Chief Complaint

“I feel a sharp pain in this area (pointing to the area below the zygomatic bone, at the level of tooth #5). It hurts all day especially when I bite with that tooth (pointing to tooth #5). I took a couple of analgesics but they failed to control it. This has been my nightmare for the last week.”

Medical History

The patient (Pt) was a 38-year old male. He did not report any substantial medical condition.

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

Dental History

Pt presented with multiple dental treatments throughout the oral cavity. Specifically, tooth #5 presented a mesio-occluso-distal (MOD) amalgam restoration that was placed several years before. (The Pt did not know the exact date).

Clinical Evaluation (Diagnostic Procedures)

Examinations

Extra-oral Examination (EOE)

EOE revealed no cervical lymphadenopathy. There was no tenderness of masticatory muscles upon palpation. Perioral/intraoral soft tissue showed no signs of inflammation, pigmentation, or any other identifiable abnormalities. Extra-oral soft tissues were healthy and asymptomatic. Temporomandibular joint (TMJ) exhibited no pain, sounds, or deviation upon maximum opening.

Intraoral examination (IOE)

IOE exhibited no gingival inflammation around the right maxillary 1^st premolar (tooth #5), but erythematosus aspect was observed. Periodontal depth of 2 mm was seen all over the teeth cervical contour after probing. The Pt’s hygiene was acceptable. Physiologic mobility was observed.

Diagnostic Tests

Teeth #3 and #6 were not tested since they were asymptomatic and presented endodontic treatment.

Radiographic Findings

Radiographically it was possible to observe root canal treatments (RCT) in teeth #3 and #6. Tooth #4 showed normal vitality, and a well-adjusted amalgam restoration. No teeth in the upper right (UR) quadrant showed the presence of caries.

Tooth #5 showed the presence of an MOD amalgam restoration (Figure 10.1), also widened apical periodontal ligament. No carious lesions were identified beneath the amalgam restoration.

Pretreatment Diagnosis

Pulpal

Pulp Necrosis, tooth #5

Apical

Symptomatic Apical Periodontitis, tooth #5

Treatment Plan

Recommended

Emergency:NoneDefinitive:Non-surgical Root Canal Therapy (NSRCT) of tooth #5

Alternative

Extraction

Restorative

Composite restoration

Prognosis

Tooth structure was well maintained, the occlusion was atraumatic, and no chronic apical lesion was observed.

Clinical Procedures: Treatment Record

First visit (Day 1): Before any clinical intervention, a full medical history was obtained, and the informed consent was signed by the Pt. A brief explanation of all procedures was given to the Pt. It was decided to use a preemptive analgesia protocol, by asking the Pt to take 25 mg of dexketoprofen trometamol (Stein Corp., Cartago, Costa Rica) before the treatment. After 15 minutes, local anesthesia was administered by infiltration of one cartridge of mepivacaine hydrochloride 2% with adrenaline (epinephrine) 1:100,000 (Septodont, Lancaster, PA, USA). After five minutes, the tooth was evaluated to assure that the anesthetic effect was achieved by repeating the percussion test. Complete isolation was performed by using a latex rubber dam and clamp #2 (Hu-Friedy, Chicago, IL, USA).

The existing amalgam was removed using a #6 carbide round bur. The remaining tooth structure was evaluated for the presence of fissures and fractures using a surgical microscope. Any residual caries were removed, and further isolation was achieved using OpalDam^® (Ultradent, South Jordan, UT, USA) light-cured flowable dental dam material. Immediately, the endodontic access was performed by using a cylindrical diamond bur, in conjunction with copious irrigation of 3.5% sodium hypochlorite (NaOCl) solution. The pulp chamber was rinsed, and two root canals (buccal and palatal) were identified and located using ultrasonic diamond instruments. Both canals were gently rinsed with 3.5% NaOCl before any instrumentation.

Once the initial disinfection was completed, the working lengths (WL) of both root canals were determined by using an electronic apex locator Root ZX^® II (J. Morita, Kyoto, Japan). A size #10 hand file coupled to the electronic apex locator was gently introduced into each canal until the device indicated the locations of the apical constrictions. WLs were determined as 22 mm and 21 mm for buccal and palatal root canals respectively. Manual instrumentation of the root canals was performed, beginning with a size #15 file and finishing with a size #25 file. Between each file, copious irrigation with 3.5% NaOCl was done, and patency was established with a size #10 file. After manual instrumentation, rotatory preparation was done with the full sequence of ProTaper^® Universal (Dentsply Sirona, Ballaigues, Switzerland), until the apical portion was instrumented to an F2 file. As with manual files, between each instrument, copious irrigation was used and patency was confirmed. Just after the final preparation was done with an F2 file, passive ultrasonic irrigation was used. For this procedure, a stainless steel non-diamond ultrasonic tip (Satelec, Merignac, France) was adjusted 3 mm coronal to the working length. Both root canals were filled with NaOCl and passive ultrasonic activation was performed for 30 seconds (avoiding the contact of the instrument with dentin walls). Once the root canals were irrigated and prepared, a final irrigation with 17% Ethylenediaminetetraacetic acid (EDTA) was used, leaving the irrigant for 30 seconds. Finally, the canals were rinsed with NaOCl. The root canals were then dried by using aspiration with Capillary™ tips (Ultradent, South Jordan, UT, USA) and ProTaper^® Universal F2 paper points (Dentsply Sirona, Ballaigues, Switzerland).

For the obturation phase, continuous wave technique was selected by using a B & L Biotech obturation device (B & L, McKinney, TX, USA). Two F2 gutta-percha (GP) points were adjusted. GP points were coated with a thin layer of root canal sealer TopSeal^® (Dentsply Sirona, Konstanz, Germany) and were placed into the root canal. The apical third of each canal was obturated with the Alpha unit (B & L, McKinney, TX, USA), followed by gentle vertical compaction with #5 and #7 Schilder^® pluggers (Obtura Spartan Endodontics, Algonquin, IL, USA). The remaining canal was obturated using warm GP with the Beta unit (B & L, McKinney, TX, USA), followed by vertical compaction. A radiograph was taken to confirm appropriate obturation of the root canal (Figure 10.2).

After obturation, the remaining sealer was cleaned, and a dry sterile cotton pellet was placed in the pulp chamber. Cavit™ temporary restorative material (3M, North Rhine-Westphalia, Germany) was then placed in the endodontic access and the Pt was then instructed not to eat or drink for 2 hours following treatment, and to visit the clinician as soon as possible for the permanent restoration. A final radiograph was taken (Figure 10.3).

Since the Pt reported preoperatory pain, a pharmacologic analgesic protocol of multiple doses was selected by using an analgesic combination (multimodal approach). The Pt was asked to take 25 mg of dexketoprofen trometamol (Laboratorios Stein, Cartago, Costa Rica), combined with 500 mg of paracetamol (Laboratorios Stein, Cartago, Costa Rica) every eight hours for the next three days. The Pt was advised to continue taking dexketoprofen for an additional two days if pain and discomfort persisted. The Pt was advised to return for evaluation if symptoms persisted beyond this five-day period.

After one week, the clinician overseeing the final restoration was contacted to ask about the improvement of the Pt. The clinician reported that the Pt was asymptomatic and had taken the prescribed medication for only the first 3 days. Tooth #5 had been successfully restored using composite restorative material A2 Filtek™ Z350 (3M, Two Harbors, MN, USA).

Post-Treatment Evaluation

Second visit (29-month follow-up): The Pt returned for a control appointment. Clinical examination revealed a normal healthy periodontium and the absence of caries in teeth #4, #5, and #6. Tooth #5 was asymptomatic, and palpation and percussion tests were normal. The composite restoration on tooth #5 was adjusted and functional. Radiographically, the periapical tissues did not show any sign of inflammation or pathologic changes (Figure 10.4).

Third visit (63-month follow-up): The Pt returned for reevaluation. There were no adverse changes in the clinical and radiographic evaluation of the tooth since the first visit (Figure 10.5). The Pt was scheduled to reappoint after a period of one year, for continued evaluation.

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