Supervised Neglect or Intelligent Monitoring?
A case is presented illustrating nineteen years of observation before treatment was finally carried out. It raises the dilemma of early versus delayed intervention, in the endodontic context.
The patient, at the time twenty one years of age, and healthy, first attended the practice on 1 September 1993, and volunteered the history of the recent placement of a crown after root canal treatment. Radiographic examination (Figure 1)
Figure 1. 1 September 1993.
confirmed the presence of a well fitting prosthetic crown, supported by a metal core, on the first lower left molar (46). At that time, the quality of the endodontic treatment was considered excellent, even though the apical extent of the filling material was slightly short. The slight peri-apical radiolucency was accepted to be the normal view of a healing peri-radicular granuloma and no treatment was indicated.
One year later (7 December 1994) the patient attended the clinic for a routine examination and it was found that the peri-apical radiolucency had increased in size (Figure 2).
Figure 2. 7 December 1994
A diagnosis of peri-radicular periodontitis was self evident. The patient confirmed that he had no symptoms and clinically no other signs of endodontic disease was found.
At this stage it was necessary to consider the nature and extent of any attempt to treat this condition. Re-treatment of the root canals would have dictated the destruction of the prosthetic crown and disassembly and removal of the post core. Careful examination of the radiograph confirmed that the post core was large in size, well fitting and quite possibly consisted of an interlocking, jigsaw, design, all of which would have contributed to a very difficult procedure. Considering the quality of the original treatment, it was rather doubtful whether this complicated, difficult procedure would have held any benefit to the symptom free patient. It was also considered that re-treatment could even have the opposite effect, that of a flare-up and failure in the form of an acute abscess, instead of healing. Compounding the risks were the real possibility of iatrogenic root fracture during the treatment. In any event, the presence of the large posts were a risk factor contributing to spontaneous root fracture at any moment in time.
All this was clearly communicated to the patient, even in writing.
This became a recurring theme over the next eighteen years. The tooth was regularly re-examined with radiographs on 19 September 1995, (Figure 3)
Figure 3. 19 September 1995
13 January 1998 (Figure 4)
Figure 4. 13 September 1998
26 January 2000, (Figure 5)
Figure 5. 26 January 2000
10 January 2003, (Figure 6)
Figure 6. 10 January 2003
12 May 2004 (Figure 7)
Figure 7. 12 May 2004
and 28 January 2010 (Figure 9).
Figure 9. 28 January 2010
During all this time the tooth remained free from signs and symptoms of disease, other than the slowly increasing size of the peri-apical radiolucency observed on all these radiographs.
Eventually, on 25 April 2012, the patient presented on an emergency basis with acute swelling and pain on the tooth. Another radiograph was taken. (Figure 10)
Figure 10. 25 April 2012.
Periodontal examination confirmed the absence of any pocketing, precluding to some extent the presence of a root fracture. A diagnosis of an acute peri-radicular abscess was obvious and it was decided to proceed with re-treatment.
Removal of the crown and core proved to be relatively easy. Root canal re-treatment was carried out using modern techniques and instruments, not available nineteen years previously. Healing of the soft tissues took place within a week. A new prosthetic crown was placed.
Figure 11. Trial fit of GP cone
Figure 12. Trial fit of GP Cone
Figure 13. 10 May 2012
Figure 14. 16 May 2012
Complete healing will only be confirmed once the peri-apical, or rather peri-radicular tissues, are found to have returned to the normal, opaque, radiographic view. That would signal an excellent prognosis.
It is interesting to ponder the pathogenesis of this abscess, over a period of no less than nineteen years. The first sign of disease appeared shortly after placement of the crown, but it took eighteen years before it finally developed into a serious clinical problem, requiring drastic intervention. This case represents the typical endodontic conundrum. Should the re-treatment not have been commenced in 1994 when the failure of the original root canal treatment first became apparent?
Hindsight is perfect vision and the eventual treatment certainly confirmed the feasibility, but would it have been as simple eighteen years ago? I would dare to say no, simply because of the evolution of technology and also my own skills. The last two decades have seen many improvements in endodontic technology and all this have enabled me to perform this case, early in 2012, with ease, confidence and speed. It would not have been as simple in 1994.
Yet, despite this argument to the contrary, is it justified under any circumstances, to allow disease to exist unhindered in the mouths of our patients? Is it ethical to “supervise” disease?
Secondly, it is a fact that we treat patients and not radiographs. It would be a travesty to subject all teeth with peri-apical radiolucencies to endodontic re-treatment, based on the radiographic view alone. Radiographic interpretation is simply too subjective in nature. One practitioner will consider a radiolucency as significant while another might hold a different view.
The plain answer is that we don’t have all the answers. It is considered preposterous to be dogmatic or pedantic in the twenty first century. We are all still seeking that elusive holy grail, the truth, especially the truth of endodontic diagnosis.
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