I always love a good recall. Why? Because I love to show these types of cases when people tell me that endo doesn’t work. I can’t tell you how many comments I see in these Facebook groups suggesting an implant because the endo is just going to fail in another 5 years. Even if that’s true that the root canal may fail in the future, I always ask…isn’t an implant in 5 years going to be better than the implant that is available today? ‘Nuff said.

Anyway, I want to share a case with you that even makes ME think about and question my treatment plan. Listen, I don’t have a crystal ball and I need my patients to know that some of my treatments are not going to work. But that doesn’t mean that I don’t stop trying. I am completely transparent with my patients and I give them their options. So when you are in this situation (since it ain’t your body) let your patient make their own decision. If you can’t do the treatment, don’t change the way you have the conversation with the patient. Instead, refer it out if you have to, and see what your specialist can do. Now, if they consistently tell you to extract the tooth, then you have a problem.

Let me show you this example.

This patient presented with pain to percussion on tooth #2. The tooth had been previously treated so it had no response to cold. So her diagnosis was Previously Treated and Symptomatic Apical Periodontitis.

The periapical radiograph looks kind of normal and one can say that the root canal looks like it was done well –maybe just a small overfill on the palatal canal, but that doesn’t really bother me. Again, since I always want to know the full tooth story, I take a cone beam. And to my surprise…

There is a giant lesion with a sinus communication.  Now, the sagittal slice shows a big lesion, but the axial slice shows an even bigger dimension of the lesion…

This lesion encompasses the whole tooth!! Now, many people would take one look at this case and say this tooth is not restorable because that lesion is just too big.  Wait, what? I have said it before and I will say it again….

SOMETIMES SIZE DOES NOT MATTER!

Endo is the one place I know of where size does not matter, and those bigger lesions just don’t scare me. In fact, it amazes me how sometimes patients don’t have more pain when I see things like this. And if you are just starting out using a cone beam, you are going to see all sorts of things that will scare you. But that’s because we are so used to seeing things in 2D with our PAs. So remember, things will always be much bigger when you visualize it in your cone beam.

So when you look at this case, what do you see?
What possible etiologies of failure do you see?
Is it a crack?  Heck no!
Is it a missed canal? Well, maybe.
But you know what, even I didn’t know. And sometimes I don’t know until I try.

One thing I did take notice of was that there was still intact buccal and lingual bone in the axial view.  So there were no probings in this case.  I don’t just rely on my CBCT imaging to give me the answer. I also marry it with my traditional tests to see how my findings correlate with each other.  Right away, because of this, a cracked tooth goes to the bottom of my differential diagnosis.

Since I don’t know why this tooth is failing, I let my patient know.  Luckily she was intent on saving her tooth, but not all patients are as driven as she was.  So those are the moments that it is up to us, the dentists, to be the patient’s advocate.  But, if you DON’T believe a tooth can be saved, then you’re going to treatment plan for the implant, aren’t you??

Of course, I decided to retreat this tooth, but not until I had a very thorough discussion with my patient.  My patient totally knew that my efforts could be questionable. And she knew that I may not have an answer for her until I did a one year recall to actually see if the bone was regenerating.  She signed up, understanding all the risks involved.

I didn’t feel like I needed to give away my time for free. See, you can try the procedure and it can fail, and you can still get paid for your time. Why do we feel like we need to give a refund if our efforts don’t work? If you talk about it thoroughly and document that presentation well, you won’t run into a negative situation in the end. If this is a struggle for you, I would love to talk about it, so leave me a comment below.

Ok, so when I accessed the tooth, the gutta percha was sooo black. I kind of love it when I see that because it tells me that I can improve the situation.  By the way, I did also find a missed MB2 that was very hard to see in the CBCT. But, in retrospect, the MB canal is slightly offset to the buccal, so there is room for that canal in the root. Let’s take another look at it. 

I removed the contaminated filling and medicated the tooth with calcium hydroxide. I let that tooth medicate for about a month and then obturated the tooth.

As I said in the beginning, I always love a good recall.  So here it is…drum roll please!

One year later that bone is back baby!!  And here is another view to prove it…

And another where you can see my MB2…

 

So, before you go extracting teeth, think of all the possibilities.  If you put my post-op radiograph next to the preop radiograph, they don’t look very different, so don’t judge a book by it’s cover…you just never know what you might find inside.  

-Sonia

 

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