October 2006 – Retreatment Solves Multiple Problems
This 71 Year old male presented with a history of previous endodontic treatment and acute periradicular abscess in this maxillary left second premolar (#25). There was both intra and extraoral swelling. Palpation was very positive. Percussion was acutely sensitive. Periodontal findings were within normal range but as expected, the tooth exhibited high levels of mobility and appeared extruded in the socket. The patient was afebrile but very uncomfortable. The only medical consideration was the presence of previous hip replacement prosthesis.
Radiographic examination showed previous endodontic treatment with a lesion of endodontic origin. The tooth had been restored with a post and core crown but a substantial portion of the post space was unfilled. The treatment appeared to be approximately 7 years old. A diagnosis of acute apical abscess and persistent periradicular pathology was made.
The crown was removed and the post space was found to be quite wet. Removal of the gutta percha filling material elicited purulent drainage from the canals (2 canals were found, one previously undiscovered and untreated.) Although the initial palatal canal working length instrument was long, I was pleased to see two separate foramina and a portal of exit that pointed directly to the heart of the radiolucency. This unfilled POE was the likely source of the pathology. The canals were cleaned and shaped and dried. CaOH was placed in the canal for 2 weeks. The swelling resolved and the patient became comfortable within 24 hours.
Cone fits (with sealer) showed an outline of a system with multiple foramina and a portal of exit on the mesial aspect of the root that appeared to be as big (or bigger!) than the “main canal”.
Final obturation was followed by creation of a post space AND placement of CaOH paste in the post space as an interim dressing to aid with interim asepsis. The case was closed with a sponge pellet and Cavit. The patient was told to have the tooth restored immediately.
This case showed multiple problems, an undiagnosed second canal, multiple POEs and previous post space contamination. Symptoms resolved once these problems were properly addressed.