Chief Complaint

“My tooth hurts when I drink or eat something cold. The pain lasts for several minutes. My dentist said I have a big cavity and the tooth may not be savable.”

Medical History

The patient (Pt) was a 26-year-old male. Vital signs were as follows: Blood pressure (BP) 118/78 mmHg right arm seated; pulse 76 beats per minute (BPM) and regular; respiratory rate (RR) 18 breaths per minute. A complete review of systems revealed a history of sinus problems related to seasonal allergies. The Pt admitted to smoking one pack of cigarettes per day and had no known drug allergies (NKDA). He was taking 600 mg ibuprofen 4 times per day for dental pain.

The Pt was American Society of Anesthesiologists Physical Status Scale (ASA) Class I.

Dental History

Pt was referred for an evaluation and treatment (Tx) of tooth #23. Pt complained of sensitivity to cold from tooth #23. The previous week the sensitivity to cold got worse and the pain lasted longer. He contacted his general dentist who examined him a few hours prior and referred the Pt to the office. His oral hygiene was fair. He had a few restorations and moderate gingivitis. No history of orthodontic Tx or trauma.

Clinical Evaluation (Diagnostic Procedures)

Examinations

Extra-oral Examination (EOE)

Pt was alert, normally developed, and not stressed. The EOE revealed no swelling, no sinus tract, and no lymphadenopathy in the submandibular and neck areas.

Intra-oral Examination (IOE)

Soft tissue appeared normal. A pinkish discoloration and large cavitation were noted near the disto-buccal (DB) surface of tooth #23. A 4 mm probing defect was present along the DB line angle of tooth #23. No other resorptive lesion was noted clinically in any other teeth. All teeth had normal physiological mobility.

Diagnostic Tests

+: Normal response to Endo Ice®; -: No response to percussion or palpation

Radiographic Findings

The periapical (PA) radiograph revealed a large irregular radiolucency on the distal (D) aspect of tooth #23 extending to the level of the crestal bone and into the root (Figure 25.1). Tooth #23 had Class 3 invasive cervical resorption. There was evidence of crest bone loss. No periapical radiolucency was noted for tooth #23. No other resorptive lesion was noted in other mandibular anterior teeth.

Pretreatment Diagnosis

Pulpal

Symptomatic Irreversible Pulpitis, tooth #23

Apical

Normal Apical Tissues, tooth #23

Treatment Plan

Recommended

Emergency:Pulpal Debridement and Surgical Repair

Definitive:Non-surgical Root Canal Therapy (NSRCT)

Alternative

Extraction; Orthodontic Extrusion and Non-surgical Approach

Restorative

Composite restoration followed by a full coverage restoration

Prognosis

Clinical Procedures: Treatment Record

First visit (Day 1): The medical history was reviewed (RMHX). Pt agreed to proceed with a periodontal flap and lesion excavation before finalizing the Tx plan. Consent was obtained. Local anesthesia was administered as follows: 108 mg 2% lidocaine (lido)/0.054 mg epinephrine (epi) (1:100.000). A full-thickness mucoperiopstal flap was reflected using sulcular incision from mesial (M) of tooth #20 to the D of tooth #27. A 6 x 8 mm resorptive defect was present on tooth #23 extending to the level of crestal bone. The lesion was excavated. It was friable and did not provide proper texture for a biopsy specimen. The tooth was then evaluated under microscope (Global Surgical Corporation, St. Louis, MO, USA). The tooth structure was solid beneath the defect. Trichloracetic acid (CCl₃COOH; Sigma-Aldrich, St. Louis, MO, USA) was applied by a small cotton pellet on the resorptive lesion for 4 minutes and rinsed with 0.9% sodium chloride (NaCl). The resorption defect was prepared while Cavit™ (3M, Two Harbors, MN, USA) was placed to protect the canal (Figure 25.2) and restored with composite restoration (Figure 25.3). The flap was well irrigated with 0.9% NaCl. A total of five interrupted silk sutures (4-0) were placed (Figure 25.4). A rubber dam (RD) and clamp were placed over tooth #23. Access was completed. Pulpectomy was performed by instrumentation alongside copious irrigation with 0.5% sodium hypochlorite (NaOCl). The canal was dried and medicated with calcium hydroxide (Ca(OH)₂; Ultradent, South Jordan, UT, USA). The access cavity was filled with Cavit™. The RD was then removed. Occlusion was adjusted and postoperative instructions (POI) were reviewed including no smoking for at least one week. Pt was advised to use Peridex™ 0.12% (3M, Two Harbors, MN, USA) rinse twice daily for one week and ibuprofen 400 mg every 6–8 hours for pain control.

Day 2 follow-up call: Pt reported very mild postoperative (PO) pain but no medication was required for pain control.

Second visit (1 week): Suture removal visit. Healing of the surgical wound was uneventful. The Pt was made aware that even after comprehensive dental care, the external resorption can return. He was made aware he must have a full mouth series taken to rule out the possibility of resorption involvement in other teeth. An appointment was scheduled for completion of NSRCT.

Third visit (2 months): Continuation of NSRCT for tooth #23. The medical history was reviewed (RMHX). Local anesthesia 54 mg 2% lido/0.027 mg epi (1:100,000) was administered. After RD isolation and access preparation, buccal (B) and lingual (L) canals, which were joined at the apical 2 mm, were located. A working length was established and confirmed with a radiograph (Figure 25.5). Mechanical instrumentation was performed with .04 taper EndoSequence^® rotary files (Brasseler USA, Savannah, GA, USA) using a crown down technique and copious irrigation with 0.5% NaOCl. Canals were dried with paper points. Master cone gutta-percha (GP) points were then placed to length with AH Plus® Root Canal Sealer (Dentsply Sirona, Konstanz, Germany). Canals were filled by System B™ (Kerr, Orange, CA, USA) and back-filled using Calamus® Dual (Dentsply Sirona, Johnson City, TN, USA). Tooth #23 was temporarily filled with Cavit™ and Fuji^® IX GP (GC America Inc., Alsip, IL, USA). A PO radiograph was taken (Figure 25.6). PO instructions were reviewed. The Pt was scheduled for a follow-up appointment.

Working length, apical size, and obturation technique

Postoperative Evaluation

Fourth visit (15-month follow-up): RMHX. Tooth #23 was asymptomatic and non-tender to percussion and palpation. Apex appeared normal in the periapical film (Figure 25.7). The temporary restoration was still in place. Gingiva margin was slightly inflamed. Mobility was normal. Pt was advised to schedule a dental hygiene appointment, permanent restoration, and a follow-up.

Fifth visit (2-year follow-up): RMHX. Tooth #23 was asymptomatic. The tooth had been restored with composite core build-up in the access opening by general dentist. Apex appeared normal (Figure 25.8). No resorptive lesion was noted. Mobility was normal. Tooth gingiva margin was slightly inflamed (Figure 25.9). Oral hygiene instruction was given. Satisfactory healing had been achieved.

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