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Case of the Month

<< Back to 2005 Case List

January 2005 – Treatment Plan Decision Compromises Long Term Surgical Result

Fig. 1 - Upon Presentation

January's case of the month involves treatment that I originally provided in 1993. The patient arrived in my office after having had endodontic treatment and post and core crown restoration of this mandibular left first molar. Her current complaint was slight percussive sensitivity and inability to comfortably chew on this tooth. The restoration had been placed within the last 18 months. A radiolucency was present at the mesial root apex. Periodontal findings were normal and percussion sensitivity was confirmed. A diagnosis of chronic periapical peridodontitis was made.

The patient was adamant that the crown remain in place and that we avoid removal. At the time of initial crown placement, she had dental benefits while living in another part of the country. Since then she had moved and had lost her benefits. The patient claimed that she was no longer in a financial position to be able to afford the fee for endodontic disassembly retreatment and placement of a new restoration. She did not want to risk porcelain fracture while attempting to have it removed.

After some discussion, I suggested that surgical resection of the Mesial root and placement of a retrofilling could be performed. At the time of the initial examination in 1993 I was (unfortunately) less resolute in my insistence that the coronal portion of the endodontic/restorative treatment be no less than optimal. This compromise of treatment standards was to most likely doom the case to eventual failure.

Fig. 2 - SRCT on Mesial Root
Note the amalgam Retrofill circa 1993

The surgery was performed and the root resected. Although I was not using a surgical operating microscope at the time, I beveled the root to allow for filling of both canals as well as taking care to retroprep and fill the isthmus. I was fairly happy with the clinical result but something was nagging me: What about the coronal aspect of the canal? Was there a space in there? Perhaps the core material was radiolucent and it wasn't actually a space in this area? ( Fooling myself ?!) It was too late to find out now - I had made my decision at the time I initiated the surgery. My willingness to acquiesce to the patient's financial pressures would to be my undoing.

Over the next 10 years the patient was seen for several other conservative endodontic treatments. This tooth was never acutely sensitive but the patient said that it never felt completely comfortable.

Fig 3. - 12 Year Recall - Sensitivity



Figure 3 shows a 12 year recall image with a diffuse radiolucency at the mesial root apex. The patient was now reporting sensitivity to chewing, sensitivity to buccal palpation and was not comfortable eating in the area. The discomfort was not acute, yet it was significant enough for her to seek a consult with me.

Fig 4. - 12 Year Recall - Open Mesial Margin?



Closer examination of the mesial crown margin revealed it to be open. The coronal aspects of the mesial canals were now surely contaminated. Although I assumed I had achieved apical seal to the best of my ability, this case could never succeed in the long term without addressing this coronal leakage problem. Rather than attempt to definitively retreat the tooth a final time, the patient elected for extraction. She would include the tooth in her new partial lower denture that would also replace two molars on the right side. Again, implants were simply not an affordable option for her. I am awaiting the gross specimen and will post the photos should I receive it upon extraction.

Conclusion
Endodontics is all about keeping contaminants out of the canal space. Bacterial ingress at any point along the apical-coronal continuum will cause the case to fail. In this particular case, I was persuaded to compromise on my treatment principles by a patient who placed unreasonable constrains on the treatment. My compromise of led to failure of the treatment. Had I insisted that the case be disassembled and conservatively retreated, chances are she would still have the tooth today.

Unfortunately, we must also practice in the real world, where patient's finances are not unlimited. The patient understood the risks when we started and would have to be satisfied with the knowledge that for the original lesser surgical fee she retained use of the tooth for over a decade.

The moral of the story is that compromise in any aspect of Endodontic treatment will often lead to eventual failure and loss of the tooth. Do what you know is right..