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March 2001Retreatment without Success


Fig.1

This 32 year old female was referred to me for endodontic consideration of teeth #s 21 and 22. Both had been endodontically treated by the referring generalist several weeks earlier without resolution of symptoms.

The patient initially presented with percussive sensitivity and acute discomfort to palatal or incisal pressure. Both teeth appeared to be virgin with the exception of the previous access openings. There was no history of trauma or discoloration. Palpation sensitivity was present over the apices and adjacent areas. There was no intra or extra oral swelling. The periapical areas showed slight thickening of the PDL spaces with short fill of 321 and long fill of #22.(Fig.1)

I was familiar with the clinician who performed the initial treatment and although the endodontic fillings were less than perfect, I was surprised at the level of discomfort that the patient was displaying. She was in acute distress and medicating herself several times a day with Tylenol #3 and Ibuprophen 400 mg. Even these medications barely controlled the pain that she claimed was in the general area but localized to these two teeth. Percussive sensitivity remained acute. She was becoming distraught and was considering extraction.

After my initial examination, I decided to retreat the case conventionally. The patient was scheduled for nonsurgical endodontic retreatment. Administration of local anesthesia to the area seemed to provide immediate relief. Rubber dam was placed and the initial gutta percha fillings were removed. Nothing unusual was found. The canals were recleaned, shaped and the case was repacked using my standard technique of vertical condensation of warm gutta percha and Kerr sealer. (Fig 2.) I suggested that she continue with the NSAIDs and report to me in 48 hrs.


Fig. 2

After 48 hrs the patient reported that the symptoms had not been relieved and that she was still in severe discomfort. What could I have missed?


Fig. 3

Fig. 4

I decided to schedule the patient for surgical approach, although I was concerned that radiographically the case looked absolutely normal. (This was to prove to be a very important finding in resolving the case.) A standard BU (Trapezoidal) flap was raised and the root apices were beveled and retrofilled. (Figs. 4- 6) Again, I was surprised to find that the periapical areas appeared to be clinically normal in all respects. ( Although my intuition told me that there was been no endodontically definable pathology, I had to cover all the endodontic possibilities.)


Figs. 5 & 6 - Retrofills in place

The flap was sutured with 5/0 Prolene (Fig 7) and given standard post op instructions as well as another prescription for Tylenol #3. ( By now the pharmacy had been making inquiries as to why the patient was consuming vast quantities of this Codiene based narcotic preparation.)


Fig. 7

Symptoms persisted and I was close to being out of answers. At this point I began to question the initial diagnosis. Why were the patient's symptoms not responding to competent and correct endodontic care?

SOLUTION
The answer was that the problem had never been endodontic in the first place. After this extended treatment attempt, I decided to place the patient on Tegretol 200 mg tid on the assumption that her symptoms were associated with a neurologically related problem. Her symptoms resembled that of an atypical facial neuralgia or neuritis involving the Maxillary division of the Trigeminal nerve. To make matters worse, the patient developed an allergic reaction to the medication that required brief hospitalization, but her symptoms did resolve with the medication. Her medication was changed to a different drug and she responded favorably.

Summary
Retreatment Diagnosis can often be difficult. Be sure the initial diagnosis is correct before attempting retreatment.

1. Virgin teeth do not spontaneously become endodontically involved as a rule. (There are rare exceptions with certain medical or developmental problems )
2. Two adjacent teeth rarely become symptomatic in exactly the same way at exactly the same time unless trauma is involved. Even then, it is very rare.
3. Pulp tests performed prior to commencement of the initial treatment would have likely yielded a positive response, contraindicating endodontic treatment. This would have suggested that referral, rather than endodontics , was indicated.
4. Be confident in your treatment. If you are satisfied with the clinical and radiographic appearance of your endodontic treatment, then it is very likely that symptomatic patients that are having problems have a condition unrelated to the endodontic seal. These problems can include adjacent cracked teeth, vertical root fractures, periodontal problems, occlusal problems, or , as in this case, neurological problems misinterpreted as pain of endodontic origin.