Jon Richards DDS MS
An unfortunate reality of failing endodontic therapy is the time lapse from the time of completion to the realization there is a problem. Most often the treating clinician and patient both are unaware there is a problem. In this case, the patient was pregnant and due to deliver in 2 months. She was beyond miserable and had a maxillary fascial space infection and made the emergency call after hours on a weekend. She was really miserable.
The initial therapy was completed approximately 5 years prior. She never had experienced symptoms. She also had been faithful in getting her regular dental exams, but at no time was there a concern or detection of an endodontic problem. The PA radiograph was indicative of advanced pathosis at the MB, DB, and P apices.
After access through the crown, the pulp chamber was full of gutta percha. This is a common sign that a carrier-based obturation was likely to be encountered as much of the gutta percha gets stripped from the core obturator- and this was indeed the case here. Metal obturators were found to be present in the three most common canals. Three were removed and an immediate eruption of pus from the MB canal resulted.
An untrreated MB2 was located and cleaned. The remaining gutta percha was removed with hand files and solvent and patency was established and maintained. Ca(OH)2 was placed and the access was temporized. She was given oral antibiotics to assist with the facial swelling.
After 3 weeks the patient returned. She reported her pain was immediately improved and took approximately 4 days to resolve.
It was determined that obturation would be delayed for several months in order to confirm that her signs and symptoms not only resolved, but didn’t return. The Ca(OH)2 was irrigated and replaced, and a thick GI access temporary was placed.
After 3 months she returned reporting no return of her pain. 4 canals were obturated and the access was restored with amalgam. At this time there was already radiographic evidence of periapical healing.
She returned two years later for a recall appointment.
While most (if not all) office will bill for these visits, we never charge for follow-up evaluations. We view these visits as a crucial time for feedback of the treatment we provide. It can be argued that if a recall appointment had been made and kept with the initial therapy in this case, the patient could have avoided the emegency treatment and pain that she had to endure.
Fortunately, the radiograph at two years indicated regeneration of the periapical tissues. The periapical findings present at the initial visit had resolved and a normal appearance of the PDL and lamina dura was observed.