The first picture is how this premolar arrived (with the patient) to my office. Discharge was present through the gums from a chronic abscess. Looks like a radiolucent post was placed practically to the apex. There’s some remnant gutta-percha or cement mid-root and probably an apical perforation at the base of the post.

The tooth was retreated over a couple of appointments. Sure enough there was a perforation at the apex of the root, but laterally. I was never able to regain the true canal beyond the perf. A carbon fiber post was removed, Calcium Hydroxide was used as an interappointment intracanal dressing, and then MTA (Mineral Trioxide Aggregate) was used to fully obturate the canal.

There is a 21 month interval between the two films. Osseous healing is progressing well, and no mucosal lesions were evident at the time of the second film.

This case also serves as an example of the fact that a 1-year recall on endodontic cases does not provide enough time to properly evaluate healing. From a strict radiographic interpretation, this case has not healed and is therefore not currently a success. One strike against the relevance or clinical significance of that Cochrane Review.

By the way, I did address the molar’s obvious periodontal issue verbally. The patient is aware of a guarded long-term prognosis there.

Everyone likes to show off their best work, but when can you remember being at a continuing education presentation and the presenter shows off work that they have produced that is less than ideal?

Here is a case that was fraught with issues from the beginning:

The patient will be on a recall schedule with me for the next year or two while I keep tabs on healing within the jaw bone. Hopefully the problem of chronic infection from this tooth is solved. Options are very limited now if the infection persists.

Written on the referral slip that arrived with this patient was a note from their dentist, “Please perform apical surgery.”

I suppose the dentist was concerned about the post being irretrievable. My concerns were the probable coronal leakage that was causing the apical lesion and the fact that apical resection of the root would put me up against the end of the post — leaving me in a difficult position for a retrofilling. Apical surgery will not hold up against coronal leakage in a predictable fashion.

Assuming that the dentist could do a crown with a decent coronal seal, why not take the post out and retreat the root canal work? Retreatment would offer a more predictable solution for the tooth.

Ah, but a deep screw post like this is quite daunting to remove. We worry about the risk of fracturing or perforating the root.

Here’s what your average neighborhood endodontist should be able to do for you:

Microscopes, ultrasonic instruments, and training allow us to deal with cases like this in a conservative, predictable fashion. Orthograde retreatment of cases like these are viable options and should be presented to patients. Jumping straight to the surgical option is a disservice to your patient.

Update (August 14th, 2008): Here’s the post-op film:

I was watching this video, thinking that the dentist was doing an ok job. The only things that made me a little worried were the lack of eye protection on the patient and the extremely long hair the assistant was tossing around.I was about to give a passing grade until he said that he’s putting a titanium post into the tooth to strengthen it. That’s completely false. He should know better and if he does, he’s doing an unnecessary value-added service (that will increase the fracture potential of the tooth)…from what I can see of the tooth the post is unnecessary from even a restorative-retentive perspective.

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.

Unlike many of my peers here in North America, I use lots of calcium hydroxide paste in my cases for reasons like these. The medication gives less-than ideal work a more-than fighting chance to be successful.

Here’s how I first saw these teeth. There is a blurry history of trauma (kickboxing injuries) and when I first saw the patient there was discharge associated with 22.

This first xray is from August 2nd, 2006.

At this point, 22 looked like it had suffered from incomplete root formation, some external resorption, possibly dens-in-dente, and of course infection. I thought I’d have a rough time locating the canal.

Not so. During treatment, I found a massively large canal that was much, much shorter than where I expected it to end. I cleaned things up as best I could and then loaded the canal up with calcium hydroxide for a couple of weeks (or a month…I can’t remember off hand).

The next xray is from October 11th, 2006. Obturation is obviously short of where the root ends, but electronic apex readings were consistent to this point. This angle also shows that what I thought was a root with a canal was actually just one side of the actual root. I started to worry about some sort of vertical root fracture having split the root up the middle. There was no internal visual evidence of this however, and the medicated phase had cleared up the sinus tract.

Later films will show that that left part of root might actually be a root tip that’s floating around from a horizontal root fracture. I reasoned that the short apex readings were either from a resorptive perforative defect through the root at that level, or because of the blunderbuss apex.

When there’s doubt, I use the apex locator as my diviner of length. Once I can get consistent readings with it, I tend to trust it beyond what my eyes see.

One more thing: I informed that patient that a lesion was now becoming apparent apical to 21.

The next film is from November 8th, 2006. Tooth 22 was doing fine, but another sinus tract had appeared. A sinugram traced it to the apex of 21.

A retreatment with a medicated phase was initiated for the tooth.

The canal was cleared, medicated with calcium hydroxide for a month, and then obturated. The apical canal area was irregularly calcified because of the incomplete root formation and the previous work. That’s still no excuse for the voids in the obturation…But proof of success is always in the pudding.

This xray is from February 26th, 2007. It’s post-obturation of 21.

And this next one is from July 30th, 2007. The lesions are shrinking and trabeculation is becoming apparent within them. I’m still not sure what happened with 22 and I’m not sure at this point what is happening. There’s either some external resorption going on as the bone heals and remodels, or that one thing that looks like a root is a root and it’s moving around…

I’ve been temped to go back into 21 and try to improve the appearance of the apical obturation so that the case is more presentable. That, however, won’t necessarily be serving the patient’s best interest. Healing is occurring, so we know there are no bacteria up there. The remaining obturation is good. Any corrective work would be for my benefit rather than the patient’s.

I was moving wood last weekend to try to clear the backyard up a bit more before the landscaping started. I had just climbed on top of the pile of wood that I was creating when one of the pieces rolled down and landed on my left hand. It then bounced off and landed on my right index finger tip squishing it so much that it broke skin just under the front of the nail. Blood copiously dripped out.

I was so deeply under the influence of Advil Cold and Sinus pills for my allergies that I hardly felt anything. I did notice that my knuckles were scraped quite nicely on my left hand and did think that my right index finger should be hurting more than it was.

Anyway, being right-handed, and having a sore finger there, it’s a given that this week all of my cases would involve picking my way down calcified canals or around curves. The finger is definitely hurting now.

Here’s a retreatment that I finished today. It was completed by an endodontist late last year and remained bite sensitive. He recommended apical surgery to address the symptoms. The patient came to me for a second opinion.

Because I thought that I could improve on the endo, I recommended a retreatment with consideration for an adjunctive surgery if necessary. Long story short, the post op film shows some decent improvement on the technical quality, but what’s more interesting is the up-bend at the tip of the mesial root. WTF? No wonder my finger is sore today.

At least the patient is comfortable with the tooth now.