|Case of the Month
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March 2003 – Space - The Final Frontier
Endodontic treatment is sometimes regarded as "Placing little white lines" in the radiographic canal space. It can be very satisfying for the clinician when properly performed endodontics are combined with a well designed, well executed restoration. However, should the tooth become symptomatic, the endodontic treatment is almost always viewed as the cause of symptoms. The case is most frequently referred back to the Endodontist, m most often with a note saying that the tooth is "sore". This occurs even though the problem may be related to the occlusion, periodontium or other non-endodontically related problem. The fact remains that once the Endodontist performs endodontic treatment on a tooth...once he places those "little white lines", he now "owns" the case and all the problems that may go with it...forever. When you understand that concept, you can appreciate that it is quite a vulnerable position in which to be placed.
One of the biggest problems that is faced by Endodontists is the referral's lack of understanding of the effects of empty, unfilled canal spaces...anywhere in the tooth, not just during at the apices.
March's Case of the Month continues our examination of the topic of restoration of the endodontically treated tooth. Last month's case( February 2003) showed how orifice bonding can enhance the endodontic seal and prevent ingress of contaminants into the previously completed canal orifices.
I treated the maxillary second molar approximately two years ago (Fig. 1). The case was uneventful aside from a very large accessory canal in the palatal midroot. (Note the sealer splash). The case was sent back to the referring dentist for restoration. A post space was prepared, depth and reference point both noted on the post op report. I also mentioned that the first molar appeared to have radiolucencies at the apices. Pulp tests performed at the time of the endodontic treatment showed this tooth to be non-vital. ( Probably due to the depth of the amalgam) I recommended to the dentist that this also should be treated. The patient was asymptomatic and elected to leave the tooth without treatment for the time being.
Figure 2 shows the area approximately two years later. I was asked to eventually treat the first molar as I suggested. Upon presentation of the patient, I became alarmed when I examined the previously treated second molar. Although the tooth had been restored with a full crown, there was no evidence of any material in the palatal post space preparation. The canal had been left virtually untouched ( Green arrow). Furthermore, the orifices had apparently been excavated to a level below that of the original level of the gutta percha fill, without placement of amalgam into the prepared space. Large voids were now left ( Red arrows) which will no doubt accumulate fluids as the crown margins leak with time. (This is inevitable, as all crown margins will leak eventually to some extent.)
This may not seem to be much of a problem at the moment. But it raises some questions that have serious ethical and financial implications if the case eventually needs retreatment:
It is very likely that this case will fail ( endodontically), NOT because of anything wrong with the endo treatment or through any fault of the patient. The case will fail because of the restoring clinician did not understand the implications of lack of coronal seal and the dangers of unfilled canal spaces.
- What if the case needs to be Endodontically retreated because of this?
- Should the Endodontist retreat the case for free ?
- Is that fair?
- Should the patient have to pay for the retreatment?
- Will insurers agree to pay for endodontic retreatment in such a case?
- If disassembly is required, who should be responsible for the cost of the new restoration, especially of was only performed a year or two previously?
- How do you go about explaining the liabilities of this type of treatment to referring clinicians without offending them?
For years, Endodontists concentrated on apical seal. More recent attention has focused on the role of coronal seal, and it remains the "great endodontic unknown." Just how important is it to overall success? Because of the variations in endodontic techniques, timing and methods of restoration, a clear, absolute correlation between coronal seal and Endodontic failure will probably never be able to be made. But, one concept remains clear : For the completed case to be successful, Endodontists must still rely upon the restorative dentist to make the right decision when it comes to restoration of the tooth. This means designing the restoration in a manner that adequately seals the canals from the oral environment and prevents bacterial ingress. Spaces, in any form, should be avoided and efforts must be made to ensure that coronal and canal seal are one continuous entity. Although Endodontics often does an admirable job of filling the canal system, coronal space is the final frontier that must be addressed for overall treatment success.