Case review
Female born March 3, 1914 with a chief complaint of
" ..a pimple on the gum beside the tooth.."

Medical History: Patient had a history of high blood pressure which was being controlled with Zestoretic.

Dental History: Original root canal treatment had been completed on tooth #5 more than 15 years previously. A new porcelain fused to metal crown had been placed 2 years previously. At that time the patient had been advised to have the tooth retreated but in the absence of any clinical or radiographic sign or symptoms had declined. The patient had noted pain and swelling on the gingiva adjacent to tooth #5 one week previously for which her general dentist had prescribe antibiotics.

Clinical Examination: Clinically, swelling with a draining sinus tract stoma was noted on the alveolar mucosa adjacent to tooth # 5. Tooth #5 did not respond to cold testing, was sensitive to percussion with all probing measurements < 4mm. All of the other teeth in the quadrant responded within normal limits to pulpal and periapical testing.

Radiographic Examination: (Figure 1) Tooth #5 had received previous root canal treatment with silver points both of which were short of the radiographic apex. The cone in the palatal canal also appeared to have been sheared off at a distance below the canal orifice. A significant periapical radiolucency was noted which was asymmetric about the apex.

Diagnosis: Pulpal - Previously root canal treated. Periapical - Chronic periapical abscess.

Treatment Plan: Orthograde endodontic retreatment of tooth #5

Potential Complications:
• 1) The patient wished to retain the existing crown if at all possible since it was only 2 years old.
• 2) The patient was advised that due to the asymmetric nature of the periapical radiolucency there was a possibility the tooth might be cracked and that if it was it would have to be extracted.
• 3) The patient was advised that in the event we were unable to remove the silver points in their entirety or were unable to instrument to the apex of the tooth periapical surgery may also have to be undertaken to achieve a successful resolution.
  
  Clinical Notes: Patients blood pressure was taken (142/88). Local anesthetic was administered and rubber dam placed. Access was created through the occlusal existing restoration using the surgical operating microscope. Once the old core material had been removed from the pulp chamber and the silver points isolated using the BUC-1 and 3 ultrasonic tips a careful examination was made of the pulp chamber at high magnification (20X) to rule out the presence of a crack. Next we negotiated alongside the silver points using #6, 8 and 10 hand files using 5.25% NaOCl as a lubricant. This created some room for us to insert #15 Safety Hedstrom files alongside the silver points and remove them. An attempt was then made to determine a working length using an electronic apex locator but was unsuccessful since both canals were blocked out. A radiograph was than taken (Figure 2) and a tentative working length calculated. Filling the pulp chamber with 5.25% NaOCl we negotiated to the apex plus 1mm with a #6 hand file to ensure patency and the working length was confirmed with the electronic apex locator. Instrumentation was then completed with ProTaper rotary instruments. The tooth was then irrigated with 17% EDTA and medium feather tip GP cones were fitted to ½ mm of the working length. The canals were then irrigated with 99% isopropyl alcohol and paper points. The cones were then cemented with Roth?s 511 sealer and a trial cone radiograph taken (Figure 3). The case was then obturated using the vertical compaction of warm gutta percha and backfilled using the Obtura 2. The pulp chamber and access cavity were then filled with amalgam and a final radiograph taken (Figure 4).
  
  Recall: The patient was seen 2 weeks later at which time the patient reported she was symptom free. Clinically the sinus tract had almost completely resolved with complete resolution of the initial swelling.