Case Report

Todd Miller

Subjective:
Chief Complaint: “My dentist couldn’t finish my root canal.  The tooth never got numb.”

Medical History: 12 y/o male.  ASA I.  Suffering from anxiety and attention deficit disorder. NKDA. The patient is currently taking Adderall.

Dental History: It has been two years since the patient has had a dental prophylaxis.  He was seen by a general dentist approximately one and a half months ago on an emergency basis due to cold sensitivity in the lower left quadrant.  The general dentist initiated root canal treatment on tooth #20.  Due to difficulties obtaining profound anesthesia as well as anatomic challenges, the dentist did not complete treatment and instead placed a temporary filling, and referred the patient to OHSU.
 
Objective:
BP: 110/71   Pulse: 88
Clinical Evaluation

EOE/IOE WNL. No swelling, lymphadenopathy or sinus tract noted. The patient has a composite resin filling on the DO of tooth #20, with a temporary filling in the access opening.  Tooth #19 has an existing occlusal amalgam restoration.

Radiographic Evaluation:
20 was previously accessed, is shorter in length than tooth #21, and has loss of definition in the apical 1/3rd.  A radioopaque material can be seen filling the coronal 2/3rds of the canal space.

Assessment: #20: Previously initiated treatment, with symptomatic apical periodontitis.

Plan:
Recommend completion of NSRCT #20.  Prognosis is favorable.  PARQed patient and patient’s mother including possibility of perforation, separated instrument, failure of RCTs, need for permanent restorations upon completion of RCT, and possible need for apical surgery in future if tooth if resistant to initial therapy. Patient and pt’s mother consented to treatment.

Treatment:
PARQ, consent. 1.8 cc 2% Lidocaine HCl with 1:100,000 epinephrine via Gow-Gates.  0.9 cc 3% Carbocaine HCl via intraosseous injection.  RDI and access.  Ca(OH)2 paste removed and canal orifices were located.  One round lingual orifice and one broad, ribbon shaped buccal orifice were visible through the dental operating microscope.  Root ZX II electronic apex locator was used for establishment of working lengths, which were confirmed by radiograph. 

Working Film with 20/.02 files in the lingual and buccal orifice at EAL established lengths of 17.5mm.

Cleaning and shaping procedures were completed using pre-curved stainless steel hand files as well as nickel titanium rotary instruments.  Copious irrigation was performed throughout the procedure using 5.25% NaOCl and 15% EDTA.  After a final irrigation with 0.12% Chlorhexidine, and drying thoroughly with paper points, canal was obturated with gutta percha and Kerr EWT sealer, by warm vertical compaction with System B.  Backfill was completed using the Obtura II.  Sponge and IRM was placed as a temporary filling and post operative instructions were given to the patient and his mother.  The patient was referred to his general dentist for the placement of a permanent restoration.

Final film: