Non-surgical Root Canal Treatment Case I:
Maxillary Anterior
Denise Foran
Chief Complaint
“I have many fillings in my front teeth and one of them towards the left feels like it is loose.”
Medical History
The patient (Pt) was a 34-year old Caucasian female. A complete review of systems was conducted. Vital signs were recorded: Blood pressure (BP) was 110/72 mmHg, respiratory rate (RR) 16 breaths per minute, pulse 70 beats per minute (BPM). The Pt denied any surgical history (Hx). She reported an allergy to Levaquin®. She was taking Klonopin® 0.5 mg every 12 hours (Q12H) for generalized anxiety disorder and paroxetine 20 mg daily (QD) for depression. She denied alcohol and drug abuse and was a non-smoker.
Pt was classified as American Society of Anesthesiologists Physical Scale Status (ASA) Class II.
Dental History
The Pt reported that her dentist restored a few cavities on her front teeth about a year ago. She did not have any discomfort prior to the treatment (Tx). About a year after the restorations were made, she stated that one of her teeth felt weak and was starting to change color. She reported that she had orthodontic therapy as a teenager but has never had any major dental problems.
Clinical Evaluation (Diagnostic Procedures)
Examinations
Extra-oral Examination (EOE)
EOE was within normal limits (WNL). Skin and perioral regions were normal in color and texture. Temporomandibular joint (TMJ) was WNL. There was no evidence of clicking or popping or signs of any dislocation. Maximal opening was WNL. There was no lymphadenopathy of the head and neck regions upon palpation.
Intra-oral Examination (IOE)
IOE of the soft tissues was WNL. Gingival tissues were normal in color and texture. Oral cancer screening was negative and oral hygiene was good. Periodontal probings measured 3 mm on all surfaces of the maxillary anterior teeth. There was no bleeding on probing and no gingival recession. IOE exam of the hard tissues revealed a complete adult dentition and multiple composite restorations on the maxillary anterior teeth. The Pt had a Class I molar occlusion.
Diagnostic Tests
| Tooth | #9 | #10 | #11 |
| Percussion | – | – | – |
| Palpation | – | – | – |
| Cold | + | – | + |
| EPT | + | – | + |
EPT: Electric pulp test; + : Normal response; – : No response
Radiographic Findings
One periapical (PA) radiograph was taken (Figure 7.1). Tooth #8 was restored with a distal (D) composite restoration. Teeth #9 and #10 were restored with mesial (M) and D composite restorations. Tooth #11 did not appear to have any restorations. There was a periapical radiolucency at the root apex of tooth #10. All other teeth had normal periapices.
Figure 7.1 Preoperative radiograph of tooth #10.
Pretreatment Diagnosis
Pulpal
Pulp Necrosis, tooth #10
Apical
Asymptomatic Apical Periodontitis, tooth #10
Treatment Plan
Recommended
Emergency:NoneDefinitive:Non-surgical Root Canal Therapy (NSRCT) of tooth #10
Alternative
Extraction, no treatment
Restorative
Porcelain crown
Prognosis
| Favorable | Questionable | Unfavorable |
| X |
Clinical Procedures: Treatment Record
First visit (Day 1): Informed consent was obtained for NSRCT of tooth #10. Local anesthesia was achieved via local infiltration in the buccal (B) mucosa overlying tooth #10 with 34 mg of lidocaine (lido) and 0.017mg of epinephrine (epi). Tooth isolation was achieved with a 9A clamp on tooth #10 and a rubber dam (RD) with frame. Initial access was made through the lingual surface (L) of tooth #10 with a FG #4 SL round bur and a high speed handpiece. The access cavity was examined with an operating microscope to investigate the presence of any additional canals. A size-15 Lexicon® K-file (Dentsply Sirona, Johnson City, TN, USA) was placed into the canal, and the working length (WL) was determined with the use of an electronic apex locator (Root ZX®II, J. Morita, Kyoto, Japan). The WL was determined to be 23 mm from the incisal edge of tooth #10. The canal was instrumented using size #15, #20 and #25 ReadySteel® FlexoFiles® (Dentsply Sirona, Ballaigues, Switzerland) and rotary files (Dentsply Sirona). Rotary instrumentation was achieved with the use of a crown down technique to a master apical file of size #35. The canal was irrigated with 6.0 ml of 5.25% sodium hypochlorite (NaOCl) throughout the instrumentation process. The canal was dried with sterile paper points. Inter-appointment medicament of Ca(OH)2 paste was placed in canal (Ultradent, South Jordan, UT, USA). The tooth was temporized with a cotton pellet and CavitTM G (3M, Two Harbors, MN, USA). Occlusion was adjusted for Pt comfort. Post-operative instructions (POI) were given. The Pt was advised to take over-the-counter (OTC) ibuprofen 600 mg every 6 hours as needed for (PRN) pain. The Pt was advised to contact the office if she experienced any severe pain or swelling. An appointment was scheduled for the completion of endodontic treatment (Tx).
Second visit (Day 7): The Pt returned after one week for the completion of endodontic treatment. She reported no complications since the initial Tx visit. Local anesthesia was achieved via local infiltration in buccal (B) mucosa overlying tooth #10 with 34 mg of lido and 0.018 mg of epi. Dental dam isolation was accomplished using protocol from first visit. The temporary filling was removed and the canal was irrigated with 6.0 ml of 5.25% NaOCl, 1.0 cc of 17% Ethylenediaminetetraacetic acid (EDTA) and 3.0 ml of 2% chlorhexidine. A master cone, size #35/.04 gutta-percha point (Dentsply Sirona, Petropolis, Brazil) was placed to proper length with tug-back. A radiograph was taken to confirm placement of the master cone (Figure 7.2). The tooth was obturated using lateral condensation technique and zinc oxide eugenol-based sealer (Roth International, Chicago, IL, USA). Tooth #10 was temporized with a cotton pellet and CavitTM G. A final post-treatment radiograph was taken (Figure 7.3). The Pt was referred to her general dentist for a permanent restoration. She was placed on a one-year endodontic recall to evaluate periapical healing. A post-operative (PO) report was sent to her general dentist.
Figure 7.2 Master cone radiograph of tooth #10.
Figure 7.3 Post-treatment radiograph of tooth #10.
Working length, apical size, and obturation technique
| Canal | Working Length | Apical Size, Taper | Obturation Materials and Techniques |
| Single | 23.0 mm | 35, .04 | Zinc oxide eugenol sealer, Lateral condensation |
Post-Treatment Evaluations
Third visit (1-year follow-up): The Pt returned for PO Tx evaluation of tooth #10. The Pt had remained asymptomatic and her chief complaint had resolved. The soft tissue was WNL and periodontal probing’s were WNL and unchanged. One PA radiograph was taken. There was evidence of PA healing of the initial radiolucency associated with the periapex of tooth #10 (Figure 7.4). The tooth had been restored with a permanent bonded core as per the general dentist. Teeth #9 and #11 were stable.
Figure 7.4 One-year post-treatment radiograph of tooth #10.
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