empathetic when I see someone like that come through my doors.
Here is her referral slip…
And some radiographs …
She had severe lingering pain to cold on #2, there was a small crack line on the distal marginal ridge and teeth #2 and 3 were tender to percussion (#2 being slightly more tender).
I diagnosed her with Symptomatic Irreversible Pulpitis and Symptomatic Apical Periodontitis #2, and we started emergency root canal therapy at that very moment due to her pain level.
I called the patient the next day, and she stated that she was feeling much better, and I was relieved to hear it.
But … plot twist!
She called our office the following week and stated that “something still didn’t feel right.” Hmmm.
This case was done long enough ago that I wasn’t taking preoperative cone beam scans back then. (Another learning lesson for me! These come in clutch, my friends.)
Upon her return, I decided to take a scan to see if there was anything that I was missing or that the 2D didn’t show me. And much to my surprise I saw this…
You guys, I was FLOORED.
I saw a GIANT endodontic periapical lesion that extended from the MB root of #3 to the distal of #2.
Since #2 was vital, I knew that this lesion had nothing to do with #2 and was completely associated with #3. As I further evaluated #3, I noticed that there was a wicked dilaceration of the MB root, some pretty severe hypercementosis of that root and an untreated MB2.
Based on this information, I knew the etiology of this lesion right away… the bugs that never left that tooth causing a periapical lesion and a whole lot of pain. Oof. (Side note: you can appreciate the sinus membrane thickening as a result of her odontogenic infection!)
In order to save #3, I would have to find the untreated canal and achieve patency on the mesial root. The problem is that with all of that hypercementosis, and that wicked curve, that might not be possible without a file separation occurring.
So, I explained to the patient that she would likely need an apicoectomy on that tooth to get any healing. I also detailed that, since the lesion was so big, the treatment plan of a surgery would be really messy in that area.
Together we decided that extraction of tooth #3 would probably be the best choice for her long-term success. And so she was sent to the oral surgeon.
The Story of this Endodontic Periapical Lesion Continues …
A few days later, the patient called my office again.
This time, she said that the oral surgeon was planning on extracting both teeth #2 and #3, and she was really confused. The surgeon believed that the area would not heal unless both teeth were extracted.
I didn’t necessarily agree, so, I called the oral surgeon and asked him if he could just take out the one tooth (#3) for now. If we didn’t see any improvement, we could always take out tooth #2 later. He agreed, but with a good bit of hesitation.
I didn’t hear from her again after that extraction, so my thoughts were that it must have gone well. She came back for her one year recall and you can see that #3 was extracted and a bone graft was placed, and all was healing really well.
I think her CBCT showed an even more miraculous recovery.
The periapical lesion has completely resolved, the bone graft looks like it has integrated well and the sinus membrane has returned to its original position.
I didn’t hear from her again for a long time. And then, one day, she had a toothache in a different tooth: #18.
While she was in the office, I wanted to see how the upper right side was doing. This is now 9 WHOLE YEARS LATER! So, we’re talking almost a decade since this patient first walked into my office in massive pain.
I think that it is interesting to see that the sinus membrane is slightly thickened now after the implant was placed, but without tooth #3 and with no implant there was no thickening at all. It’s not bad thickening, just a finding.
Interesting food for thought, don’t ya think?
What Can We Learn?
The point of this blog is to support a more comprehensive understanding of the periapical lesion in endo.
Vital teeth don’t cause lesions, so you know that the entire periapical lesion is coming from tooth #3 and nowhere else, even though the lesion was expanding across a few teeth.
Remember what I said about my passion for changing the beliefs of dental professionals around saving teeth? This matters so dang much because it affects the lives that we touch as dentists, no matter which speciality you practice in.
I will say this over and over again for the entirety of my career: DIAGNOSIS is KING in endo (or dentistry of any kind for that matter), and YOU have an impact on patients’ well-being, whether you do root canals in your practice or not! Diagnosis IS endo, my friends.
And if you DO root canals, there’s always something more to discover and new ways to enhance your diagnostic skills. If you’re ready to invest in your endo abilities and confidence, check out E-School: Everyday Endo Made Easy.
Let me know what you learned down in the comments!
Why did she feel better after RCT on #2? You stated it was vital. Did it seem like healthy pulp when initiating RCT? I feel like #2 was park of the problem
I think that she had two independent issues.