DTIN0210

DeNtaltribuNe|april-June, 2010 Clinical 9 The patient is a 24-year old white Northern European male. His chief complaint was pain from the maxillary left lateral front tooth, with periodic swelling of the left anterior palatal. The patient’s dental history indicated previous problems in this region, documenting an emergency appointment in March 2007 due to pain and swelling from tooth 22. He was prescribed a seven-day course of Penicillin V tablets (660mg qds*4) for acute apical periodon- titis tooth 22. Following this appointment, the patient was referred for examination and treatment of tooth 22. Diagnosis The extra-oral examination on 30 January 2008 was within normal limits, shown in Figures 2 and 3. However,asisvisibleinTable one, the intra-oral examination revealed gingival bleeding on prodding, no sinus tract and fluctuant swelling of the palate mucosa in the area of teeth 21, 22 and 23. The periodontal pockets however, were within normal limits. Following the investigations, the diagnosis showed that a peri- radicular abscess was related to non-vital tooth 22. The problems associated with the diagnosis were a wide root canal, and an open apex with large apical lesion. The structured treatment plan involved conventional root canal treatment, and to be assess for surgery after six months. The treatment plan Treatment commenced on 3 April 2008. Following an initial clinical examination, the tooth was diagnosed with & apical abscess (no sinus present). Ac- cess was gained under a rubber dam and the canal was filled with exudate. The root canal length was determined both by apex locator (RootZX) and a periapical radi- ograph. The root canal disinfec- tion was completed mechani- cally using Hedstroms files (size 90/20 mm/incisal edge). Particular care was taken during irrigation due to the open apex, & ultrasonics were used for the further cleaning of the canal. A formula of one per cent NaOCl, two per cent CHX and 17 per cent EDTA were used for chemical root canal disinfection. The canal was dressed with Ca(OH)2 and IRM was applied as a temporary filling. Five days after the comple- tion of the treatment, the patient sought an emergency consulta- tion because of severe pain and swelling from tooth 22. He was prescribed an eight-day course of clindamycin (500 mg x 3*3) to ease the discomfort. Following the surgery, on May 29, tooth 22 was asympto- matic and swill sensitive to per- cussion. The temporary filling was removed and the root canal disinfected again with Irrisafe, as well as a formula of one percen NaOCl, two per cent CHX and 17 per cent EDTA. Along-termintra-canaldressing with Ca(OH)2 was placed, and IRM was applied as a temporary filling. Preparing for root treatment The patient missed the follow- ing three appointments, but re- turned on October 14. On this date the tooth was still sensitive to percussion and palpation. As there were no real signs of im- provement, it was decided that the tooth should be root filled & an appointment for apical sur- gery was made. To ease discom- fort, the root canal was filled with an 8mm length of white MTA, & a wet cotton pellet was placed over the MTA. On top of the cotton pellet, a temporary filling with IRM was placed. Treating a peri-radicular abscess Dentist Nicolai Orsteen presents a clinical case study looking at the treatment of a maxillary left lateral front tooth Fig. 1: Frontal view Fig. 11: Granulation osteotomyFig. 10: Elevation of surgical flap Fig. 12: Granulation tissue removed & root-end resection performed Fig. 13: Flap sutured with 6-0 silk sutures Fig. 7: MTA in the canalFig. 5: Working lenght radiograph Fig. 8: MTA, wet cotton pellet and IRM Fig. 9: White MTA in the canalFig. 6: MTA in the canal Fig. 2: Frontal view Fig. 3: Occlusal view Fig. 4: Pre-operatve periapical radiograph 21 22 23 Sensitivity to Cold Yes No Yes Percussion No Yes No Palpation No Yes No Mobility No No No Probing Depth (mm) 2 2 2 Restoration NoneComposite (Pal) None Table 1: Clinical findings Further radiographic investigation in April 2008 revealed that the patient was suffering from a discontinuation of the lamina dura on tooth 22, as well as a large circumscribed apical radiolu- cency (Ø 15mm). The radiographic findings in the coronal part of the root were diagnosed as dens-in-dente (see Figure 4).

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