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New basic diagnostic case - Courtesy ROOTS
The opinions and photographs within this web page are not ours. Authors have been credited for the individual posts and photographs where they are. - www.rxroots.com
From: Kendel
Newsgroups: roots
Sent: Tuesday, March 20, 2007 11:20 PM
Subject: [roots] Re- Basic diagnostic stuff-NEW BASIC DIAGNOSTIC CASE

This is not terribly uncommon in my practice. The referring dentist has missed the diagnosis

Like many things in life, repetition helps attain more consistent results

My advice is to test teeth whenever you have an opportunity----like every time you restore a tooth

I certainly did not do this when I practiced general dentistry, but it is helpful for obvious reasons, and because you will develop your diagnostic "sense"

Sensitivity testing is not black and white---it is something you develop a feel for ---at least this has been my experience.

I know I said this was "basic stuff", but I will say this diagnosis was complicated by a history of trigeminal neuralgia, and patient reporting radiating pain that did not sound dental in origin, and the history of pain was also misleading---it seemed out of character in its course.

Symptoms were relieved by treatment at the initial visit.

I hope this is helpful to someone out there in Roots-ville! - KendelG

Hi Kendel, Thanks for sharing. Basic diagnostic stuff is great...so now I have a basic question for you... Today I have visited a patient. She was sent to me because a NSRCT in 26 (international) was done a month ago more or less and she´s still symptomatic. She has pain on chewing in 26 and spontaneus pain. Tenderness to percussion but not to palpation. Periodontal probings were normal. No swelling, no mobility. She has a metal-ceramic bridge between 26-24 but it was placed with Temp Bond. The first time she had pain was after they placed the metal-ceramic bridge... ...They did the NSRCT in 26 and the pain decreased but not cease. Till...now...

Do you know the pre-op diagnosis? The patient was symptomatic at the time of the initial treatment? Then made some progress, but never had complete resolution of the periradicular symptoms? - Noemi

After examination I did some rx to check...I decided to open the cavity in order to try to find the supossed MB2 or maybe something else and do the retreatment. I clean the cavity and I saw the MB2 but I could not permebealize it. I also saw a crack between MB and MB2. I do not have methylene blue dye in that clinic (no scope) so I think about caries detector and try with it. So...with the caries detector I saw better the crack between MB and MB2 but I know that caries detector has limitations to recognized cracks. Now...the question...do you think the pain is because of the MB2 or the crack? A combination? Or maybe lack of shaping and irrigation of the others?

I am not sure this is a crack, perhaps just the line formed by the isthmus.

I would like to know tecniques or more information on how to manage a MB2 if you´re not able to permebealize with a 06. How you would deal with that? - Noemí Pascual, Barcelona - Spain

Often these canals get ledged because they make an acute angle as they course even further mesially just below the orifice, before diving axially. This is why it is imperative to transport and deroof the orifice completely before attempting negotiation. If I still am unable to negotiate the MB2, I will focus my efforts on the main canal, and thoroughly treat this to the foramen

If I were to be treating this case, based on what you have shared, I would remove the obturation, gain patency in all three main canals, run through my irrigation regimen including a CHX soak, then dress the canal systems with CaOH2 and place a solid interim restoration. during instrumentation I would return to the MB2 and spend a few minutes with pre-bent hand files, attempting to "dance" deeper in the system. I would do this for a few minutes at a time, and if I felt no progress was being made, I would return my focus to the other main canals. This keeps me from getting frustrated!!!!

I hope this is of some help - Kendel

Hi Noemi, Maybe I am missing something, but isnt the line between MB1 and MB2 just the anastamotic area between the two canals? - Abdul

Hi Noemi,Great pics !!! even without SOM, how did you take? Your new camera??? , intraoral camera ???

I agree with Abdul, the line between MB1 and MB2 is an anastomotic area or the floor treasure map...

I resend your last pic, explore this point with a endo explorator (sonda endo), DG-16 from Maillefer or Sybron Endo are extremelly useful, the explorator sholud be thin and sharp in any case. If you feel the entrance is here or in the point where you are exploring before, try carefully deroof/troughing/desgastar/profundizar at this point, with US points or round skiny long neck burs (ex. LN 006 Maillefer or Munce Burs). - Nuria

Dear Noemi, I agree with others, there is NO crack between the MB1 and the MB2. This is the isthmus between the two canals I see almost all the time. Sometimes it's just a white line which helps me to find the MB2 (check out Freds "through the line").

The discomfort is probably the result of infection that was not resolved with the retreatment. A very good chance the reason is the untreated MB2. As someone has said the MB2 is hard to negotiate for several reasons, the main one is the angle of entry. You should always use a #15 or #10 file from the palatal cusp into the MB2 enterance pushing to buccal while rotating the file in a watch wind fashion. You should do this very gently after the MB2 has been de-roofed and moved mesialy with a small bur or with ultrasonics. There is a great instruction "manual" how to do this on Roots I think Rob Kaufman wrote it. - Thomas

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