Non-surgical Root Canal Treatment Case VIII:
Mandibular Molar
Ahmed O Jamleh and Nada Ibrahim
Chief Complaint
“I have a pimple on the left side of my face that oozes intermittently.”
Medical History
The patient (Pt) was a 9-year-old male. He had normal mental and physical development, and normal vital signs at presentation (height 146 cm; weight 55 kg; vital signs were as follows: blood pressure (BP) 117/53 mmHg, right arm seated; pulse 94 beats per minute (BPM) and regular; respiratory rate (RR) 18 breaths per minute; temperature 36.6°C). His past medical history was unremarkable with no known drug allergies (NKDA). He used no medications apart from an antibiotic, recently prescribed by his dermatologist, to treat a draining sinus on his face, which apparently failed to respond.
The Pt was considered American Society of Anesthesiologists Physical Status Scale (ASA) Class I.
Dental History
A few months ago, the Pt was referred to a primary care dental clinic and had tooth #19 accessed with partial root canal instrumentation and non-setting calcium hydroxide paste (Ca(OH)2; UltraCal® XS; Ultradent, South Jordan, UT, USA) placement. The dentist referred him to the endodontic clinic for further management.
Clinical Evaluation (Diagnostic Procedures)
Examinations
Extra-oral Examination (EOE)
EOE showed a 1 cm erythematous nodule at the skin overlying the left mandibular body (Figure 14.1A). The nodule had a crusted surface and was tender to touch. There was no fever, facial swelling, or cervical lymphadenopathy.
Figure 14.1 Preoperative images showing a 1 cm erythematous and crusted-surface nodule (A) and the offending tooth with no intraoral swelling (B).
Intra-oral Examination (IOE)
IOE revealed poor oral hygiene and chronically inflamed gingivae. Tooth #19 was temporarily restored with resin modified glass ionomer dental filling (RMGI) (PhotacTM Fil, 3M ESPE, Neuss, Germany; Figure 14.1B), exhibited no mobility or periodontal pocketing, and had fairly intact margins. The tooth was non-responsive to cold test or electric pulp stimulation test, but was not tender to percussion and palpation.
Diagnostic Tests
| Tooth | #18 | #19 | #20 | #30 (Contralateral) |
| Percussion | – | – | – | – |
| Palpation | – | – | – | – |
| Cold | + | – | + | + |
| Mobility | WNL | WNL | WNL | WNL |
| EPT | + | – | + | + |
EPT: Electric pulp test; WNL: Within normal limits; +: Responsive; –: Not responsive
Radiographic Findings
A periapical (PA) radiograph showed a radiolucency involving the mesial (M) root apex and extending to the furcation area. The lamina dura surrounding the M root was lost with no evidence of external or internal root resorption (Figure 14.2).
Figure 14.2 Preoperative images showing periapical (Orthoradial (A), mesial (B), and distal (C) angulations) and bitewing (D) radiographs.
Pretreatment Diagnosis
Pulpal
Previously initiated therapy, tooth #19
Apical
Chronic Apical Abscess, tooth #19 with cutaneous sinus tract
Treatment Plan
Recommended
Emergency:None
Definitive:Non-surgical root canal treatment (NSRCT) of tooth #19; informed consent obtained
Alternative
Extraction of tooth #19
Restorative
Core build-up and crown placement
Prognosis
| Favorable | Questionable | Unfavorable |
| X |
Clinical Procedures: Treatment Record
First visit (Day 1): Vital signs were as follows: BP 115/60 mmHg; pulse 90 BPM. Pt was asymptomatic (ASX). Chief complaint was taken, medical history and dental history were reviewed (RMHX), the clinical evaluation, diagnosis, treatment options, and treatment (Tx) plan were discussed with Pt. PA and bitewing radiographs were taken. Tooth #19 showed no percussion, no palpation, mobility WNL, and probing less than 3 mm. The Tx options were reviewed with the Pt and his guardians including tooth saving through NSRCT versus tooth extraction. The Pt’s legal guardians were informed about potential complications that might occur during and after the procedures. NSRCT was chosen and informed consent was obtained. The Pt was scheduled for Tx at the end of the month.
Second visit (Day 29): RMHX. BP 112/51 mmHg, pulse 85 BPM. Pt was ASX. Local anesthesia; 3.6 mL of 2% Lidocaine (lido) with 1:100,000 epinephrine (epi) were administered for inferior alveolar nerve block (IANB) and long buccal nerve block on the left side. Single tooth (tooth #19) rubber dam isolation (RDI) was performed. Access cavity was done through the resin modified glass ionomer (RMGI) to warrant four-walled access cavity. Four canal orifices were detected (Mesiobuccal [MB], mesiolingual [ML], distobuccal [DB], and distolingual [DL] canals). Copious irrigation with saline was performed to flush the remaining non-setting Ca(OH)2. Crown-down technique was performed. Coronal pre-flaring of the canals was done with ProFile® instrument size #40, .06 taper (Dentsply Sirona, Ballaigues, Switzerland). Irrigation with 6% sodium hypochlorite (NaOCl) was performed. The estimated working length (WL) was established with an electronic apex locator and adjusted for correct WL radiographically (Figure 14.3A). Shaping the canals was completed with K3TM rotary instrument size #35, .06 taper (SybronEndo, Orange, CA, USA) in the middle third, and size #30, .06 taper followed by size #35 .06 taper to the WL. The canals were further disinfected with 6% NaOCl and 17% Ethylenediaminetetraacetic acid (EDTA). The canals were then dried with paper points and filled with non-setting Ca(OH)2 by using a Lentulo® Spiral Filler (Dentsply Sirona, Ballaigues, Switzerland). The access opening was restored with RMGI. Postoperative instructions (POI) were given.
Figure 14.3 Periapical radiographs taken for working-length determination (A), master cone fit (B), and obturation (C).
Third visit (6 months): RMHX. BP 124/66 mmHg, pulse 80 BPM. Pt was ASX. The extra-oral opening appeared to be healing with slight dimpling of the skin (Figure 14.4). Local anesthesia of 3.6 mL of 2% lido with 1:100,000 epi for IANB was administered. RDI was performed. Access preparation was performed. Non-setting Ca(OH)2 was almost gone. After a rinse with NaOCl, WL was checked. After recapitulation, a final passive ultrasonic rinse was administered: 6% NaOCl, 17% EDTA, saline and then 2% chlorhexidine. Canals were dried with paper points. Cold lateral compaction technique was performed. AH Plus® Root Canal Sealer (Dentsply Sirona, Konstanz, Germany) was applied. Master cones sizes #35, .06 taper were fit in the four canals (Figure 14.3B). Finger spreader size #30, .02 taper was used for compaction. Accessory cones were placed sequentially untill the canals were fully obturated (Figure 14.3C). Pulp chamber was cleaned with alcohol-moistened cotton pellet. Access cavity was closed with Cavit™ (3M, Two Harbors, MN, USA) and RMGI. Occlusion was checked (light contact with the opposing teeth). The Pt was scheduled for follow-up, and POI were given.
Figure 14.4 Extraoral image showing the sinus tract was healed with slight dimpling.
Working length, apical size, and obturation technique
| Canal | Working Length | Apical Size, Taper | Obturation Materials and Techniques | |||
| MB | 19.0 mm | 35, .06 |
|
|||
| ML | 19.0 mm | 35, .06 | ||||
| DB | 20.0 mm | 35, .06 | ||||
| DL | 20.0 mm | 35, .06 |
Postoperative Evaluation
Fourth visit (3-month follow-up): The Pt was ASX and comfortable. Clinical examination revealed no signs of apical infection; the tooth was non-tender to percussion and there was no apical erythema, tenderness, or discharge. Radiographic examination showed considerable osseous healing around the M root except the apical area (Figure 14.5A).
Figure 14.5 Recall radiographs after 3 months (A), 8 months (B), 12 months (C), and 14 months (D) intervals.
The Pt failed to attend the six months postoperative evaluation.
Fifth visit (8-month follow-up): The Pt was ASX and comfortable. PA radiograph showed partial resolution of the periapical radiolucency (PARL) (Figure 14.5B).
Sixth visit (1-year follow-up): The Pt was ASX and comfortable. PA radiograph showed more resolution of the PARL. The RMGI was replaced with composite filling (Filtek™ Bulk Fill, 3M ESPE, Two Harbors, MN, USA) (Figure 14.5C).
Seventh visit (14-month follow-up): The Pt was ASX and comfortable. Adequate healing of the PA area with radiographic signs of reactive ostitis and traceable lamina dura was noted (Figure 14.5D).
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