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Medical Forum / General / Dentistry / November 2007Tooth #20 - the continuing saga
Well, I finally went ahead and got it extracted. I had high hopes of this finally being the beginning of the end of the pain. So far, not so much. The tooth itself is apparently not cracked, which is somewhat disappointing. It does have a strange groove down the middle of the root, as if it was trying to form two roots, but didn't quite make it. Does this mean anything significant? I can post a link to some non x-ray digital images of the extracted tooth if anyone is interested. As for the pain at this point, it's much worse than it ever was before, even 6 days post extraction. In fact, it seems to be getting worse over the past few days. As for the quality of the pain, it seems to be different than before, but it's hard to tell. The gum tissue is sutured closed over the socket, so does that rule out the dreaded dry socket? I get the sutures removed tomorrow. John. > Well, I finally went ahead and got it extracted. I had high hopes of > this finally being the beginning of the end of the pain. So far, not [quoted text clipped - 17 lines] > > John. You almost certainly have a dry socket at this point. The good news is that assuming it's not infected (it probably isn't) you are nearly over the hump. Most lower second premolars have one root, but it's not uncommon for them to split partially or even completely into 2 roots. Steve And if the endo was only in one canal....... :-( Steve > You almost certainly have a dry socket at this point. The good news > is that assuming it's not infected (it probably isn't) you are nearly > over the hump. Most lower second premolars have one root, but it's not > uncommon for them to split partially or even completely into 2 roots. > > Steve IIRC there were two filled canals visible in the radiograph. Could have had a third. Maybe it was the 1st molar giving trouble ? >And if the endo was only in one canal....... > [quoted text clipped - 7 lines] >> >> Steve > IIRC there were two filled canals visible in the radiograph. > Could have had a third. > > Maybe it was the 1st molar giving trouble ? I didn't remember the film. You are correct about other teeth potentially being involved. Hard to tell from here, and even sometimes in person! D >> IIRC there were two filled canals visible in the radiograph. >> Could have had a third. [quoted text clipped - 6 lines] > >D "Therein lies the rub" ;-) >Well, I finally went ahead and got it extracted. I had high hopes of >this finally being the beginning of the end of the pain. So far, not [quoted text clipped - 4 lines] >root, as if it was trying to form two roots, but didn't quite make >it. Does this mean anything significant? Ususally not. >I can post a link to some >non x-ray digital images of the extracted tooth if anyone is >interested. Sure. >As for the pain at this point, it's much worse than it ever was >before, even 6 days post extraction. In fact, it seems to be getting >worse over the past few days. As for the quality of the pain, it >seems to be different than before, but it's hard to tell. The gum >tissue is sutured closed over the socket, so does that rule out the >dreaded dry socket? No. >I get the sutures removed tomorrow. > >John. > >Well, I finally went ahead and got it extracted. I had high hopes of > >this finally being the beginning of the end of the pain. So far, not [quoted text clipped - 12 lines] > > Sure. Here it is, along with the x-ray (I'm pretty sure the 4th view of the tooth is the same side as the x-ray): http://geocities.com/g0177325/ In reply to others: the first molar has never had pain-on-pressure symptoms like #20, so I think we can rule out that as the source. > In reply to others: the first molar has never had pain-on-pressure > symptoms like #20, so I think we can rule out that as the source. Is that area there in the oval a bit of orange, or is it just the way the tooth looks? http://img152.imageshack.us/img152/3103/tooth204croppedjy1.jpg On Nov 15, 5:04 am, Zzzdent...@dentalminds.com wrote: > > In reply to others: the first molar has never had pain-on-pressure > > symptoms like #20, so I think we can rule out that as the source. [quoted text clipped - 3 lines] > > http://img152.imageshack.us/img152/3103/tooth204croppedjy1.jpg This site is blocked at work. Please send it to me at jla8128@gmail.com. >>> Well, I finally went ahead and got it extracted. I had high hopes of >>> this finally being the beginning of the end of the pain. So far, not [quoted text clipped - 17 lines] > In reply to others: the first molar has never had pain-on-pressure > symptoms like #20, so I think we can rule out that as the source. On the rightmost x-ray, there is a bit of pink sticking out from between the roots. This may indicate a perforation of the root, with gutta percha sticking out. This happens sometimes while instrumenting severely curved canals. If this represents a perforation, it was not obvious on the x-rays you showed before. It is conceivable that this area may have been helped by being sealed off with something like MTA, but surgery would have been necessary to access the need, and even so it may not have worked. But this may help to explain the endodontic failure. Steve  SignatureMark & Steven Bornfeld DDS http://www.dentaltwins.com Brooklyn, NY 718-258-5001 >>>> Well, I finally went ahead and got it extracted. I had high hopes of >>>> this finally being the beginning of the end of the pain. So far, not [quoted text clipped - 29 lines] > >Steve BTW great pix ! Would like to see a close up of image #3, especially the furcal area. Appears to be a root perforation. Would be very difficult to repair with MTA because this seems to be the interproximal surface <distal ?>. Could just be a bone spicule though, can't really tell. BTW apical surgery for a mandibular bicuspid can be a bit dicey due to the proximity of the mental foramen/ neuro-vascular bundle. > >>>> Well, I finally went ahead and got it extracted. I had high hopes of > >>>> this finally being the beginning of the end of the pain. So far, not [quoted text clipped - 36 lines] > > Appears to be a root perforation. Are you referring to the lighter colored line in that deep furrow? My skills at macro photography with a Canon A520 are limited, this picture is probably about as good as it's going to get. > Would be very difficult to repair with MTA because > this seems to be the interproximal surface <distal ?>. [quoted text clipped - 4 lines] > a bit dicey due to the proximity of the mental foramen/ > neuro-vascular bundle. > Are you referring to the lighter colored line in that deep furrow? The pinkish bow-shaped line about 2/3 of the way down the root. Looks to me like an errant gutta percha point emorging out the side of the root. Steve SignatureMark & Steven Bornfeld DDS http://www.dentaltwins.com Brooklyn, NY 718-258-5001 On Nov 15, 1:40 pm, Mark & Steven Bornfeld <bornfeldm...@dentaltwins.com> wrote: > > Are you referring to the lighter colored line in that deep furrow? > > The pinkish bow-shaped line about 2/3 of the way down the root. Looks > to me like an errant gutta percha point emorging out the side of the root. > > Steve Actually, looking at the actual tooth with a magnifier, that line is just the backside of the deep furrow that happens not to be coated with dried blood. One gutta percha canal is completely contained within the tooth, and the only place the other emerges is at the root tip which I presume is also where that puff of filler came out and is also visible on the x-ray. John. >On Nov 15, 1:40 pm, Mark & Steven Bornfeld ><bornfeldm...@dentaltwins.com> wrote: [quoted text clipped - 14 lines] > >John. OK, how about washing off all of the blood with a little H2O2 and re-photographing the 'furrow" <furca> from the perpendicular ? >> >Well, I finally went ahead and got it extracted. I had high hopes of >> >this finally being the beginning of the end of the pain. So far, not [quoted text clipped - 20 lines] >In reply to others: the first molar has never had pain-on-pressure >symptoms like #20, so I think we can rule out that as the source. What about the other bicuspid, #21 ? > >> >Well, I finally went ahead and got it extracted. I had high hopes of > >> >this finally being the beginning of the end of the pain. So far, not [quoted text clipped - 22 lines] > > What about the other bicuspid, #21 ? #21 is completely pain free as well. > #21 is completely pain free as well. Are those openings in the oval areas? How many orifices (holes) can you see near the end of the root with the magnifier? http://img233.imageshack.us/img233/2808/rootnt9.jpg One other thing that I noticed was that on the xray the gutta percha fills appear to be divergent for a tooth with two connected roots that appear to be convergent with a common root tip. This is all in for forensic interests of course just to try to figure out why the tooth persisted in giving you problems. As you can probably tell, unusual anatomy can present with all sorts of twists. Anyone who has done a root canal has experienced aggravating failures. When you're working blind into a small dark hole of a canal with twists and curves with a tiny file, it can be quite challenging. Zzzdentist www.dentalminds.com On Nov 16, 10:31 am, Zzzdent...@dentalminds.com wrote: > > #21 is completely pain free as well. > > Are those openings in the oval areas? How many orifices (holes) can > you see near the end of the root with the magnifier? > > http://img233.imageshack.us/img233/2808/rootnt9.jpg (Thanks, I got your email with the jpegs.) There are in fact two holes at the root tip where the gutta percha exits. > One other thing that I noticed was that on the xray the gutta percha > fills appear to be divergent for a tooth with two connected roots that > appear to be convergent with a common root tip. Yes, that's the way it seems. I'll post a picture of the tip head on tomorrow... > This is all in for forensic interests of course just to try to figure > out why the tooth persisted in giving you problems. As you can [quoted text clipped - 4 lines] > > Zzzdentistwww.dentalminds.com Though your analysis is standard fare from the dental educators, I must tell you that based on symptoms and history that lower bicuspids are very prone to vertical fracture. Sure, upper Bi's are notorious, but it happens to lowers too. With better examination and better photographs, at a higher magnification it should be apparent that there is a vertical root fracture of tooth #20. This is not uncommon and is rarely diagnosed before extraction. A bit of puff or overfill would not cause the symptoms described. If any tooth keeps hurting after endodontic treatment after more than 6 to 12 months one should consider root fracture and the tooth should be extracted. This is a judgment call and should be carefully considered. Did a #29 RCT+Crn as a RPD abutment about 2 yrs ago. A fistula formed and it was at first thought to be a RCT failure. Sent the patient for an endo consult, and we thought that it may be a perio leision. While treating the perio leison a 10mm pocket was found in the middle of the buccal. Since the patient was already anesthetized, went ahead and opened the tissue. Cleaned out all granulation tissue and left the buccal plate at the exisiting level. At this time, 6 mos. post surgery, and at recall, all is well, pt has zero pain, fistula has resolved, and the gigngival tissue looks completely normal. Pt. has been informed that #29 is likely to fail at sometime in the future. On the positive side the RPD has double T-clasps for #28 and #29. We are crossing our fingers and hoping for the best. >> #21 is completely pain free as well. > [quoted text clipped - 16 lines] >Zzzdentist >www.dentalminds.com > >Well, I finally went ahead and got it extracted. I had high hopes of > >this finally being the beginning of the end of the pain. So far, not [quoted text clipped - 12 lines] > > Sure. Here it is, along with the x-ray (I'm pretty sure the 4th view of the tooth is the same side as the x-ray): http://geocities.com/g0177325/ In reply to others: the first molar has never had pain-on-pressure symptoms like #20, so I think we can rule out that as the source. Looks like a damn good root canal... >> >Well, I finally went ahead and got it extracted. I had high hopes of >> >this finally being the beginning of the end of the pain. So far, not [quoted text clipped - 20 lines] > In reply to others: the first molar has never had pain-on-pressure > symptoms like #20, so I think we can rule out that as the source. |
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