Date: November 28, 2022
Submitted By: Rodrigo
54 years old Male patient referred for assessment and treatment of #11
Chief complaint: “I feel pressure on my gum. I had trauma to this tooth approximately 40 years ago”.
Clinical findings: Percussion (+) slight / Cold (-) / EPT (80/80) / Mobility: WNL / Probing: WNL / Palpation: discomfort and slight swelling at the mucobuccal fold. Tooth is slightly discoloured…
Imaging findings: Pulpal obliteration and RL area at the apex. This area is compatible with an inflammatory process of endodontic origin. I also noticed a RO area compatible with the apical portion of the root (fractured).
Question:
Treatment options:
1- RCT
2- RCT + Apical surgery
3- Apical surgery
4- Extraction
Thank you!
Rodrigo
Hey Rodrigo. I was out in the hot tub and your case popped into my head. If he was 14 yrs old when the trauma occurred then the tooth likely calcified after that time due to revascularization of the coronal segment and could still be vital, unless there was a previous trauma at a younger age. A false positive EPT for necrosis could be presenting (type l error) considering the PCO, despite the relatively high likelihood ratio for the EPT test generally. It would make sense to remove the root tip from a palatal approach, place a membrane if appropriate and reassess healing in 3-6 months. If it heals and the colour change is not an issue to him there is no need for internal bleaching and the tooth can be left intact without RCT. Interested to see your approach.
Thank you David! Great to read your thoughts… I will post the full treatment in the next few weeks. Take care!
Good case Rodrigo! If it’s been there for 40 years it’s worth trying to keep for 40 more. Thinking RCT and apical surgery as root tip would likely be non-vital from the horizontal positioning. May need to bone graft/membrane the palatal aspect as it seems close to a perforation from the root tip, with surgery likely resulting in a through and through defect otherwise. While the case may work with a retrofilling alone, I suspect the RCT will result in a better debridement, but also allow for internal bleaching to follow. Thanks.