What do you do when you see severe calcification? Sometimes, even I don’t know if a tooth is actually going to heal, particularly when I can’t follow the two cardinal rules of endodontics.
In my opinion, this special case broke the law, but it does serve to prove that sometimes, the remedy for our patients involves a tincture of time.
Diagnosing the Patient
This patient had no pain at all. The periapical radiolucency was an incidental finding at his 6-month cleaning. He didn’t remember any previous trauma, and honestly, he was irritated to be in my chair. (You know those patients that I am talking about. They’re the ones who have no pain and not only don’t understand why they are in your chair but also don’t believe a word you are saying to them.)
You can see from the periapical radiograph below that there is a lesion and that the apical third of tooth #26 has severe calcification. His probings were within normal limits, the tooth did not respond to cold, and there was no pain to percussion or palpation. I diagnosed the tooth as Necrotic Pulp and Asymptomatic Apical Periodontitis #26.
I gave this tooth two appointments, because sometimes I feel that maybe if I try again on another day, I just might have a better outcome. But the second visit just confirmed that this canal was blocked to the max — I wasn’t making any progress. It was severe calcification at its worst!
Is it Severe Calcification… or Just a Blocked Canal?
Now, this is not to say that you should stop short on your cases. In fact, it’s very rare that I run into this kind of situation — maybe 1% of the time. (Meaning that if you find that this happens to you a lot, there is most likely another issue at play.)
To me, there is a difference between true calcification and a tight canal. Most of the time, it is just a tight canal. If you can feel a little tackiness with your hand file, then there is more canal (as long as you didn’t ledge yourself out of the canal). This canal had a hard stop and I couldn’t feel that “stick” that I could follow to patency. I did use my Gentlewave on this tooth hoping it would open something up for me. When it didn’t, I obturated to the length that I could instrument to.
How to Respond to Severe Calcification
So what do I do in these cases? Well, this is the exact reason apicoectomies were created! If I can’t get to the end of the canal in an orthograde fashion, I know I can get there surgically. This is a good example of a case that could require surgery.
That said, if you’re dealing with severe calcification and you know that surgery is the best treatment, when exactly do you do it? Do you do it now, or do you wait?
The “Wait & See” Approach
Since I knew that the patient would likely have no pain, I decided to wait and see how he was doing at his one-year recall. That said, at the end of the appointment, I prepared him for the worst case scenario: the apico. I told him that I’d prefer to give the tooth one year to heal with the understanding that, should there be any pain, he would contact my office.
One year later, he actually showed up for his recall appointment! (This is always exciting because most people don’t show up. Would you agree?) And I’m not going to lie — I was a bit nervous to take the radiograph, because he’s not the warm and fuzzy type.
What Happened to the Lesion?
When I looked at the results of the x-ray, I couldn’t believe my eyes! One year later, the lesion was completely resolved!
Even with not getting to the end of that canal due to the severe calcification of the tooth. And you know, maybe it was the Gentlewave that made the difference, maybe not. Regardless, I am glad that I gave this tooth some time to heal on its own and didn’t rush into surgery. The lesson? It’s so important to remember to give teeth a chance!
A Positive Outcome
I hope this blog makes you feel better, because these challenging situations happen to me, too. And you know what? Sometimes, it’s not YOU… it’s the tooth. And sometimes, the anatomy is going to dictate what your root canal will look like. (Severe calcification be darned!)
You know, when I looked at my postoperative radiograph (it definitely wasn’t my prettiest root canal), I reminded myself that having a happy patient and a happy outcome is the ultimate goal.
In this tooth story, we hit the mark!