Patient Case: Give (Natural) Teeth a Chance
My patient, a 28 year old woman, came to me for a second opinion. Her tooth had been previously treated with a root canal, and now she was having pain when she bit down. She’d already been to another endodontist, and they had told her that there was nothing that could be done to save her tooth.
In this x-ray, the tooth on the right with the white area shows the previous root canal treatment and filling. This patient was not willing to give up her tooth so quickly, and so she sought out another opinion – mine.
I welcomed her into the office and learned she’d had a root canal several years ago. The root canal filling (gutta percha) was overextended by about 5mm. This overextension was also very close to the inferior alveolar nerve. (In this x-ray, in the center tooth, you can see a white line coming out of the left root).
If surgery had been the treatment of choice, there definitely would have been a risk for paresthesia (a numbness, loss of local sensitivity, or tingling feeling). But surgery was not where I wanted to start. I always say, “I never know what I can do until I try.”
I was completely transparent with my patient and let her know all of the possibilities and risks. I told her that I have gotten out overextended gutta percha before, but it wasn’t a guarantee that I could do it in her case. I also was not convinced that the overextended gutta percha was the cause of her pain. With all of the information in front of her, she made an informed decision and asked me to try.
I cleaned out as much gutta percha as I could. I then took my file to the apex of the tooth, engaged it slightly and gave it a yank, and viola…that little “tail” came out! The dance party that occurred in that operatory was incredible! My patient, assistant, and I were all so happy we had accomplished the one thing the patient was hoping for.
However, that wasn’t what had the power to make or break the case; it was the bacteria that was present in the entire length of the canal that would. It was at this point that I confirmed that surgery was not a good first option. Sure, it would have removed the overextended material, but it would have done nothing to clean the bacteria out from the rest of the tooth. My patient would’ve had short-lived success, since that tooth was BLACK inside, filled with infection. I thank my calcium hydroxide as part of the treatment for taking care of that!
By the time she came back to finish treatment on the tooth, she was pain-free.
Once again, making the right diagnosis is crucial. When I understood that it was the bacteria that was causing the symptoms, and not the extra-long gutta percha, then I was able to approach the case appropriately. It’s very important that we as dentists take the time to ensure the patient has the same understanding of what is causing their pain.
The answer isn’t necessarily what looks obvious on the radiograph; we as dentists need to take our time and follow the clues to place the blame for the pain where it should be.
- We don’t know what we can do for our patient until we try. We don’t give up!
- Extraction of a tooth is not always the answer.
- As a patient, make sure your dentist or dental specialist is clear with you about all of the possible outcomes of treatment. This allows you, the patient, to make an informed decision about your own health.