Dental Tribune United Kingdom Edition

February 2014United Kingdom Edition12 Endo Tribune page 11DTß Path: Large PA area with furca- tion obliteration LR6 Perio: good bone levels, no sub- gingival calculus, PDL space wid- ening around mesial portion of the tooth To summarise the findings, the patient attended with a grade 1 mobile LR6, which was TTP, had a 9mm pocket mesially and was negative to sensibility testing. The LCPA radiograph of the LR6 showed a very large periapical ra- diolucency surrounding the root of the LR6, external root resorb- tion around the mesial root, wid- ening of the periodontal ligament (PDL) space mesially and furca- tion obliteration. With all of this in mind it leads us to a differential diagnosis of: (As originally outlined by Si- mon et al1 ) • Purely endodontic lesion • Perio-endo lesion: - Primary perio - Primary endo - True Perio-endo • Radicular cyst With all the symptoms taken into account I came to a provi- sional diagnosis of an acute flare up of chronic periapical peri- odontitis, in which sinus drainage had been established through the mesial pocket. Prognosis: Due to size of periapical (PA) area, mobility, 9mm pocket, communi- cation with oral cavity and mesial external root resorbtion, the prog- nosis for this tooth is relatively poor, especially as MTA was not available to me at the practice. All options were discussed with the patient and she wished for the RCT to be done here at the prac- tice and completed by me, whom has a very keen interest in endo- dontitcs but no specialist training. So a treatment plan was drawn up and the patient happy for treatment to begin Treatment plan: Acute Phase: extirpate the LR6, course of antibiotics: 500mg Amoxicillin TDS five days (due to systemic involvement of the lymph nodes) Stabilisation phase: Treat the periodontal issues, avoiding root scale debridement (RSD) on the LR6, incase of a perio-endo ori- gin, in which cell damage caused by the RSD can limit the regener- ation potential for the endodontic treatment (2) , OHI, diet advice, flu- oride application, Smoking ces- sation and a fluoride toothpaste prescription (5000ppm). Restorative phase: Restore cari- ous lesions in LL6 and LL7, Com- plete root treatment on LR6, due to degree of tooth tissue remain- ing if a conservative access can be cut, restore with GIC and com- posite. Maintenance Phase: Review RCT and perio at 3, 6 and 12 months Recall phase: Caries risk - High, Perio Risk - High, Oral cancer risk – medium, 3-monthly CE Treatment Completed First visit: - LR6 extirpation A minimally invasive access was cut into the LR6 – by preserving as much tooth tissue as possible it greatly improves the chances of a long term successful endo- dontic treatment. Ideally all four sides of the tooth need to remain intact, this allows for better isola- tion and a stronger external tooth structure. Four canals were locat- ed and cleaned to the EWL at an ISO size 20 hand file with copious amounts of two per cent sodium hypochlorite; then dressed with ledermix and restored with GIC. A good access is key to locating canals quickly and by spending slightly longer making it as neat as possible it can really help. (photos of the access can be seen in figures 4 and 5) Second visit: - The patient re- ported she was out of pain after the extirpation was completed, which meant we could proceed to stabilise all other active disease. A supra and sub gingival scale was completed on all teeth except LR6 (incase of perio-endo lesion (2) ), smoking cessation given, amal- gam restorations placed on LL6 and LL7 occlusally and fluoride applied to all teeth. Third visit: RCT stage 1 LR6 The temporary restoration was removed and all four canals re- located using hand files, once re- located the access to each canal was improved using Gates Glid- den burs, a size 2 to 1/3 estimated working length (EWL), size 4 to 3mm short of that and finally a size 6 counter sunk into each ca- nal by no more than half the depth of the bur around 3mm, (by doing this it also makes creating Nayyar cores much easier as once the bulk of the GP has been removed the size 6 Gates Glidden bur can be counter sunk once again pro- viding a space for the nayyar core to be placed. Each canal was then prepared to 2/3’s EWL using protaper ro- tary instruments sizes S1, S2, F1 and F2.(3) Handfiles were then placed into each canal measured to the EWL and a diagnostic radiograph was taken. When taking a diag- nostic radiograph on multi-rooted teeth, I use a mesial swing on the tube head in order to ensure each file is in a separate canal. This can be seen in the diagnostic ra- diograph figure 6. Once the diag- nostic radiograph has been taken the tooth is dressed with non-set- ting calcum hydroxide and again sealed with GIC. The radiograph then con- firmed the working lengths for each canal as: • MB – 18mm (OA) • ML – 18mm (OA) • DB – 21mm • DL – 21mm (OA) indicates open apex Fourth visit: RCT stage 2 LR6 The obturation stage for this tooth brings its own chal- lenges as there is no guarantee that a seal can be achieved with an open apex present, which is why conventionally MTA is used to close the open area and allow for an effective seal and this is what I would have done had MTA been available. Instead, I adopted a technique that had never been formally taught to me and pre- pared the mesial canals 1mm past the radiographic apex in order to ensure effective cleaning at the open apex. Once all of the canals had been prepared to their EWL’s to size F2 protaper (3) with thor- ough irrigation of two per cent sodium hypochlorite (the Irrigant used is warmed to increase effec- tiveness (4) and after placement a handfile is used to ensure the ir- rigant reaches the apex) the total time the irrigant spends in the canals accumulatively was 10 + minutes, this combined with the time of the procedure is in excess of 40 minutes.(5) Obturation – a single point obtu- ration techniqure was used, using an eight per cent ISO 25 F2 Prota- per point, using again a technique never taught to me. I placed the GP point beyond the apex until an ‘With all the symp- toms taken into account I came to a provisional diagno- sis of an acute flare up of chronic peri- apical periodonti- tis, in which sinus drainage had been established through the mesial pocket’ Long Cone Periapical Radiograph (LCPA) LRQ Figure 3 Figure 4 – access cavity Figure 5 – Access Cavity Figure 6 – Working length radiograph with size 15 hand files Figure 7 – apical removal of GP Figure 8 – composite restoration Figure 9 – post operative radiograph of the RCT on the LR6 Figure 10 – 9 month post op RCT LR6 Table 1