Case Report

Leila Tarsa

37 year old Caucasian female presented for evaluation and treatment of tooth #31.

SUBJECTIVE

Chief Complaint:  “I don’t exactly know which tooth it is, but two weeks ago I had so much pain even in my jaw!”  Patient was referring to her lower right quadrant.  Patient had no complaint of pain at the time of her visit (0/10 VAS).
Medical History:  The patient has no known drug allergies.  She has seasonal allergy, history of asthma (in childhood), and anemia (after giving child birth).  Patient is not taking any medications.  ASA: II 
Dental History: According to the patient, she experienced pain on LR starting 2 months ago (in August 07).  On 10.02.07, patient visited her dentist complaining of discomfort on biting on LR.  The dentist suspected pain originating from tooth #31, and referred her for an endodontic evaluation and possible treatment to our clinic.

OBJECTIVE

Vital Signs: BP 119/80    P 74
Extra-oral Exam:  Within normal limits.  No swelling, lymphadenopathy, or facial asymmetry was noted.  TMJ evaluation revealed  right joint clicking upon opening (asymptomatic)

Intra-oral Exam:  #31 presents with a defective DOB amalgam restoration (open distal margin).  Oral hygiene is fair with generalized mild plaque accumulation.  No swelling or sinus tract noted.  #30 has SSC with open margins.  #20 and 29 have no restorations.  #18 and 19 are missing.

* No Obvious crack detected with fiberoptic light for tooth #31

Radiographic Interpretation:

#31 Periapical radiolucency evident on the mesial root.  Calcification of the canal space is obvious on the mesial root of #30.  Tooth #32 is soft tissue impacted and mesially angulated.

ASSESSMENT

#29 normal pulp with normal periapex (even PDL space with intact lamina dura)
#30 previous pulpotomy with normal periapex
#31 necrotic pulp with symptomatic periradicular periodontitis and radiolucency

PLAN

Recommended NS RCT #31.  The following alternative treatment options were presented: 1. Extraction, or 2. No treatment.  She was informed of the risks involved in nonsurgical root canal treatment including perforation, missed canal, instrument separation, and the possible need for surgical treatment if healing does not occur.  The importance of returning to her dentist to have a final restoration placed on the tooth after endodontic treatment was stressed to the patient.  She was informed that her prognosis was good, and she consented to NS RCT for #31.  Also, it was emphasized to the patient that SSC #30 needs to be replaced, and RCT may need to be considered on #30 prior the new crown fabrication.  In addition, it was brought to the patient’s attention that #32 may need to be extracted if it interferes with fabrication of a crown for #31.

TREATMENT

Working Length:  MB 21.0 mm
                             ML 21.0 mm
                             D    21.0 mm

The canals were irrigated with 5.25% NaOCl, and coronal flaring was started using Gates Glidden drills #2-4.  Profile OS 50/.07, 40/.06, and 30/.06 were used for additional coronal shaping.   The instrumentation was continued with Profile .04 hand files using the crown-down technique with copious irrigation of 5.25% NaOCl.  #10 SS K-file was used for recapitulation in between files.  The distal canal was cleaned and shaped to 40/.04, MB to 35/.04, and ML to 35/.04.  Master gutta-percha cones were placed in the canals and a cone-fit radiograph was taken.  A final rinse with 15% EDTA followed by 5.25% NaOCl as the final irrigant.  The canals were dried with paper points.  Obturation was completed with gutta-percha and Roth’s ZOE sealer using warm vertical compaction with the System B and Obtura II.  The tooth was sealed with a cotton pellet and IRM.  Post-operative instructions were given.  The patient was again reminded of returning to her dentist for a final restoration and returning to the graduate endodontology clinic in six months for recall evaluation of healing.