Real Patient Experiences
An 18 year old male, Doug, was referred to our office because of recent cold pain from the area of tooth #10. Other than that, he had no other symptoms.
A digital image showed a large radiolucency in the apical region of teeth #9 and #10. (For those not familiar with this, the appearance of the dark area obvious on the first picture is due to the presence of a hole in this patient’s jawbone at that location). A fistula (an opening that can occur through the
gingiva, which usually forms in the presence of draining purulence) was detected between #9 and #10. There were no teeth sensitive to percussion and the application of cold to the teeth showed all the teeth in the area had a slight, normal reaction, except tooth #10 which did not have any sensation at all. Additional testing (EPT) indicated the pulp within #10 was non-vital. The examination findings allowed for the diagnosis of a LEO. (This is the acronym for Lesion of Endodontic Origin. The presence of this type of pathology happens when the pulp within a tooth dies and the infectious byproducts which are created leak out of the root through portals of exits and cause holes in the bone to occur. It is possible at first a patient may not even be aware of this problem. However, it is expected that at some point symptoms will occur — pain and possibly swelling — which can be quite severe). Since this tooth does not have any caries or a restoration, it is reasonable to expect there is a past history of trauma to his teeth.
When a patient has this type of problem, her/his options are: 1) ignore the problem (which is not wise) 2) extract the tooth (which is not desirable) 3) have root canal therapy.
After a thorough discussion of the problem and options, Doug chose to proceed with endodontics and at our first visit the necrotic tissue within the tooth was removed, the canal system was sanitized, then medicated and a temporary filling was placed in the access. (See Root Canal Therapy under the Procedures tab to learn more about how this procedure was performed). Doug returned about 6 weeks later (note that the area already shows signs of bone regeneration within the lesion) and the canal system was sealed with gutta percha, another temporary filling was placed and he was instructed to return to his dentist for final restoration.
It is important to track the healing of the lesion to be sure healing is normal and complete. For a LEO as large as this one it can take a year or more for complete healing to occur. However, note the first recall image after only 6 months shows astounding healing of the apical bone and after one year the lesion is just about totally healed.
This is an example of how successful endodontics can be and fortunately for this patient, the problem was detected and dealt with before symptoms occurred. The only unanswered factor in this case is we did not determine which tooth caused this patient’s initial cold pain, as it would not have been from tooth #10, since its pulp was non-vital. The area has been non-symptomatic since our efforts and our patient extremely happy.
A 42 year old male, Joe, was referred to us after his general dentist became concerned by the radiographic appearance of tooth #31. We had the patient in for an evaluation and consultation. Joe reported having had a root canal performed by an endodontist about 6 years ago. The tooth was non-symptomatic, but digital images showed apical radiolucencies at the end of the mesial and distal roots. (For those not familiar with this, the radiolucencies are the dark spots on the image at the end of each root and indicates there are holes in the bone there). In addition, a fistula was noted in the gingiva on the buccal (cheek) side of the tooth. There were no abnormal probings around the tooth, which might be an indication of a deep fracture. The findings allowed for a diagnosis of a failing root canal.
Dr. Marshall discussed the problem in great detail and advised the image showed that although the previous treatment had been done very well there was evidence of a chronic infection. He explained the goal of endodontics is to sterilize then seal the root canal system and if something prevents these goals from being attained, the treatment could fail.The options for dealing with a problem such as this are: 1) ignore the problem (which is expected to lead to pain and possibly swelling, someday), 2) extract the tooth and possibly consider an implant and crown to replace it, 3) have the root canal retreated to see if the tooth can be saved, 4) have a surgical root canal (see Apicoectomy under the Procedures tab to learn more about that type of treatment).In most cases, it is always better to try and save your own tooth, if after a thorough examination and discussion of options it seems reasonable. Joe chose to have Dr. Marshall try to save the tooth for him (see Endodontic Retreatment under the Procedures tab to see how this is done).
At the first visit, Dr. Marshall performed disassembly, making an access through the crown and then removing the post and the previously placed gutta percha. The canal was sanitized and medicated and the patient scheduled to return two weeks later. When he returned, Joe indicated the tooth felt great and we found the fistula had already healed. The canal system was sterilized and sealed with gutta percha and the access cavity closed with a temporary filling material. The patient was given post operative instructions, which included the necessity to see his general dentist in a few weeks for final restoration. In a situation like this, it is very important to track the progress of healing to be sure our efforts proved to be successful, so Joe was scheduled to return for a recall image.
After approximately 6 months he returned and indicated the tooth felt great. Our picture showed that the periapical pathology had totally healed and new bone had regenerated to fill in the holes which had been created by the chronic infection. This case shows that sometimes it is best to not give up on a tooth. Although sometimes extraction and replacement might seem to be a better option, it makes sense to save your own, natural tooth, when it is reasonable. _____________________________________________________________________________
A 57 year old male, Pete, was referred to our office because of pain and swelling from the upper, left portion of his mouth. We found a 4-unit bridge, held by teeth #12 and #15 (for those that don’t know, the teeth that hold a bridge are called the abutments and the “fake” teeth in the middle at #13 and #14 are called pontics). Pete said the bridge was very old and his dentist had recommended it needed to be replaced, but he was currently out of work and could not do that presently. Dr. Marshall found swelling on the buccal side of tooth #12 and that tooth was extremely painful to percussion and quite mobile.
Our digital image showed apical pathology (the dark spot) at the approximate location of his swelling and testing indicated the pulp within tooth #12 was non-vital. Our evaluation findings allowed us to make a diagnosis of an AAA (this is the acronym for Acute Alveolar Abscess). This type of dental problem is associated with pain and swelling, both of which can be quite severe. Obviously, ignoring the issue is not possible, so Pete had to decide whether to extract the tooth (and lose the bridge), or save it. The image shows he does not have very much bone for the placement of implants, as the sinus is very large and close to his ridge of bone. So, if he chose to extract tooth #12, his restorative solution might be to have a removable partial denture (an appliance that can replace multiple teeth, but is usually not as stable or desirable as a fixed bridge). If Pete decides to save the tooth, he has to realize at some point he will have to replace the old bridge. The margins (where the bridge meets the tooth) are starting to break down and eventually decay will occur underneath it and the affected tooth could be lost.
After considering his options, Pete asked Dr. Marshall to proceed with root canal treatment to save this tooth. At that visit, the big concern was the pain and swelling, so emergency root canal treatment was indicated. Dr. Marshall proceeded by making an access opening into the crown of #12, the necrotic tissue and purulence were removed, then canals cleaned and medicated. An antibiotic was prescribed and over the next few days Pete’s symptoms totally alleviated. When he returned about four weeks later the tooth was no longer mobile, his root canal therapy was completed and a space for a post was prepared in one of his canals. He was instructed to see his dentist in a few weeks for restoration.
One year subsequent to treatment we had Pete back for a recall image to check the healing of the apical lesion. We found new bone had regenerated and the pathology was almost totally healed. The tooth was nice and tight and Pete said the tooth felt fantastic. His dentist had provided a beautiful post & restoration and a new bridge had been treatment planned.
A sixty-nine year old man, Jim, was referred to us for an evaluation. He advised the following history: about one month previously, he experienced pain and swelling in the area of his lower, front teeth.
When his dentist took a radiograph, he noted a very large radiolucency in the jaw bone at the root ends of multiple teeth. For someone who might not be familiar with this, the dark area seen in the first digital image represents a hole in the patient’s jaw. There are various reasons why this could happen and the first order of business is to determine the etiology or cause of the problem.
Jim’s dentist was immediately concerned that the large size of the radiolucency might indicate it could be a lesion of extra concern and referred him to a local oral surgeon. A biopsy was taken, sent to an oral pathologist and the finding was that the lesion was a periapical granuloma. This type of tissue is commonly found when a patient has a simple root canal problem and is referred to as a lesion of endodontic origin or LEO.
At the consultation appointment, Dr. Marshall performed a thorough evaluation and found the patient had necrotic pulps (see the Endodontic FAQ under the Patient Information tab and scroll down to What is the pulp? to learn more) within two of his teeth. A fistula, which looks like a little blister and is sometimes present with this kind of problem, was observed. Since there were not any caries or previous restorations, we could expect there was a previous history of trauma to this part of his mouth, which caused the pulps to die. Sometimes when this occurs, the ensuing infection can leak out of the root ends, or any other openings from the canal system to the external root surface (these are commonly referred to portals of exits) and causes the bone to deteriorate and a hole or LEO to form. This can seem a little scary, but in actuality all the patient needs is a root canal (or in this case, two root canals) to solve the problem (see Root Canal Therapy under the Procedures tab to learn more about this type of treatment and how easily it can be performed). There was a thorough discussion of the problem and all the options for dealing with it and although there were currently no symptoms at all, it was explained there was definitely a problem that needed to be addressed. Dr. Marshall recommended root canals were needed to save these teeth. Jim said he usually gets a little nervous with dental procedures and we assured that endodontics could be provided in a very comfortable manner.
When the patient returned for his treatment appointment, since he had previous hip surgery, his orthopedic surgeon recommended he should premedicate with Amoxicillin.
At this visit, the necrotic tissue was removed from the roots, the canal systems were cleaned and a special material was placed to facilitate the healing process. A second appointment was scheduled and when he returned two weeks later the canal systems were sterilized and sealed with the final root filling material. When the treatments were completed the patient indicated how happy he was and admitted he had never felt a thing at either visit. Dr. Marshall explained the importance of him returning to our office for a recall image, to be sure the area was healing well, and advised a lesion that large could take a year or longer to totally heal. We took a final image of our work and forwarded it with a report to his general dentist. Jim was told to wait a couple of weeks to be sure the teeth felt fine and then he saw his dentist for beautiful restorations.
He returned to our office six months later for a recall image, which took only a few minutes. It clearly showed the large lesion was healing beautifully with the regeneration of new bone. At two years, the bone is completely normal in appearance and the healing astounding! In addition, Jim said the teeth feel great! The long term prognoses for these teeth are excellent! Key to the success of this case was recognition of a problem, proper diagnosis, appropriate treatment and restoration, and the monitoring of the healing.