Huh?
Iatrogenic, Retreatment October 29th, 2007
So why does it matter to me what the restorative dentist does in the tooth? The answer is ethics for one, and the second reason is more selfish. Often the first thing to fail in a tooth that is having trouble is the endo. In today’s society where people take no responsibility for their actions and find it much easier to assign blame to others, the patient shows back at my office with the impression that their tooth is having trouble because of inadequacies with my work:
March 2006, consultation appointment. A long discussion about why this 1.5 year old endo is episodically symptomatic. Her dentist did the work. I recommended retreatment, another discussion ensued about the post and the reason it was placed. She was not optimistic about root canals in general because of the history of this tooth.
December 2006. Because of the patient’s trepidation about endo, I decided to medicate the tooth and only complete the retreatment once signs of osseous healing were evident. I babysat the tooth while it was medicated for a few months and saw some obvious signs of healing. Symptoms had also disappeared. Retreatment was completed. A discussion about posts ensued again because the patient was wondering whether one was necessary or not. I told her I didn’t see a need for it because of the amount and strength of internal structure.
Last week. The patient’s dentist sent her back to see me because the tooth has been episodically symptomatic (demonstrating recurring parulis formation) since the retreatment was done. Upon further questioning, the patient said the tooth started acting up after the permanent restoration in the crown was done. She said she told her dentist she didn’t want any posts and he said he wouldn’t do the filling unless he put posts in. He insisted, so she felt she had no choice.
From the film it’s obvious that a non-metal post was placed in the P canal, gutta percha has been removed from the coronal 1/3’s of the buccal canals and material consistent with the core resin was placed into those areas. Apical bone appears good still, a lesion has developed in the furcation. The lesion in the furcation is associated with all of the work that was done in the coronal canal areas. There’s likely been a strip perforation in one or more of the roots. My guess is the MB root.
As much as I tried to diffuse a potential situation with this patient, I know that she’s going to have a few unpleasant words with her dentist.
November 8th, 2007 at 5:01 pm
okay, why did he strip the GP from the buccal canals in the first place if he already placed the post in the palatal canal? i have heard of creating multiple little “mini” post spaces in each canal in a molar to increase core retention and minimize fracture – sometimes my endo guy will place these spaces in a select few molars i ask him to complete when i know retention will be a problem but i’m worried about fracture. this requires removal of about 3-5 millimeters of coronal GP from each of the three-four canals in molars (i tend to avoid posts altogether in premolars, esp upper b/c of their high fracture rate) and are filled with amalgam or core past or whatever i’m using as a core material.
what is the prognosis for this tooth? extraction and implant? if i were this dentist, i’d refund the money. actually, one of the “picture perfect” endo’s i completed about 6 months ago failed and i cut the guy a check as soon as he went to the specialist for the consultation. it just seems like the right thing to do.
November 8th, 2007 at 5:04 pm
what’s up this with blog comment approval thingy? you gettin’ harassed? it must be all that porn you’ve been downloading. it attracts lots of undesirables into your web-space. you must be getting lots of inappropriate comments from deep-throat dentists.
November 11th, 2007 at 12:50 pm
Nayar showed that corono-radicular buildups (3mm dimples in canal orifices) retain cores as well as posts. That’s assuming an adequate ferrule, which one should have in any case. Root fracture is more of an issue with posts than with the dimples.
Prognosis of this case is guarded, but because of the lack of probing, it’s still favourable if I can get a good seal of the perf with MTA.
Comment moderation is on for now because people have been breaking anonymity rules on the blog. I’ll reconsider in a while.
Any comments from deep throat dentists might be inappropriate…but welcome.
December 12th, 2008 at 1:40 pm
Looks like a horizontal root fracture in the MB root rather than a perf in the palatal root.
December 12th, 2008 at 2:10 pm
Could be but that’s unlikely based on a few things:
1. This is a common area for furcation canals to exist,
2. Without a history of trauma on this tooth, any root fractures will likely be vertical, especially after an endo,
3. If this is a horizontal root fracture, the fracture line would probably be visible through the entire root structure rather than ending at the canal space. A lesion would develop circumferentially to the fracture line rather than just in the furcation.
4. I agree, there’s probably no perf in the P root. The evidence and history, however, is consistent with a strip perforation in the MB root. The lesion is originating in the so-called “Danger Zone” and there was minimal straight-line access to the MB canal system in the initial endo. This leads to the potential of even further thinning of root structure in the wrong spots during further endo treatment or post space preparation.
Thanks for the comment!