Chief Complaint

“My gum near the upper front teeth on the right side is swelling.”

Medical History

The patient (Pt) was a 42-year-old Asian male. Vital signs were as follows: blood pressure (BP) 120/80 mmHg. The Pt was taking medicine for hypertension, which was well-controlled.

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

Dental History

The Pt had caries on tooth #7 about twenty years ago and subsequent root canal treatment and restoration with composite resin by his general dentist. Six months ago, the Pt began experiencing acute pain on tooth #7, and then swelling. Incision for drainage was performed by his general dentist. Last month, the dentist referred him to see an endodontist for treatment because of the recurrence of sinus tract swelling.

Clinical Evaluation (Diagnostic Procedures)

Examinations

Extra-oral Examination (EOE)

Clinical examination revealed no lymphadenopathy of the submandibular and neck areas.

Perioral and extra-oral soft tissue appeared normal.

Intra-oral Examination (IOE)

A buccal (B) sinus tract was situated between teeth #7 and #8 (Figure 16.1). A B gum on tooth #8 formed the small fibrous tissue. The Pt’s oral hygiene was acceptable. Periodontal depths of 2–3 mm were measured around the circumference of the tooth. The mesial (M) area was restored with a composite resin.

Diagnostic Tests

EPT: Electric pulp test; +: Response to percussion or palpation, and normal response to CO2 snow, or EPT; –: No response to percussion or palpation: N/A: Not applicable

Radiographic Findings

Tooth #7 showed radiolucent composite resin restoration at the M area. The root apex had 7 mm periradicular radiolucency with suboptimal root filling. Tooth #8 showed radiolucent composite resin restoration on the distal (D) area. The root canal filling reached 1 mm point from the radiographic apex. A gutta-percha (GP) point was inserted into the sinus tract to trace the source and the radiograph taken confirmed the tooth to which the tracing of the sinus tract led was tooth #7 (Figure 16.2 A, B).

Pretreatment Diagnosis

Pulpal

Previously Treated, tooth #7

Apical

Chronic Apical Abscess, tooth #7

Treatment Plan

Recommended

Emergency:None

Definitive:Re-treatment of tooth #7

Alternative

Root-end surgery of tooth #7 or extraction of tooth #7

Restorative

Permanent crown

Prognosis

Clinical Procedures: Treatment Record

First visit (Day 1): A periapical (PA) and an axial occlusal radiograph were taken with GP points from the B sinus tract located between teeth #7 and #8 (Figure 16.2 A, B). The treatment (Tx) options were reviewed with the Pt including re-treatment (re-Tx) and apical surgery. The re-Tx of tooth #7 was recommended because of caries around the composite resin filling margin and the insufficient condensation and it was explained to the Pt that tooth #7 might have root fracture. The Pt agreed with this plan and informed consent was obtained.

Second visit (3 months): Diagnostic tests showed: Spontaneous pain (-), percussion pain (+), palpation (+), sinus tract (+). Anesthesia, 1.8 ml of 2% lidocaine (lido) with 1:100,000 epinephrine (epi) was administered. The tooth was isolated with a rubber dam (RD). Composite restoration and carious dentine were removed. Root filling material was removed with Gates-Glidden burs and the ultra-sonic tip under the dental operating microscope (OPMI^® pico, Carl Zeiss, Oberkochen, Germany). The canal was instrumented short of the apex because the apical part was constricted. After antimicrobial medicament was placed, the tooth was sealed with a wet sponge and a temporary (temp) filling (Caviton® EX, GC Corporation, Tokyo, Japan).

Third visit (4 months): Diagnostic tests showed: Spontaneous pain (-), percussion pain (-), palpation (-), sinus tract (+). Anesthesia, consisting of 1.8 ml of 2% lidocaine (lido) with 1:100,000 epineferine (epi), was administered. The tooth was isolated with a RD. The patency was achieved, and the canal was prepared to the apical size #40 with hand instruments, K-files (Zipperer, Munich, Germany), and irrigated with 3% sodium hypochlorite (NaOCl; Dental Antiformin, Nippon Shika Yakuhin, Yamaguchi, Japan). The working length (WL) was estimated using an electronic apex locator (Root ZX^®II, J. Morita, Kyoto, Japan).

Fourth visit (6 months): Diagnostic tests showed: Spontaneous pain (–), percussion pain (-), palpation (–), sinus tract (+). Anesthesia, consisting of 1.8 ml of 2% lido with 1:100,000 epi, was administered. The tooth was isolated with a RD. The canal was irrigated with 14% Ethylenediaminetetraacetic acid (EDTA, Showa Yakuhin Kako, Tokyo, Japan) and 3% NaOCl. The canal was obturated by lateral (L) compaction of GP, using Canals^®-N sealer (Showa Yakuhin Kako, Tokyo, Japan). A PA radiograph was taken (Figure 16.3).

Working length, apical size, and obturation technique

Postoperative Evaluation

Fifth visit (3-month follow-up): The PA radiograph (Figure 16.4) showed osseous healing in progress around the root apex. Tooth #7 was restored with the resin core (Clearfil™ DC Core Automix, Kuraray Noritake Dental, Nigata, Japan). The tooth was functional with no signs of swelling or sinus tract. The Pt was symptom-free. The radiograph indicated periradicular healing.

Sixth visit (6-month follow-up): Significant healing of the previous radiolucent area was noted on radiograph (Figure 16.5 A, B). The tooth was functional with no signs of swelling or sinus tract. The Pt was symptom-free. The tooth was restored with full crown.

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