Restoring status quo ante in a third molar communicating lesion, w. vital pulp

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mrt1travel@yahoo.com - 29 Nov 2006 03:40 GMT

Due to proximity of adjacent tooth, third lower molar caries resulted
in a communicating lesion for many years, but no pain, with occasional
taste of exudate. 3 months ago 4mm piece broke off exposing interior of
tooth. With risk of lingual nerve damage on exicision in an adult, the
preference is to keep the tooth, but closing the cavity completely is
prob. neither possible (due to proximity to gingival surface and access
difficulty from adjacent molar ) - or advisable due to likelihood of
pressure bildup.
What are your preferred solutions ?

1) Exicse (declined, prefer current management with cotton filling
placed w. explorer)

2) Rootcanal (declined, overkill for a third molar, would also leave
the side open)

3) Eugenol management ?

4) Management with new compound less irritating to oral mucosa than
eugenol ?

5) Placing filling after placing a wire in split section so that a
canal can allow continued exudate flow?

Thank you for your insight. The pulp is definitively vital, cooling
pain disappears at once, there is
only light tapping pain. One would think there is a low abscess risk as
long as there is an opening..

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Steven Bornfeld - 29 Nov 2006 04:07 GMT

> Due to proximity of adjacent tooth, third lower molar caries resulted
> in a communicating lesion for many years, but no pain, with occasional
[quoted text clipped - 24 lines]
> only light tapping pain. One would think there is a low abscess risk as
> long as there is an opening..

    I have to take your word on the risk of lingual nerve damage in the
case of an extraction.
    I must confess curiosity as to what your role in this scenario is.
Your language suggests medical training; however I personally doubt a
dentist would consider "eugenol management".
    Whether the risk of extraction is undertaken depends upon the perceived
risk. You imply the third molar is at least partially impacted, but
this is not clear. Furthermore, I cannot assume that root canal is
"overkill" if extraction is not feasible. Of course the root canal may
well not be feasible either; however the consequences of untreated
abscess in this area are not insignificant.
    BTW, if there is exudate from the pulp chamber there is abscess; if the
pulp is vital in this case it will not long remain so.
    If root canal and restoration is not possible I see no option other
than extraction. The neglect of this situation during the period when
simpler treatment would have been possible seems to me to preclude
successful treatment otherwise, and have put the patient in a position
where a certain amount of risk is unavoidable.

Steve

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Newbie - 29 Nov 2006 16:50 GMT

>> Due to proximity of adjacent tooth, third lower molar caries resulted
>> in a communicating lesion for many years, but no pain, with occasional
[quoted text clipped - 45 lines]
>
>Steve

Well said, but I still question:

>With risk of lingual nerve damage on exicision in an adult"

I seriously doubt there is any risk to the lingual nerve.
Perhaps the mandibular n. but not the lingual.

Permanent mandibular n. paresthesia is rare with good
surgical technic in my experience.

Chronic infection on the other hand carries significant
risk.

Extract the tooth I say !

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Mark & Steven Bornfeld - 29 Nov 2006 17:06 GMT

>>>Due to proximity of adjacent tooth, third lower molar caries resulted
>>>in a communicating lesion for many years, but no pain, with occasional
[quoted text clipped - 60 lines]
>
> Extract the tooth I say !

My guess is that you are right, and the issue is the inferior alveolar
nerve. But no matter--I have sent patients to oral surgeons to extract
lower third molars where they declined to do it, and I respect their
decision to do so. But none of these were acutely involved teeth, and
if it really HAS to come out, it HAS to come out, and the risk of
sequellae must be accepted.

Steve

Signature

Mark & Steven Bornfeld DDS
http://www.dentaltwins.com
Brooklyn, NY
718-258-5001

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mrt1travel@yahoo.com - 29 Nov 2006 23:01 GMT

Thanks for your replies. Textbooks suggest lingual nerve issues in 4 of
100 patients fr. wisdom tooth extraction, much of the research centers
on whether this rate can be improved by using a "separator" piece
during the operation, but the evidence says it makes no difference, the
nerve is very vulnerable, and not only the lingual nerve.
Being in the lifesciences, to me it seems the body has managed low
level infections
in teeth for eons. There is no real exudate flow into my mouth, but for
years, after
flossing, I could sometimes taste this. My understanding is that a
canal leading to
an apical "boil" is created only under pressure, and here it is open.
The distal-contacting
portion of the cotton is beige discolored after one night of exposure.

I wondered what material you recommend to put in there before the
cotton
I am currently using, the gold standard used to be Eugenol in pulpitis,
but
one has moved away from this I understand...thx again,

Incidentally, - I had my top ones out, I am avoiding the excision of
the lower only due to the risk. They are not impacted, rather, they are
pushed out.

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Mark & Steven Bornfeld - 29 Nov 2006 23:14 GMT

> Thanks for your replies. Textbooks suggest lingual nerve issues in 4 of
> 100 patients fr. wisdom tooth extraction, much of the research centers
[quoted text clipped - 20 lines]
> the lower only due to the risk. They are not impacted, rather, they are
> pushed out.

Not sure how you decided the nerve is at risk. I'm sorry, but your
problem does not lend itself to internet diagnosis, except in the most
general way.
Sorry to say, I do NOT see this as a do-it-yourself situation.

Good luck,
Steve

Signature

Mark & Steven Bornfeld DDS
http://www.dentaltwins.com
Brooklyn, NY
718-258-5001

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Newbie - 30 Nov 2006 19:32 GMT

>> Thanks for your replies. Textbooks suggest lingual nerve issues in 4 of
>> 100 patients fr. wisdom tooth extraction, much of the research centers
[quoted text clipped - 28 lines]
>Good luck,
>Steve

Same here and I dispute the claim that:

>> Textbooks suggest lingual nerve issues in 4 of
>> 100 patients fr. wisdom tooth extraction

No textbook can replace actual surgical experience.

Get thee to a dentist ! (or oral surgeon) !

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Newbie - 29 Nov 2006 16:28 GMT

>Due to proximity of adjacent tooth, third lower molar caries resulted
>in a communicating lesion for many years, but no pain, with occasional
[quoted text clipped - 24 lines]
>only light tapping pain. One would think there is a low abscess risk as
>long as there is an opening..

The preferred solution is extraction by a competent oral surgeon IMO.

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