Objectives

At the end of this case, the reader should be able to appreciate pre‐operative diagnosis and its relationship to the outcome of endodontic treatment. In addition, the reader should understand the rationale for debridement of the root canal system, be aware of protocols to disinfect and obturate the root canal system and be able to assess endodontic outcome over time.

Introduction

A 72‐year‐old female presents with sensitivity associated with the maxillary left second premolar (UL5) following buccal cusp fracture. The tooth was very painful at the time of fracture; however, the pain had subsided.

Chief Complaint

Patient complained of mild sensitivity that is present all the time.

Medical History

Unremarkable.

Dental History

The patient receives regular dental and hygiene care. She has a full complement of teeth except for third molars and a moderately restored dentition. The patient reports that she sustained fracture of the UL5 that extended subgingivally. The tooth was very painful at the time of fracture, but only mildly sensitive at the time of examination. The tooth was subsequently crown lengthened and restored with a direct composite restoration.

Clinical Examination

Extraoral examination was unremarkable. Intraoral examination revealed a moderately restored dentition and good level of oral hygiene. The soft tissues were healthy. The periodontal probing depths were all <4 mm and mobility was physiological. The tooth was in occlusion with the mandibular second premolar. The UL5 was non‐responsive to cold and electric pulp testing and was tender to percussion [++] and palpation [+] but not to biting [−]. Control teeth UL3 and UL7 responded within normal limits to cold test, electric pulp test, percussion, palpation and biting.

Diagnosis and Treatment Planning

Diagnosis of the UL5 was pulpal necrosis with symptomatic apical periodontitis.

Treatment options discussed with the patient were:

• No treatment (not a recommendation).
• Root canal treatment (recommendation).
• Extraction (not a recommendation, always an option)

The patient wished to retain her tooth and root canal treatment followed by a cuspal coverage restoration were planned. The pre‐treatment prognosis was favourable as the tooth was restorable and had a good crown‐to‐root ratio and no periodontal disease or issues.

Treatment

Root canal treatment was carried out under local anaesthesia and dental dam isolation. The operating field was disinfected with sodium hypochlorite. The access was observed under a surgical operating microscope and no second canal was observed. Working length was determined with the aid of an electronic apex locator and confirmed radiographically (Figure 9.3.2a). Biomechanical preparation was completed with a combination of stainless steel hand files and nickel titanium rotary files and the canal was irrigated with sodium hypochlorite and ethylenediaminetetraacetic acid (EDTA). The canal was dressed with an aqueous paste of calcium hydroxide between treatment visits. The tooth was restored with a provisional restoration.

A non‐routine post‐treatment radiograph was taken to evaluate placement of calcium hydroxide relative to the resorption site on the apical‐distal area (Figure 9.3.2b). The radiograph revealed calcium hydroxide at the site of a likely lateral canal and infection‐induced resorption at the portal of exit. At the second appointment, the patient was asymptomatic. Root canal treatment was completed with gutta percha and sealer using warm vertical condensation obturation (Figure 9.3.2c). The tooth was temporised with intermediate restorative material (IRM). The occlusion was checked and post‐operative instructions were given. The patient was advised to proceed with the restorative phase of treatment as soon as possible.

The post‐treatment prognosis was favourable, endodontic treatment was executed to a high standard and there were no untoward events.

Follow‐Up and Outcome Assessment