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.
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