Case Report

Michael Wheatley

Subjective:
Chief Complaint: “It hurts when I bite.”

Medical History: 94 y.o. female ASA II. She has high blood pressure, high cholesterol, and gout. She is currently taking Alopurinol (uric acid reduction), HCTZ, and Famotidine (cholesterol). She is allergic to Penicillin (gets a rash) Her current vitals are bp 108/65 p 67

Dental History: The patient originally developed her current chief complaint over 2 years ago. At that time, #19 was determined to be the source of her pain and the original root canal was re-treated. Her pain to biting continued and she had root canal therapy on #20. Over the following 6 months she had her occlusion verified and adjusted a number of times with no resolution in symptoms.
 
Objective:
BP: 108/65   Pulse: 67
Clinical Evaluation

EOE/IOE WNL. No swelling or lymphadenopathy noted. #18 and #19 have full gold crowns, which are intact with no recurrent decay. #20 has an intact PFM. There is a 5-unit bridge with #11 and #14 serving as abutments. Both abutments are intact. #15 has a large alloy.

Radiographic Evaluation:
Teeth #14, #18, #19, and #20 all have root canals with no apparent periapical pathology. The restorations show good marginal adaptation and no recurrent decay is evident.

After Apicoectomy and retrograde fill with white MTA:

3-Month Recall:

Assessment:

Pulpal: Previous Root Canal Therapy
Periapical: Symptomatic Apical Periodontitis

Plan:
It was recommended any occlusal or non-odontogenic source of pain be ruled out before any further endodontic treatment was undertaken. If those exams failed to produce a source of the patient’s chief complaint, she was offered apical surgery as an opportunity for the tooth to be visually evaluated for cracks and missed anatomy.

Treatment:
A comprehensive exam was undertaken with the assistance of a prosthodontist to assess the occlusion and muscles of mastication. The patient was also evaluated for a non-odontogenic source of her pain. All of those exams and consultations failed to produce an alternate source of the patient’s pain.

It was then decided to go ahead with apical surgery. The patient was counseled that the surgery might not yield any definite relief of her pain. The patient was given 800mg Ibuprofen pre-operatively as well as a 1 minute Peridex (.12% Chlorhexidine) rinse. Two carpules of 2% Lidocaine with 1:100,000 epi were administered by a gow gates block and long buccal block. A papilla-based horozontal incision from the distal of #22 to the distal of #18 with vertical release at the distal of #22 was made with a 15c blade. A full thickness flap was reflected. An Osteotomy was created with #4 surgical round bur and the root ends of the mesial and distal roots were resected 3mm with a multipurpose bur. Retropreparations were created with a KIS ultrasonic surgical tip. The 3mm preps were then filled with white MTA. A continuous suture was placed with 5-0 vicryl. The patient was given post-operative instructions and a prescription for 12 tabs 800mg Ibuprofen 1 tab q 6h prn and a bottle of Peridex and instructed to rinse twice a day for 1 week.

The patient returned for suture removal 3 days later. She was asymptomatic. She required the Ibuprofen for the first 48 hours. The area was healing WNL. Sutures were removed without anesthetic. She reported she had not had any pain to biting but also had been avoiding the left side since the surgery. The patient was reminded to discontinue the Peridex rinse after 1 week and to return in 3 months for a post-operative exam.

She returned for a 3-month evaluation. She recovered without incident. She reported no biting pain. PPPM are WNL. Radiographically, the osteotomy had healed with visible pdl around both mesial and distal roots. The patient will be evaluated at 6 months and was instructed to call if symptoms reoccur.