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Exontics or Endodontics? - Courtesy ROOTS

I would like to share this case with you and get your opinion.

Young, healthy lady in her early 30's came to an emergency appointment about a week ago. A big buccal swelling was noted. Huge lesion, including the furcation surrounding tooth #36. The doctor removed the crowns (#36, #37) and opened the access on tooth #36 which was very sensitive to percussion. Puss started flowing from the canals. The tooth was left open and antibiotics were prescribed.

I saw the patient yesterday. Tooth #37 is now more sensitive to percussion then #36. Swelling on buccal is better but still there. No periodontal pockets (unbelievable) noted. There is class II(-) mobility (I was sure to find class III). She feels much better now.

I started the retreatment and will see tomorrow how she feels. Puss (transparent fluid) was flowing (bubbling) from the D canal, stopped after a thorough suction with a needle. Prepared the 3 canals without a problem. Dressed with Ca(OH)2 and temporized with IRM.

What do you think, does this tooth stand a chance? Would it be better to extract the tooth and do a biopsy ? The patients is motivated to save her tooth.

Pre-Op

IntraOral Picture (the fluid is Puss)


Thomas,The size of the lesion isnít as important as the fact that you had no perio pockets. I still think you may be able to get into a pocket if you can squirrel a probing down the mid distal, but maybe not.

If not, I would assume itís treatable. A case like this Iíd leave open for a week, have them come back, completely clean and shape all canals with copious irrigation, especially using NaOCl, 2% Chlorhexidine, Sterilox Catholyte, and everything else I can find underneath the kitchen sink cabinet. Iíd then close with a thick viscous mix of calcium hydroxide and close. Sometimes these nasty ones are hard to close and it could flare up and require a repeat ďmega-irrigationĒ/recapitulation performance. Once you get it calmed down and presuming the perio is still intact, you have control of the case and can finish the endo. If the calcium hydroxide washes out apically you may need to replace it. I figure these things just take time and patience and the prognosis is the same as any other case (as long as itís not cracked, doesnít have a subtle perio defect that you didnít probe, and isnít a zebra Actinomyces type strain. If it doesnít respond to an initial meticulous attempt, I would consider biopsy for Actinomyces looking for sulfur granules, etc.

Good luck. These things heal if they are truly endo. Some people decompress them to hasten the healing, thatís another option. I have one like this I need to recall pretty soon that I treated about 2 years ago. Iíll see if I can get them in and see how it looks. - Terry

I believe in what you said and started to retreat because of lack of perio pockets, as I see this as a very positive sign - that the lesion is of endo origin. Endo-Perio is much worse, and in this case I would deem the tooth hopeless. I will try to probe better soon and see if I missed a solitary pocket - I hope not. Do you find a flexible probe better then the stiff ones we have in our clinic ?
Prognosis - same like other cases, unless it has actinomyces or feacalis.
I will see how it goes, as I also predict a nasty flareup is more then possible. - Thomas