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30 I I case report _ failed root-canal treatment _I recently received an e-mail from a general dentistwiththeimageoftooth#15(Fig.1).Thee-mail read: “I have an X-ray of our son’s #15 root-canal treatment done five years ago by an endodontist. He has pain. I would like your opinion on the re- treatment?” There was no additional information. The e-mail gives rise to several additional ques- tions. It directly and indirectly addresses several im- portant clinical and treatment-planning principles. These questions include: 1. Which teeth with previous root-canal treatment can and should be re-treated or have endodontic surgery, and which should be extracted? 2. If re-treatment is the best option, how should this be accomplished? 3. Ifsurgeryistheimmediatebestoption,isitalsothe best long-term option? 4. What clinical and radiographic features of the root canal pictured are needed to decide the answers to Questions 2 and 3 above? 5. What additional subjective and objective infor- mation is needed to address fully the question asked by the clinician in the e-mail? This article was written to answer these questions inaclinicallyrelevantmanner,addressingtheneeded treatment-planning concerns and strategies for clinical management. There is vital information that has a direct bearing on the management of this case that is not provided. For example, it would be helpful to know the reason this tooth was not restored after the root canal. The answer is unknown. Valid questions include whether the patient may have had significant pain after the procedurethatledtothedelayincoronalrestoration. Is the patient non-compliant? Did the patient move and neglect the coronal restoration for that reason? Is there another possible reason for failure besides coronal leakage? Could another tooth be involved? These questions (and a host of others) have implica- tionsforclinicalmanagement.Theseincludeknowing whether the patient will follow up with the restora- tive recommendations of the general dentist if this tooth is re-treated. As an aside, if the patient is non-compliant, given all of the other considerations, extraction is indicated. It is wholly unproductive to retreatthetoothtolaterfindoutthatthepatientdid not have the tooth restored a second time. It would also be ideal to have more digital radio- graphsfromdifferentanglesandideally,aCone-beam Computed Tomography scan of the tooth to deter- mine whether there is a vertical root fracture and/or possiblyaperforation.Itisrecklesstomakejudgments about clinical situations without a comprehensive understanding of the situation from multiple radi- ographic angles and without correlating the clinical examination with the symptoms. A correct diagnosis involves blending the findings with regard to percus- sion, palpation, mobility, probing and radiographic interpretationwiththesubjectiveexaminationinorder Fig. 1_Clinical case (tooth #15). roots1_2010 Comprehensive evaluation of previous root-canal therapy Author_ Dr Richard E. Mounce, USA Fig. 1