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!
-Sonia
P.S. For more tooth stories and helpful tips, you can follow me on Facebook, Instagram, or Linked In.
Can you please let me know if the diagnosis should be chronic apical periodontal abscess instead of periodontitis?
Hi Dr. Gudipati, thank you for your question. In this case, the AAE-accepted term of asymptomatic apical periodontitis applies since there is no pain to percussion, but a lesion is present. -Sonia
Thankyou Dr. Sonia for sharing your interesting cases with us. It really helps to critically think about the most challenging cases and that what Endo is about!
Regarding this case, i am just wondering why did you opt for a CBCT scan in the middle of the treatment when you couldn’t reach the apex.In my opinion, i would go for a CBCT to confirm what exactly was going beyond that dead end point. May be it would help me and my patient to explain in a more better way what exactly was happening.
Thankyou again for sharingyour love for Endo. Keep sharing please.
Regards.
Hi Ahmed, I knew that this outcome was a possiblity from the very beginning from my preop CBCT. I actually had the discussion with the patient about all of this before I started. I don’t see how another CBCT was going to tell me anything new, and I didn’t feel it was necessary to radiate the patient anymore. -Sonia
Thank you for sharing the information. My question is, in your 1 year follow up radiograph we can see a slight shadow of the canal in the apical portion of the tooth which was densely calcified before. Does that mean there is also some reduction in calcification with the elimination of lesions?
If yes, will you go for re-treatment to obturate it more apically or you will just leave this case right here?
Thank You
Hi Dr. Singh, I think what you are seeing here is a decreased area of attenuation in the imaging. This does not always correlate to a canal being there. That being said, if there is no lesion and no pain, I would not treat this tooth any further. Hope that helps! -Sonia
Great case to learn .
Thanks a lot
Hitesh, Thank you for reading! I’m glad you found this case helpful. -Sonia
Hello ma’am.. i always struggle with accessibility with respect to second molars especially maxillary teeth.. Does it happen to you too?
I am an endodontist with 3years clinical experience
Hi Dr. Bhat, thank you for your question. And yes, it happens all the time! It depends on how the tooth sits in the mouth and how wide the patient can open. I have mini heads on my handpieces and short files for a reason, LOL. – Sonia
Amazing…this is why I love to read your work… there a positive outcome and u bring a lot of hope ….
Thanks for sharing
Fatema, Thank you for reading! I’m glad you got so much out of this case. -Sonia
Thanks Sonia , for sharing exciting case and your approach.
Hi Khalida, Thank you for your feedback! I’m glad you enjoyed this case. -Sonia
Wonderful experience and outcome Tk to shear !!!
Hi Vivian, Thank you for your feedback! I’m glad you found this case helpful. -Sonia
Hi Sonia, It was a nice case to learn one more aspect of endo. I have a question, if there is no periapical lesion in this case, the canal is fully patent, but there is no response to cold test, asymptomatic patient (Necrotic pulp with normal periapex), would you still be doing root canal for this case?
Hi Krupah, It depends – are you interpreting your cold test correctly? It’s possible to have a necrotic tooth that does not have a lesion. So, yes, if there is evidence that the tooth is necrotic due to bacteria getting into the pulp, then I would still do the root canal. – Sonia
Hello Dr Sonia 🙂 I am a general dentist but an endo enthusiast… so upto how much ever knowledge I have or have been learning, canals are calcified coronally and once patency is gained then we always have a way to reach till the apex…..so can you please guide further regarding this particular case ……
Yasmin,
Can you please let me know exactly what your question is. I am a bit confused. Thank you so much in advance.
-Sonia