I have to tell you, this case really pisses me off.
I had a patient the other day who came to see me for a consult. I actually know her — she is a dental assistant who I’ve worked with. She had some previous root canals that had been giving her some trouble recently. She had some swelling that came and went, so she sought help from her general dentist.
This is what her general dentist told her that really ticked me off — he told her “root canals don’t work and that is the old way of doing things”. So it was recommended that she extract her teeth and move on to implants. Now, I know I am hearing this from her second-hand, but she IS a dental assistant, so I feel like she is no stranger to dental lingo and can give me an accurate recount of the conversation. Her conversation with her general dentist did not sit well with her either, and she definitely did not want to lose her teeth, so she came to me for a second opinion.
So, here is her history and what I found on the examination, and you can tell me what you think.
Teeth #13 and 14 are the teeth in question, here are the preop radiographs:
She said her root canals were done by an endodontist, which is great, but I can already see issues with these root canals. Tooth #13 looks like it has a short obturation and tooth #14 looks like the MB obturation does not appear centered in the root. I was able to diagnose her with Previously Treated #13 and 14 and Asymptomatic Apical Periodontitis #13 and 14 because she had no pain to percussion at the time of the evaluation.
When I don’t know the whole tooth story, I use my CBCT to help me fill in the holes. Here is what the axial slice shows me:
“Holy missed canals, Batman!” No wonder why these root canals are not working! The two cardinal rules of root canal therapy have been violated.
You have to find all the canals and get to the end of every canal if you want it to work.
Let’s take a closer look at the root of #13 and the MB root of #14.
This coronal view of #13 shows clearly that the canal splits apically and there is a bifurcation, and the buccal canal has not been treated. You can also appreciate that the lingual canal has a short obturation, so this tooth doesn’t stand a chance.
Same thing goes for tooth #14. Here you see the MB2 canal not treated in that MB root. This tooth does not stand a chance to heal properly either.
I will tell you this MB2 was hard to find. The orifice of the MB2 was a few millimeters apical to the MB orifice. You can see in this postop just how far I had to trough in an apical direction to pop into this canal.
What’s crazy is that the MB2 has its own portal of exit and it took her 10 years to flare up. Isn’t it funny how the body works?
This patient is still in treatment as I still have to treat tooth #13. Since her current bridge is about 10 years old she also wanted to replace the bridge. We plan on temporizing her bridge prior to the retreatment on #13 to make the post removal a bit easier.
So, before you tell a patient that they need to have their teeth removed and replaced, make sure you know the whole tooth story first. Don’t assume that there is no more potential to improve the clinical situation.
Unfortunately, we will treat people by what we believe to be true ourselves, so THAT, my friends, is the purpose of these blogs — to help create awareness that more teeth are able to be saved than you think.
Final note: please be careful what you say to your patients and seek out a specialist evaluation if you really don’t know the whole story. Remember, we are in the business of saving teeth, so let’s do what we signed up for.
I wish I could afford ConeBeam to look at these teeth before treatment. I’m sure I would refer more out if I could see these bifurcations and extra canals. You did a great job with this one.
Dentists need to treat these teeth as though they were in THEIR mouth instead of falling back on extraction and implants IF they are reasonably restorable.
Thanks for having my back! If a cone beam is out reach for you, just knowing the possibilities and relying on someone with a CBCT to give you an accurate diagnosis is a start! Thanks for following-
Comment :/excellent endo traitement.
Liked the blog. There are so mnay things being said about extracting and implant is better i would like to save if its my tooth not just extract and implant
great efforts to save the tooth Dr. 👍🏻
Thank you so much for reading!
Excellent! This tooth should go many a mile now.. Also which Cbct are you using? The images look very sharp and clear.
Thank you Gautam – I’m using Carestream 9000, and I love it!
Great save! I agree I wish I had a cone beam to evaluate. Just amazing what you can see!
It IS amazing! Thank you for reading Payal!
We treat by what we believe and what we can achieve in a particular case rather than what can be achieved by a specialist!! Endo is quickly losing out to the aggressive implant marketing which promises life long solutions!! On a side note, What do you reckon is the success rate of RCTs?
Studies show that a root canal done well has the same success rate as an implant. But keep in mind that this is not comparing apples to apples — the high standards for how endo studies define “success” is not the same as how implant studies define “success”. However we’re seeing a paradigm shift with studies that are proving that implants are not the answer.
Thank you for reading and commenting!
Very Nice Sonia
Very Nice Sonia mam
Very nice mam…your posts always give me inspiration to work
Nicely presented case Sonia. Its really appreciated that you shared your work and knowledge to everyone.
And thank you for reading! Please help me spread the word to your other dental friends!
I don’t really understand why someone would say root canals don’t work when in reality we all know they do work and they’re really something worthwhile for to prevent a complete tooth decay. Even though I never thought on those lines I believe that this blog is an eye eye opener and everything you really need to read about the treatment service.
Thank you for putting this together in the most informative way!
Thanks so much for your feedback. Thank you for reading.
This is me! saying that they don’t work. Have had 3 done: 1 tooth 2 times, another tooth 3 times and another 1 time. Some by renown endodontists in my country. They all failed and it was painful to keep them in my mouth.
I can assume I have some weird tooth anatomy, one endodontist stated ‘what sort of tooth is this?’ I assume I have canals almost impossible to clean, point is I abhor root canals because they don’t make my situation better, they still hurt.
I really hate that there are only root canals and extraction as solutions. I envy people that have root canals that work
Hi Sorin, I’m sorry you have had so much trouble with root canals! I’m no stranger to the patient’s chair, myself, so I definitely empathize. Your story is why I believe so much in the power of ongoing endodontics education, both for specialists and general dentists. When we don’t stay up on our knowledge and keep our techniques strong, our patients suffer. I hope you’re able to enjoy a better outcome and relieve your pain soon.