Case of the Month Archives

• January 2006
• December 2005
• November 2005

January 2006

Patient Age: 15

Tooth #(1 - 32): 31

Procedure Category: Vital Pulp Treatment

Chief Complaint: Parent states "our dentists want you to evaluate the back tooth on the R"

Medical History: Cardiac, pulmonary, gastrointestinal, renal, musculoskeletal & neural systems review; non significant. Pt denies taking any medications either recently or currently. NKA, NKDA. BP 120/77, PR 61/min.

Relevant Dental History: Hx of regular annual dental care including pit & fissure sealants, fluoride treatment & OH instructions; orthodontic Tx ~18 months. Denies Hx of sensitivity/pain to function or thermal stimulation at this time.

Clinical Evaluation: Dentition consistent dental Hx; OH good MX & MD fixed orthodontic appliances in

Diagnosis:

• Pulpal: # 31 Hyperplastic pulpitis
• Periradicular:# 31 Normal

Treatment Plan Recommended:

• Emergency: NA
• Definitive: Cvek pulpotomy using ProRoot MTA

Alternative: Ca(OH)2 apexification + NS RCT

Restorative: Bonded core buildup: PFM crown upon full eruption

Prognosis: Favorable

Relevant Clinical Procedures:
1st appointment: ROS RMHx clinical and radiographic eval and Dx. Outlined treatment options including the advantages and disadvantages. Received informed consent from the Pt parent.
2nd appointment: Topical anesthetic; benzocaine 50mg in H20 soluble glycol base; Local anesthetic lidocaine 80mg epinephrine 0.04mg; IDB & LBB. Checked for profound anesthesia; Child bite block; ARD; removed decay resorptive tissues & hyperplastic pulp with coarse high speed diamond bur; Cvek pulpotomy; controlled hemorrhage with 0.8% chlorhexidine + saline irrigation; placed ProRoot MTA over pulp stumps; compacted using ultrasonically vibrated Schilder pluggers. Temporarized access cavity using CWP & IRM; Advised; 600 mg of ibuprofen q6h 5 days
Review Pt via the phone; reports doing well
3rd appointment: Topical anesthetic; benzocaine 50mg in H20 soluble glycol base; Local anesthetic lidocaine 80mg epinephrine 0.04mg; IDB & LBB. Checked for profound anesthesia; Child bite block; ARD; removed temporary: placed bonded core buildup material

Recall appointment: (1.1 Yrs post Tx) Fixed orthodontic appliance in place; #31; asymptomatic; bonded bracket; normal function; noTTP/Palp; no evidence of recurrent decay; no probings >3mm; no tissue inflamation or sinus tracts. composite build up in place & intact; responds WNL & similar to preTx sensiblity tests. Radiographically; PDL space & lamina dura; WNL with continued development.

December 2005

Patient Age: 19

Patient Sex: male

Tooth #(1 - 32): 19

Procedure Category: Surgical root canal treatment (SRCT)

Chief Complaint: “I had a root canal about a year ago and now I have gum bole”

Medical History: Cardiac, pulmonary, gastrointestinal, renal, musculoskeletal & neural systems review; non significant. Pt denies taking any medications either recently or currently. NKA, NKDA. BP 125/80, PR 65/min, RR 13/min.

Relevant Dental History: Hx of regular dental care; Pt reports # 19 Hx NS RCT & all ceramic crown placed; ~ 12 months prior; non painful buccal swelling adjacent #19 ~ 10 day ago; associated with a bad taste; Denies senstives/pain to function or thermal stimulation at this time.

Clinical Evaluation: #19; all ceramic crown in place & intact; no evidence of recurrent decay; buccal swelling present ~ 5mm in diameter; sinus tract present; extrudes pus/blood with digital pressure; # 18 & 20; in place & intact; no evidence of decay.

Diagnosis:

• Pulpal: 19 Previous NS RCT
• Periradicular: 19 Chronic suppurative periradicular periodontitis

Treatment Plan Recommended:

• Emergency: NA
• Definitive: SRCT

Alternative: RETX, Extraction

Restorative: NA

Prognosis: Good

Relevant Clinical Procedures:
1st appointment: ROS RMHx clinical & radiographic eval Dx. Outlined treatment options including the advantages & disadvantages. Possible complications involved with SRCT; specifically warned of the close proximity of the mental nerve and potential of devitalizing #18 and the use of a xenograft material. Received informed consent from the Pt.
2nd appointment: Pt. again advised of possible complication prior to the commencement of SRCT. Pre-surgical; mouth rinse 0.12% chlorhexidine ~ 1.5 minutes; 800 mg of ibuprofen. Topical anesthetic; benzocaine 50mg in H20 soluble glycol base. Local anesthetic; 40mg of lidocaine, 10mg of marcaine & 0.04mg of epinephrine; IDB; 40mg of lidocaine and 0.04mg of epinephrine infiltration; submucosa distal #18 - distal # 22. Checked for profound anesthesia. Incision; vertical relieving; mesial #21; intrasulcular horizontal relieving mesial #21 - buccal grove of # 18; mucoperiosteal tissue was reflected using a periosteal elevator; buccal cortical plate perforated apically, intact coronally & in the mid mesial root region. Expanded the boney window using Molven 2/4; curettage of the lesion proper; removed biopsy specimen; resected root ends using 267-bone bur; root tip was removed; Mesial & distal root canal systems identified; root end cavities prepared to a depth of ~ 3 mm using ultrasonic root-end preparation tips; CollaPlug placed in the bone crypt; root-end cavities restored with ProRoot MTA; CollaPlug removed; bone crypt irrigated with sterile physiological saline; postoperative radiograph was exposed; crypt packed with BioOss xenograft; reflected tissues repositioned, compressed for ~ 3 min; surgical wound closed; vertical relief incision IV 5/0 gut suture; interproximally III 4/0 Vicryl sutures; tissues lightly compressed for 5 min. Pt instructed to apply cold to the external surface of the wound region 20 min on & 20 min off. Rx; 800 mg of ibuprofen q6h 5 days; 0.8% chlorhexidine rinse 5-10ml/2min q8h 200 ml; rinse with warm salt water as regularly as possible start that evening. Review Pt via the phone reports; doing well
3rd appointment: Removed sutures, soft tissue healing well, Pt reports minimal discomfort and is not taking any pain medication.

November 2005

Patient Age:14

Patient Sex: male

Tooth #(1 - 32): 29

Procedure Category: Non-surgical root canal treatment (NSRCT)

Chief Complaint:Parent states “ His tooth is hurting and our pediatric dentist told us to come an see you”

Medical History: Cardiac, pulmonary, gastrointestinal, renal, musculoskeletal & neural systems review; non significant. Pt taking amoxycillin 500mg PO q6h & Tylenol 500mg q6h for 3 days for infection & pain; Rx by pediatric dentist. Pt denies taking any other medications either recently or currently. NKA, NKDA. BP 125/85, PR 72/min

Relevant Dental History: Hx of pain body R Md; started ~ 1 wk prior; pain on function; avoid R function ~ 1 wk; denies a Hx of sensitivity/pain to thermal stimulation; interrupted sleep ~ 3 days ago; precipitated visit to pediatric dentist.

Clinical Evaluation: Premolar & molar teeth in both the Mx & Md have several regions of discoloration. Mother denies; Hx of excess fluoride intake, medical condition, drug Tx; that could account for discoloration. # 30 had an intact occlusal pit composite resin restoration; #29 unrestored; no dental pathology other than noted above discoloration; soft tissue overlaying the apex of #29 was erythematous.

Diagnosis:

• Pulpal: 29 Pulp necrosis
• Periradicular: 29 Acute periradicular periodontitis

Treatment Plan Recommended:

• Emergency: Pulpectomy with pain management
• Definitive: NSRCT using ProRoot MTA as the obturation material

Alternative: Apexification using Ca(OH)2 with subsequent NSRCT, Extraction

Restorative: Restore the access cavity with bonded core material

Prognosis: Favorable

Relevant Clinical Procedures: Review of Medical Hx, clinical & radiographic eval, Dx. Outlined treatment options including the advantages and disadvantages. Received informed consent from the Pt parent. Topical anesthetic; benzocaine 50mg in H20 soluble glycol base; Local anesthetic lidocaine 80mg epinephrine 0.04mg via a IDB & LBB. Checked for profound anesthesia; Child bite block; applied rubber dam; accessed; Necrotic pulp. EWL C&S using a combination GG burs & 0.06 Profiles in a Crown Down technique; irrigation 5.25%% NaOCl/17% EDTA. Established WL using a radiograph; completed C&S to WL, irrigation with 5.25%% NaOCl/17% EDTA; Loosely fitted Schilder pluggers 10-12 ~1.5 -7 mm from WL. Final irrigation prior to obturation; 17% EDTA for ~1 min. 5.25% NaOCl for ~1min 17% EDTA for ~1 min. 5.25% NaOCl for ~1min. Dried with 90% alcohol and PP measured to WL. Obturation with ProRoot MTA compacted using ultrasonically vibrated Schilder pluggers. Temporized access cavity using CWP & IRM. Rx ibuprofen 600mg q6h for 4 days for pain.