Acute apical periodontitis
Dr Julius Babayemi of Omnipark Dental Centre in Rainham, Kent presents an endodontic case that utilises the enhanced magnification of the Carl Zeiss OPMI Pico microscope.
Case A female patient in her late thirties presented complaining of pain from the lower right posterior quadrant. The pain intensity kept her awake at night and was only partially relieved with analgesics. Her medical history was non-contributory. She had a history of multiple restorations that were carried out with no complications. Her oral hygiene was good, though there was localised supra-gingival soft plaque accumulation with bleeding on probing around the buccal aspect of the upper left posterior teeth.
The gingivae around most of the posterior teeth had Miller’s Class 1 gingival recession. Clinical examination using the Carl Zeiss OPMI Pico microscope revealed that the LR6 had a large MOD composite filling with recurring caries on the disto-occlusal (DO). A periapical radiograph showed a large DO cavity with apical lesions in the mesial and distal canals. The distal root was long with a straight canal, and the mesial roots were long and curved inthe middle third. The LR6 was tender to percussion with no mobility. Probing depth was within normal limits and the sensibility to the electric pulp test was negative.
A digital periapical radiograph of the LR6 was take n and showed extensive DO caries that had compromised the distal pulp horn and the canals, this also confirmed the presence of apical pathosis on the mesial and distal roots as judged by the widening of the periodontal ligament space.
A diagnosis was made of acute apical periodontitis and the patient was presented with 3 treatment options:
1. Tooth restoration – root canal treatment with the provision of a direct or an indirect restoration
2. Tooth extraction – with the provision of a partial denture, conventional fixed-fixed bridge or a dental implant retained crown
3. Refer for secondary care.
The patient opted for option 1, as she was keen to keep her tooth. She was worried that, if the LR6 were to be extracted, the adjacent and ipsilateral teeth might start moving making her RHS crossbite worse. At the first Treatment Appointment the restoration was removed and three canals – distal (D), mesio-buccal (MB) and mesio-lingual (ML) – were found.
The canal orifices were widened with an XS Protaper down to 10 mm within the coronal third of the canals. This was followed by repeated use of 2.5% sodium hypochlorite for irrigating the canals. The tooth was dressed with a combination of CaOH paste in the canals and IRM to cover the access.
On the second treatment appointment the patient confirmed that the tooth had become asymptomatic. An access cavity was re-established through the core to the canal orifices, which were then irrigated with 2.5% sodium hypochlorite.
A glide path was re-established and the canals were instrumented using balanced force technique. Copious amounts of 2.5% sodium hypochlorite were used for irrigation, and the final rinse was a combination of 17% EDTA solution and 2.5% sodium hypochlorite.
A size F3 gutta percha (GP) was selected as the master cone, measured to the working length, and carefully placed in to the canals to confirm adaption.
The master cones were lightly coated with Kerr’s Pulp Canal Sealer and placed into the canals. Heated Obtura MaxPack plugger (M-F tip) was used to down pack the Gp vertically using continuous wave condensation whilst removing excess Gp. The obturated canals were sealed with IRM plugs and an amalgam was placed to restore the tooth.
A follow-up appointment was made and the tooth prepared for a metal ceramic crown. The patient then returned for a final visit where the occlusion and contact points were checked and the outcome was deemed a success,with the patient remaining asymptomatic.
The case presented here relied on the enhanced visualisation provided by the microscope. This allowed me to reliably locate all of the canals in order to complete the required treatment. Without the superior magnification of a dental microscope, it would have been extremely difficult to successfully locate all three canals. I recently completed a 2-year postgraduate diploma course in Endodontics at the Eastman Dental Institute London and was keen to ensure that I could work to the high standards, which I had learnt on the course. This meant having access to the highest level of magnification and visualisation. Since using the OPMI Pico, the results of my endodontic work are generating much interest among my associates, with many considering completing similar courses.
In the near future, I will be holding a ‘back to basics’ endodontic course in my practice for local dentists to attend and see the enhanced possibilities provided by utilising such an innovative microscope. If you are interested, or would like to find out more, please contact me at firstname.lastname@example.org