Retreat Root Canal tooth #2, post-mortem. Perforation discovered

Okay, video number two for the day. We're going to talk about a re-treatment case that ended up not being savable. You may have some qualms already about this x-ray tooth number two, but let me take a step back and talk briefly about re-treatments. Generally, I don't have problems doing my own re-treatments. Almost all teeth that will need a re-treatment on a root canal, I will attempt. Now, oftentimes we'll come to a situation, often I'd say maybe one in twenty times, I'll come to a situation where I have to stop and either refer to a specialist with a microscope or tell them that the tooth doesn't seem re-treatable or fixable based on whatever we find on the inside. But I would not suggest re-treating a root canal without some additional training. You know, I haven't been to any special residencies, I'm not a root canal specialist. I've been doing root canals since 2006 when I graduated dental school and I've had some advanced training and lecture courses at CE and stuff. And I'm fairly comfortable doing most re-treatments. But, be cautious, be judicious in the cases that you choose. You want to make sure that whatever you end up choosing for the patient ends up being a good long-term outcome. So let's talk about this case a little bit. So this was one of my associates at my office, actually my partner, had asked me if I would consider re-treating this. And I said sure, I'd be happy to take a look at it. And I'm always cautious with talking with a patient about success rates beforehand. You know, not every root canal or every re-treatment on a root canal is going to yield a good outcome. And I want to make sure they know that going into it, that if I have to stop, take a step back, change directions, then they're prepared for that. It's always easier to pave your way than it is to, you know, deal with a, well you promised this, and this is what's happening. So prepare the patient for the worst and then hope for the best. You're always better over-delivering than under-delivering and over-promising. So, numb the patient up. One other thought, I always, always, always on a re-treatment recommend a new crown. You know, statistically, if I'm recalling this right, the most common reason that a tooth needs a re-treatment on a root canal or that a root canal becomes reinfected is because of coronal leakage. Whether that's from a filling that's been placed in the crown after the root canal or the crown itself is leaking, I always recommend a new crown. So just like on a molar, the root canal comes with a crown in a package, a root canal re-treat always comes with a new crown in a package. And if they're unwilling to do that, then generally speaking, I'm not going to be comfortable doing a re-treatment unless they're willing to redo the crown because of the potential for coronal leakage. Anyway, so once we did get this crown off, there was some decay, and I'm not sure if we can see it in the other pictures, but I'll try to show it to you. So she presented with a fistula, and this is the gut aperture cone running up, pointing toward the palatal root there through that little fistula. So here's the panoramic x-ray. All this is, you know, looks like significant bone loss. And this tooth, this area right here of the tooth, excuse me, is a post. But when we go back and look at that first x-ray, you see this right here? This is gut aperture. And come to find out later on, the dentist who had initially done this root canal placed gut aperture directly in an area that had been perforated in between the roots. And I'll show you a photo of that, but it looked a little hinky to begin with. And you'll also, you can kind of notice this, the access, if you follow this, this is generally the access where the dentist attempted that root canal. And the mesial buccal root canal is actually up in here. So they didn't actually find the mesial buccal root. So let's go forward. Here's what I found when I got inside the tooth. So let's see, this is the distal buccal root canal. This is the mesial buccal root canal. And the access before was stopped roughly right here. And you can see this is actually the perforation right there. That's where the dentist had thought, and I'm reading too much, but this is where the doctor had thought that the canal was and actually opened a little bit. So the access stopped right here. They didn't go mesially enough to find this canal. And I dug around a little bit here looking for a mesial buccal too. This, of course, is a post. And I just started to dig around it with an ultrasonic. But this is a post here. Same tooth, just a little different angulation. This is composite. So the doc before had, I think, I didn't take all this out, but I think the doctor had perforated distally as well and placed composite to cover that. But they had placed gut aperture down in this perforation spot in hopes of, I'm assuming, being able to salvage the case. But here you can clearly see that mesial buccal 1 canal. It's potential there's a mesial buccal 2. Once I discovered the perforation and the size of the perforation, we ended up scrapping it and deciding the tooth was not fixable. With that being said, yeah, it's too far gone to save. Personally, I wouldn't even recommend going any further because of the amount of bone loss that's in her interfercally. So here's the perforation. It's a pretty substantial perf. So what I did is I actually sat back. I sat the patient up. I took my mask off, my gloves off, slid my chair around in front of her. And I said, so here's where we're at. I've discovered that there's a perforation in this tooth based on the amount of bone loss and what's coming out of the area in between the tooth and how mobile the tooth is. And we had a 2 plus mobility. I don't think the tooth is long-term savable. Now, if it had been a first molar, maybe we would have tried to repair that with MTA and, you know, potentially looking at a root amputation and all that stuff, depending on how things went. But she was just ecstatic that she didn't have to pay for all that stuff, you know, the retreatment of the crown, but also glad because she'd had some issues long-term with that tooth hurting and aching and being sore. So, you know, the perforated tooth, floor of the tooth happens from time to time. I mean, I've done it a few times. You just have to be really cautious when you're looking at a tooth and accessing a tooth, especially these second molars. Make sure that you look at that x-ray. You know, the long axis of the tooth is here, not necessarily going in this direction like the dentist attempted to access. Remember, those maxillary molars oftentimes tilt backward. So they tilt backward to the distal. The lower, the mandibular molars oftentimes lean forward, but the maxillary molars oftentimes tip to the distal. So you have to remember that as you're looking for access. Yeah, so that's, I mean, that's the situation. You know, I stopped, of course, trying to harvest that post, talked with the patient about success rates long-term. You know, we could definitely get a working length through here. We pull all that gutter perch out. I don't remember what the working length was, but one, two, three canals and potentially a fourth, depending on how far I wanted to dig for it. Yeah, once we discover the extent of that perforation, I mean, this is probably a solid two millimeters, maybe three millimeters wide, going three or four millimeters down through the floor of the tooth. I don't think that was long-term savable. And the dentist, you can still see some of it. That gutter perch had actually been packed right there. Hopefully, I mean, I'm assuming in hopes that the tooth would be, have a decent outcome. She wasn't aware that he or she, whoever the dentist that did it, had perforated. But that, you know, that's a discussion matter for another day, perhaps. You know, what do we do when we botch it like this? Is it something where you want to go and hide it and not tell the patient and hope for the best? Certainly, I hope, maybe she doesn't recall it, but I hope there was a discussion that there was a perforation that took place. You know, the prognosis is guarded to poor, but in that situation, you know, I don't think gutter perch is an appropriate seal. You would have needed MTA. Now there is some chance that had the dentist acknowledged or been aware at the time of the perforation, send the patient straight to an endodontist. If you're not comfortable using MTA, have them disinfect it, dry it out real well and put some MTA in there and then finish the root canal. I mean, there's a good chance had that been done at that time, we could have prevented all the significant bone loss and potentially salvage that tooth. So those are my thoughts. You know, the first case from today, you know, talking about dealing with our own mistakes in a way that's ethical and making sure that we're creating a patient for life instead of, you know, creating a pay for the day. You want to make sure that each of us is focused on the patient's welfare. I think it's all too easy sometimes to focus on our production numbers that are showing up on the schedule. And certainly those production numbers are important because they represent how much service we're providing to a patient, but the production numbers are not the goal, right? The goal is to create a patient for life by helping to make someone healthier and happier. And if we're doing it the other way around by focusing on production for production's sake, then we got it. We got to be cautious that that'll come back to bite us in the long run. So in the end, you know, the patient was fine. Second molar, you know, she's got half of the occlusion on that upper first molar hitting tooth number 31. So she'll do just fine without that second molar. I wouldn't even recommend an implant in this situation, especially given the amount of bone loss that she had in this area from where the root canal was failing. But that's all I've got for you today. Thanks again for watching. Always remember to focus on your patient's welfare instead of their wallet. And we'll catch up with you later. Thanks. Bye.