Non-surgical Re-treatment Case II:
Maxillary Premolar
Yoshio Yahata
Chief Complaint
“I have a long-term dull pain around the right upper molar and premolar area.”
Medical History
The patient (Pt) was a 34-year-old male. He had no relevant medical history and was not taking any medications at the time of visit. His vital signs were as follows: blood pressure (BP) 132/87 mmHg; pulse 78 beats per minute (BPM) and regular. A complete review of systems did not reveal any significant findings and there were no contraindications to treatment.
The Pt was American Society of Anesthesiologists Physical Status Scale (ASA) Class I.
Dental History
Three years before presentation, the Pt experienced dull pain around his right upper posteriors. After visiting a dental office, root canal treatment (RCT) was performed on teeth #3 and #4, and tooth #5 was extracted. Following treatment (Tx), his discomfort reduced but slight pain remained. A referral dentist observed changes in his discomfort for two years under temporary (temp) restorations. However, during the follow-up, two months before presentation, he experienced dull pain around the same area. Although the dentist initiated RCT for tooth #3, the pain was not resolved and he was referred to the University hospital.
Clinical Evaluation (Diagnostic Procedures)
Examinations
Extra-oral Examination (EOE)
The EOE did not reveal any significant findings, lymphadenopathy, or extra-oral swelling. There was no discomfort on opening or closing of the temporomandibular joint (TMJ), and no popping or clicking, or deviation to either side upon opening.
Intra-oral Examination (IOE)
The IOE revealed slight redness around the gingiva adjacent to teeth #3 and #4. These teeth had temp restorations (Figure 17.1).
Figure 17.1 Intraoral photograph. Note: Root canal treatment has already been initiated as retreatment in teeth #3 and #4. In each tooth, access is sealed with CavitTM temporary filling material.
Diagnostic Tests
| Tooth | #2 | #3 | #4 | #6 |
| Percussion | – | + | + | – |
| Palpation | – | + | + | – |
| Cold | + | – | – | + |
| Probing depth | Within 3 mm | Within 3 mm | Within 3 mm | Within 3 mm |
+: Response to pain on percussion or palpation and normal response to cold test; –: No response to percussion, palpation, or cold
Radiographic Findings
Periapical (PA) radiography (Figure 17.2) indicated that tooth #2 was free from decay and restorations, while tooth #3 indicated initiation of RCT with traces of root canal medication inside the root canals. Well-defined radiolucency of 1 mm diameter was associated with the apex of tooth #4. The root canal of this tooth had been previously insufficiently filled with material that was 3–4 mm short from the apex. A wide root canal suggested excessive removal of dentin by previous Tx. The remaining coronal tooth structure was insufficient. Tooth #5 was missing.
Figure 17.2 Periapical radiograph taken at initial visit.
Pretreatment Diagnosis
Pulpal
Previously Treated, tooth #4
Apical
Symptomatic Apical Periodontitis, tooth #4
Treatment Plan
Recommended
Emergency:None
Definitive:Non-surgical Re-treatment of tooth #4
Alternative
Extraction of tooth #4 or no treatment
Restorative
Core build-up and full crown coverage
Prognosis
| Favorable | Questionable | Unfavorable |
| X |
Clinical Procedures: Treatment Record
First visit (Day 1): Informed consent was obtained. Endodontic evaluation and the Tx plan were discussed with the Pt. Alternative Txs were also explained. For tooth #4, local anesthesia was administrated by infiltration of 1.8 ml of 2% XYLOCAINE® anesthetic with 1:80,000 epinephrine (epi) (Dentsply Sirona, Tokyo, Japan). The temporary restoration was removed and rubber dam isolation (RDI) was placed, followed by access and removal of the cement “core.” After locating the canal orifice, the gutta-percha (GP) was removed using Gates–Glidden drills, hand and NiTi rotary files (EndoWave, J. Morita, Osaka, Japan) with the adjunctive use of eucalyptus oil (Eucaly soft plus®, Toyokagaku Kenkyusho, Tokyo, Japan). An operating microscope (Zeiss OPMI® pico, Carl Zeiss Meditec AG, Oberkochen, Germany) was used to verify the complete removal of previously filled GP. Working length (WL) was obtained as 13 mm using an electric apex locator (Root ZX®II, J. Morita, Kyoto, Japan). Cleaning and shaping was performed utilizing .02 taper stainless steel K-files. Irrigation with 5% sodium hypochlorite (NaOCl) using a 27-gauge needle was performed throughout the procedure. The canal was then dried with sterile paper points and medicated with calcium hydroxide (Ca(OH)2; Calcipex® II, Nishika, Yamaguchi, Japan). Access was sealed with Cavit™ (3M, Two Harbors, MN, USA) temp filling material and the temp restoration (Unifast® III, GC Corporation, Tokyo, Japan) was replaced, followed by verification of the occlusion.
Second visit (Day 25): The Pt reported that his condition had improved but he continued to experience discomfort. The redness around his gingiva had resolved. However, sensitivity to percussion and palpation for teeth #3 and #4 remained. Local anesthesia was administrated by infiltration of 1.8 ml of 2% xylocaine with 1:80,000 epi. The temp restoration was removed, RDI was placed, and the tooth was re-accessed. The pulp chamber was irrigated with 5% NaOCl; purulence or secretion of other fluids was not observed. The canal was excessively enlarged and the master apical file was set at size #90. The canal was irrigated with 5% NaOCl and then dried with sterile paper points. Ca(OH)2 was administered into the canal, access was sealed with CavitTM temp filling material, and the temp restoration was replaced.
Third visit (Day 39): The Pt presented asymptomatic (ASX) with no apical tenderness or percussion sensitivity for teeth #3 and #4. Local anesthesia was performed by injecting 1.8 ml of 2% xylocaine with 1:80,000 epi, and the temp restoration was removed. RDI was placed and the tooth was re-accessed. The canal was irrigated with 5% NaOCl and 15% ethylenediaminetetraacetic acid (Morhonine®, Showa Yakuhin Kako, Tokyo, Japan). The WL and diameter were re-established. The canal was dried and obturated using laterally condensation technique (Figures 17.3 and 17.4). Access was sealed with Cavit™ temp filling material and the temp restoration was replaced. The Pt was advised to return to a general dentist for placement of permanent restoration.
Figure 17.3 Periapical radiograph showing completed obturation of teeth #3 and #4.
Working length, apical size, and obturation technique
| Canal | Working Length | Apical size | Obturation Materials and Techniques |
| Single | 13.0 mm | 90 | AH Plus® sealer, Lateral condensation |
Figure 17.4 Intraoral photograph taken immediately after root canal obturation.
Postoperative Evaluation
Fourth visit (3-month follow-up): The Pt was ASX and his soft tissues appeared to be normal. Periodontal probing was within 3 mm with no tenderness to either percussion or palpation.
Fifth visit (6-month follow-up): The Pt remained ASX with normal soft tissues. PA radiography demonstrated osseous healing in progress (Figure 17.5). Periodontal probing was within 3 mm with no tenderness to either percussion or palpation.
Figure 17.5 Periapical radiograph taken 6 months after root canal treatment.
Sixth visit (1-year follow-up): The Pt still presented ASX with normal soft tissues. PA radiography demonstrated complete osseous healing (Figure 17.6). Periodontal probing was within 3 mm with no tenderness to either percussion or palpation.
Figure 17.6 Periapical radiograph taken 12 months after root canal treatment.
Addendum
Due to the objective, this chapter does not provide a detailed description of tooth #3. However, tooth #3 also received non-surgical endodontic treatment at this time under the following diagnosis.
Pulpal
Previously initiated therapy, tooth #3
Apical
Symptomatic Apical Periodontitis, tooth #3
Tooth #3 was also asymptomatic after RCT.
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