CY – An endodontic success story

Case Report/Young Dentist Endodontic Award

Dr. Jamie Nelson, first-place winner of the Young Dentist Endodontic Award in the UK, demonstrates that no matter how bleak the outlook, there’s always a possibility for success

 

Abstract

This article is an account of a patient on whom I performed an endodontic treatment in general practice. It reports  the examination findings, demonstrates the thought process behind the treatment planning, and describes  the treatment as well as the results.

Case details

Patient details:
Name: CY
Date of birth: 12/05/1989 (24 years old)
Gender: female
Medical history: asthma (never been hospitalized for it)
Dental history: an irregular patient at a different practice
Social history: smoker (10 a day) and light drinker (socially 4-5 units a week).

Presenting complaint:

CY attended the practice initially for a second opinion, as the patient had been informed that the tooth was unable to be saved and would require extraction. The patient was also getting pain from her LRQ; the pain itself was characterized as follows: 

Site: LRQ — posterior region
Onset: worse when eating, but usually spontaneous 
Character: dull ache, sometimes feels like the tooth is throbbing
Radiation: has on occasion radiated up to her ear
Exacerbating/relieving factors: painkillers take the edge off the pain, but don’t eliminate it
Severity: a constant 5/10, but can jump up to a 9/10 at times

HPC: The patient initially had pain from the tooth 1 month ago, but the pain then subsided for a bit, to return much worse 1 week prior to the initial examination.

Patient’s wishes and expectations: I always like to gauge what the patient wishes to gain from the experience and make a habit of sitting with them for 5 to 10 minutes, trying to gain the information required to help with any difficult decisions. This patient was very concerned about losing the tooth, since she had a minimally restored dentition — only 2 existing fillings on the LR6 and UL6. However, the patient, came in with the mindset that she would most likely require extraction with local anesthetic (XLA); therefore, anything we could do would be a bonus.

Examination findings:

Extraoral (EO)

• right submandibular lymphadenopathy with mild tenderness

Intraoral (IO)

• soft tissues — tenderness to buccal palpation LR6
• hard tissues — LR6 TTP and grade 1 mobile —  occlusal caries seen LL6, LL7, and LR6
• perio — BPE — 222, 422 (9 mm pocket mesial LR6), OH — poor, 50% plaque score

Special tests

• vitality (sensibility) —– LR6 non-responsive to Endo-Frost (-50ºC)
• radiographs requested — RBW, LBW, PA LR6
• Justification for radiographs — caries detection and periapical pathology analysis of LR6

Radiographic report

• Site: right and left, upper and lower, distal of 7’s to mesial of 4’s 
• Justification: caries detection
• Exposure: 0.25 ms, 60 mA, 60 kV
• Grade: 1
• Report 
  • Caries —  occlusal radiolucencies LR6,  LL6, and LL7
  • Path —  furcation obliteration LR6
  • Perio —  good bone levels; no sub-gingival calculus

Radiographic report

• Site: LR6
• Exposure: 0.2 ms, 6 mA, 60 kV
• Grade: 1
• Report 
  • Caries — occlusal radiolucency LR6 
  • Path — large PA area with furcation obliteration LR6
  • Perio — good bone levels; no sub-gingival calculus; PDL space widening around mesial portion of the tooth

Summary of the findings

The patient attended with a grade 1 mobile LR6, which was TTP, had a 9-mm pocket mesially and was negative to sensibility testing. The LCPA radiograph of the LR6 showed a very large periapical radiolucency surrounding the root of the LR6, external root resorption around the mesial root, widening of the periodontal ligament (PDL) space mesially, and furcation obliteration. With all of this in mind, it leads us to a differential diagnosis of the following (as originally outlined by Simon, et al.¹):

• Purely endodontic lesion
• Perio-endo lesion
  • primary perio
  • primary endo
  • true perio-endo
• Radicular cyst

With all the symptoms taken into account, I came to a provisional diagnosis of an acute flare-up of chronic periapical periodontitis in which sinus drainage had been established through the mesial pocket.

Prognosis

Due to size of periapical (PA) area, mobility, 9-mm pocket, communication with oral cavity, and mesial external root resorption, the prognosis for this tooth is relatively poor, especially as mineral trioxide aggregate (MTA) was not available to me at the practice. All options were discussed with the patient, and she wished for the RCT to be done here at the practice and completed by me, though I have a very keen interest in endodontics, but no specialist training.  So a treatment plan was drawn up, and the patient was happy for treatment to begin.

Treatment plan

Acute
phase: Extirpate the LR6, course of antibiotic — 500 mg amoxicillin TDS 5 days (due to systemic involvement of the lymph nodes).

Stabilization
phase: Treat the periodontal issues, avoiding root scale debridement (RSD) on the LR6, in case of a perio-endo origin, in which cell damage caused by the RSD can limit the regeneration potential for the endodontic treatment.² OHI, diet advice, fluoride application, smoking cessation, and a fluoride toothpaste prescription (5,000 ppm).

Restorative
phase:
Restore carious lesions in LL6 and LL7. Complete root treatment on LR6, due to degree of tooth tissue remaining if a conservative access can be cut; restore with GIC and composite.

Maintenance
phase: Review RCT and perio at 3, 6, and 12 months.

Recall phase:
Caries risk — high; perio risk — high; oral cancer risk — medium; 3 monthly CE

Treatment completed

First visit — LR6 extirpation

A minimally invasive access was cut into the LR6 by preserving as much tooth tissue as possible. It greatly improves the chances of a long-term successful endodontic treatment. Ideally, all four sides of the tooth need to remain intact; this allows for better isolation and a stronger external tooth structure. Four canals were located and cleaned to the EWL at an ISO size 20 hand file with copious amounts of 2% sodium hypochlorite, and then dressed with Ledermix^®  and restored with GIC. A good access is key to locating canals quickly and by spending slightly longer to make it as neat as possible. It can really help. (Photos of the access are shown in Figures 4 and 5.)

Second visit — The patient reported she was out of pain after the extirpation was completed, which meant we could proceed to stabilize all other active disease. A supra- and sub-gingival scale was completed on all teeth except LR6 (in case of perio-endo lesion², smoking cessation given, amalgam restorations placed on LL6 and LL7 occlusally, and fluoride applied to all teeth.

Third visit — RCT stage 1 LR6

The temporary restoration was removed and all four canals relocated using hand files. Once relocated, the access to each canal was improved using Gates Glidden burs, a size 2 to 1/3 estimated working length (EWL), size 4 mm to 3 mm short of that, and finally, a size 6 counter sunk into each canal by no more than half the depth of the bur around 3 mm. (Doing this procedure also makes creating Nayyar cores much easier, as once the bulk of the GP has been removed, the size 6 Gates Glidden bur can be counter-sunk once again, providing a space for the Nayyar core to be placed.)

Each canal was then prepared to 2/3’s EWL using ProTaper rotary instruments sizes S1, S2, F1, and F2.³

Hand files were then placed into each canal measured to the EWL, and a diagnostic radiograph was taken. When taking a diagnostic radiograph on multi-rooted teeth, I use a mesial swing on the tube head in order to ensure each file is in a separate canal. This is shown in the diagnostic radiograph (Figure 6). Once the diagnostic radiograph has been taken, the tooth is dressed with non-setting calcium hydroxide and again sealed with GIC.

The radiograph then confirmed the working lengths for each canal as follows:

• MB — 18 mm (OA)*
• ML — 18 mm (OA)
• DB — 21 mm
• DL — 21 mm
• (OA) indicates open apex

Fourth visit — RCT stage 2 LR6

The obturation stage for this tooth brings its own challenges as there is no guarantee that a seal can be achieved with an open apex present, which is why, conventionally, MTA is used to close the open area and allow for an effective seal. This is what I would have done had MTA been available. Instead, I adopted a technique that had never been formally taught to me and prepared the mesial canals 1 mm past the radiographic apex in order to ensure effective cleaning at the open apex. All of the canals had been prepared to their EWLs to size F2 ProTaper³ with thorough irrigation of 2% sodium hypochlorite. (The irrigant used is warmed to increase effectiveness,⁴ and after placement, a hand file is used to ensure the irrigant reaches the apex.) The total time the irrigant spends in the canals accumulatively is 10-plus minutes; this combined with the time of the procedure exceeds 40 minutes.⁵

Obturation
A single point obturation technique was used with an 8% ISO 25 F2 ProTaper point — again a technique never taught to me. I placed the GP point beyond the apex until an apical twist back/tug back could be achieved (resistance to rotational or vertical displacement of the point once in place). Once that was achieved, the point was marked at the coronal end. This leaves the point long, essentially overshooting beyond the apex, but giving an apical seal. This “overshoot” is then removed by once again measuring the GP and simply snipping off the excess from the apical end (Figure 7). The shortened GP has essentially a custom thickness at the apex now and fits snuggly into the canal, hopefully, achieving an apical seal.

The canals were then lined with Tubli-Seal^™ (SybronEndo) and the GP cemented into each canal. GIC was used to line the GP as this provides a dynamic bond with the tooth, reducing the risk of GP contamination.⁶ The restoration is shown in Figure 8.

Once the restoration was complete, the postoperative radiograph was taken (Figure 9). The radiograph shows that the GP is to length, has a good taper and good density, and does not show any voids. 

Review stage

The patient attended her 3-, 6-, and 9-month review appointments and has demonstrated a huge improvement as summarized  in Table 1.

Also during the 9-month review, the 9-month post-op endodontic radiograph was taken (Figure 10).  The radiograph showed an almost complete resolution of the pathology and has demonstrated a successful endodontic treatment.

Results

Taking into account all of the  information presented, Table 1 shows a clinical breakdown of the LR6 comparing the pre- and posttreatment results. Figure 11 shows both preoperative and 9-month postoperative radiographs. 

This case demonstrates that no matter how bleak the outlook, there’s always a possibility for success. I myself treat difficult cases with an attitude summed up very nicely by Henry Ford:  “Obstacles are those frightful things you see when you take your eyes off your goal.”

References

1. Simon JH, Glick DH, Frank AL. The relationship of endodontic- periodontic lesions. J Periodontol.1972;43(4):202–208.
2. Singh P. Endo-Perio Dilemma: A Brief Review. Dent Res J (Isfahan). 2011; 8(1): 39–47.
3. Ruddle C. The ProTaper Technique: Shaping the Future of Endodontics. Endodontic Topics.  www.endoruddle.com. Accessed May 16, 2014. 
4. Cunningham WT, Joseph SW. Effect of temperature on the bactericidal action of sodium hypochlorite endodontic irrigant. Oral Surg Oral Med Oral Pathol. 1980;50(6):569-571.
5. Siqueira J, Rocas I, Favieri A, Lima K. Chemomechanical reduction of the bacterial population in the root canal after instrumentation and irrigation with 1 %, 2.5 %, and 5.25 % sodium hypoclorite. J Endod. 2000;26(6):331–4. 
6. Diaz-Arnold AM, Wilcox LR. Restoration of endodontically treated anterior teeth: an evaluation of coronal microleakage of glass ionomer and composite resin materials. J Pros Dent. 1990; 64(6):643-646.