Case Report

Ryan Lavene

SUBJECTIVE

Chief Complaint: “My tooth aches occasionally when I bite on it.”

Medical History:  He has no known drug allergies.  He describes his health as “excellent” and has no known medical conditions.  He denies taking any medication.  Vital Signs:  BP 126/74  P 68.

Dental History:  He had orthograde nonsurgical root canal treatment on #30 “over five years ago.”  In April of 2004 #30 was endodontically retreated nonsurgically by an endodontist.  He lost his dental insurance so he was referred to the graduate endodontology clinic for evaluation and treatment of #30 due to persisting symptoms.

OBJECTIVE

Extra-oral Exam:  Within normal limits.  No swelling, lymphadenopathy, or facial asymmetry was noted.

Intra-oral Exam:  #30 presents with an occlusal amalgam restoration sealing the occlusal access.  His oral hygiene is good with only mild plague accumulation.  #30 has 2 to 3 mm of facial gingival recession.  No swelling or sinus tract noted.  #32 is missing.

Diagnostic Findings:

Radiographic Interpretation:

#30 periapical radiolucency associated with the mesial root.

ASSESSMENT

#30 Previous endodontic treatment with symptomatic apical periodontitis

PLAN

Recommended surgical root canal treatment of #30.  The following alternative treatment options were presented: 1. Extraction, or 2. No treatment.  He was informed of the risks involved in surgical root canal treatment including paraesthesia, possibly identifying a root fracture, post-operative pain and swelling, possible bruising, and the likelihood of healing.  He was informed that his prognosis was good and he consented to Surgical RCT for #30.

TREATMENT

He consented to the surgical root canal treatment of #30.  Vital Signs: BP 144/76  P 80.  Dispensed 800 mg ibuprofen to the patient pre-operatively and had him rinse with .12% chlorhexidine for 1 minute.  Administered 72 mg lidocaine with .036 mg epinephrine by inferior alveolar and long buccal nerve blocks.  Performed an intrasulcular incision from the distal of #31 to the mesial of #28.  Vertical releasing incision at the mesial of #28.  Reflected a full mucoperiosteal flap and no dehiscence or fenestration was noted.  Created an osteotomy with a #6 carbide, round bur.  Resected approximately 3 to 4 mm of the root-ends of both the mesial and distal roots with a multipurpose bur.  Curetted tissue at the apex of the mesial root and submitted for biopsy.  Both the mesial and distal roots had two gutta-percha obturated canals with an isthmus between the canals.  Achieved hemostasis with CollaCote saturated with 10 drops of 2.25% racemic epinephrine.  Stained the root ends with methylene blue and no fractures were noted.  Root-end preparation of the 4 canals and the connecting isthmuses was done with KiS Ultrasonic tips.  Placed MTA using the MAP System and reapproximated the tissues.  Two periapical radiographs were taken.  Placed continuous locking sutures with 5-0 vicryl.  Gave written post-operative instructions along with ice and a bottle of .12% chlorhexidine.  Wrote prescriptions for ibuprofen 800 mg qid for four days and Vicodin 5mg/500mg prn pain.  He was reappointed to return in three days for suture removal.

Final Radiographs:

Post-operative sutures:

He returned three days later for suture removal.  He reported feeling well “just a little sore.”  #30 was still slightly percussion sensitive but WNL to palpation and mobility.  His pathology report returned as a “dental granuloma.”