5.4
Non‐surgical Management of Perforation
Taranpreet Puri
Objectives
At the end of this case, the reader should understand the causes and management of an iatrogenic perforation. The reader should also appreciate the factors that influence prognosis of perforations, as well as knowledge of current materials used in perforation repairs.
Introduction
A female, 26 years old, was referred by her general dental practitioner regarding the lower right first molar (LR6). Root canal treatment had been initiated on this tooth three months previously.
Chief Complaint
The patient was asymptomatic on presentation.
Medical History
Unremarkable.
Dental History
Regular dental attendance, historical high caries risk status. The LR6 had been severely painful, with spontaneous throbbing pain. The symptoms resolved following emergency dental treatment three months before.
Clinical Examination
Extraoral examination was unremarkable.
Intraoral examination revealed a moderately restored dentition with satisfactory oral hygiene.
The LR6 was firm with slight tenderness on percussion and no swelling or tenderness in the buccal sulcus. The tooth had an existing glass ionomer restoration, with signs of secondary caries and marginal defects. There were no periodontal probing depths greater than 2 mm and the tooth was unresponsive to sensibility testing (Figure 5.4.1).
What were the radiological findings?
A periapical radiograph of the LR6 revealed (Figure 5.4.2):
- Good bone levels.
- The LR5 had a disto‐occlusal restoration with good marginal adaptation and existing root canal filling, terminating short of the radiographic apex, with an intact and uniform periodontal ligament.
- The LR6 had a disto‐occlusal restoration extending into the pulp chamber, with straight mesial and distal roots with visible root canals. There was a perforation in the furcation of the pulp chamber floor with furcal radiolucency. Apical radiolucency was associated with the mesial and distal roots.
- The LR7 had mesial caries.
In order to aid in investigation and treatment planning, cone beam computed tomography (CBCT) imaging (Figure 5.4.3) was performed, which highlighted the precise location, extent and size of the perforation, as well as the presence of an additional distal canal.
Diagnosis and Treatment Planning
Diagnosis
The diagnosis for the LR6 was symptomatic apical periodontitis associated with a necrotic pulp and iatrogenic furcal perforation.
What were the treatment options?
LR6 chronic apical periodontitis associated with a necrotic pulp and perforation:
- Non‐surgical perforation repair and root canal treatment with cuspal coverage restoration.
- Extraction with or without prosthetic replacement.
- Leave alone.
LR5 technical deficiencies in root canal filling with no associated apical pathology:
- Monitor with annual periapical radiograph.
- Review need for root canal retreatment if cuspal coverage restoration required.
LR7 mesial enamel lesion:
- Advise patient on diet, fluoride and oral hygiene. Regular monitoring with bitewing radiographs.
- Restoration.
Treatment Plan
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