Advances in Dentistry & Oral Health - Juniper Publishers
Abstract
This clinical case demonstrates the successful retreatment of chronic apical periodontitis complicated by iatrogenic Strip furcal perforation during root canal treatment (RCT), made by a dental student. Apical periodontitis (AP) is an inflammatory process of the periradicular tissues caused by a microbial infection. The risks of retreatment, especially in obliterated root canals and student treatment, are significant. In addition, perforations can increase the chance of treatment failure. Factors that have impact include location and size of the perforation, potential microbial colonization of the endodontic system, the time between the occurrence of the perforation and its repair as well as the filling material. The clinical case could be further complicated by perforation in the risk zone, which makes the expected outcome of treatment rather unfavorable. For a long-term success it is important to disinfect and sterilize both the perforated area and the root canals. The result of this retreatment has been tracked for one calendar year in the present study. It concluded that the examined clinical case is an example of a favorable outcome of treatment of a complicated situation and also demonstrates the correct clinical approach in terms of student learning.
Keywords: Periapical Periodontitis; Retreatment; Strip perforation
Abbreviations: RCT: Root canal treatment; AP: Apical periodontitis
Introduction
Modern
dental science aims to improve patients’ oral health by preserving as
much teeth as possible. Apical periodontitis (AP), a prevalent dental
disease, resulting from a microbial infection of the root canal system,
is one of the main reasons for tooth extraction. The treatment and
nature of the healing process of chronic AP is complex and depends on
many factors. The success of root canal retreatment is affected by the
correct choice of clinical protocol, removal of bacteria from infected
root canals, control of secondary infection, size of periapical lesion,
the restorability of the tooth and its strategic position in the
dentition, periodontal health, the patient’s health history and
motivation, the skill level of the dentist Yamaguchi [1]. The basic
factor influencing success is the preoperative status of the tooth.
Teeth with an apical radiolucency show a 20% lower success rate than
teeth without lesion Sjögren [2]. A size of periapical radiolucency
greater than 2 mm diameter may have a negative outcome of RCT Ng YL [3].
The average success rates of nonsurgical endodontic re-treatments are
around 70–80% Rosen [4]. The different complications during RCT may
raise additional dilemmas during the decision-making process. We present
a clinical case of retreatment of chronic apical
periodontitis, complicated by iatrogenic strip furcal perforation during RCT, made by 5th
year student in a clinical student hall under the guidance of a
supervisor. The strategic importance of the tooth and the patient’s
strong desire to keep it were crucial factors for the proceeding of the
retreatment. Further factors which highly affect the treatment prognosis
are time, size and shape of the perforation as well as its location.
Moreover, controlling the infection at the perforated location is also
of importance Aidasani & Mulay [5].
Case Report
A
45-year-old female patient visited the Department of Conservative
Dentistry, Faculty of Dental Medicine, Medical University – Sofia,
Bulgaria, with complaints of pain and discomfort when eating and slight
swelling in the area of lower left first molar 36. The patient reported
previous endodontic treatment of that tooth with acute symptoms when she
was 18 years old. After treatment, the final recovery took place with
the placement of a ceramic crown. The patient did not provide data on
systemic diseases and allergies. During the intraoral examination a
tooth with a ceramic crown was present, the mucosa above the periapex
was red, and a bulging vestibular sinus track, lightly red without a
formed tip, was also observed. While palpating the mucosa in the area
above the apex the patient felt slight pain and discomfort. A vertical
percussion and mobility examination did not indicate any signs of pain.
The radiographic examination done outlined a diffuse extensive
flame-like radiolucency in the apex area of the distal root, destruction
of lamina coritcalis apically and gradual transition between the area
of bone destruction to healthy surrounding bone filling, loss of lamina
dura apically at both roots (Figure 1). A root canal filling at MV and
ML canals was present; short, without reaching the foramen apicale, very
thin and delicate, inhomogeneous shade of the filling which was an
indication of insufficiently shaped and widened canal; shadow between
the filling and the root wall.
The
patient was given informed consent stating that the treatment would be
done by a student. The treatment started with a removal of the crown,
followed by opening of the pulp camber, locating all canals and removing
the old root canal filling manually. During retreatment iatrogenic
strip furcal perforation occurred due to an incorrect instruments
stroke. The patient reported a feeling of strong pain and slight
bleeding. The bleeding was stopped, and a radiography was performed in
order to precisely locate the perforation. (Figure 2). The perforation
was located in the region of cervical mesio-vestibular canal (Figure 3)?
After the bleeding was stopped, the perforated area was irrigated with
2% sodium hypochlorite and dried again, followed by sealing with gray
MTA Angelus (Angelus, Londrina, PR, Brazil) and then an absorbent cotton
roll was placed over the seal. X-ray sealing quality control was also
performed (Figure 4).
During
the follow-up appointment the shaping of the canals was initiated with
constant irrigation with sodium hypochlorite 2 % and saline irrigation
to eliminate MO and fixate necrotic matter in RC. This was done to
remove the contaminant layer and prevent and/or reduce pain as well was
provide suitable conditions for the healing process. The working length
was determined by an apex locator - Apex locator Woodpex V and an X-ray.
Manual canal instruments were used for the shaping of the root canals.
The master apical file for MV canal is №35- 15mm, ML-№40-13 mm, DV-
№35-16mm, DL-№35- 16mm. Furthermore, a pale-yellow serous exudation was
discovered. It was not abundant but could have compromised the
treatment. This required a standard alternating irrigation, intracanal
medicament Ca(OH)2. Thus, paste was applied with iodoform for
a period of 1 week and temporary filling was places. Considering the
clinical discovery, three iontophoresis procedures were prescribed along
with Metronidazole. The filling of the root canals was with MTA
Angelus. A control radiography showed accurate and homogeneous root
filling (Figure 5). The choice of using calcium silicate cement was
based on the results of previous studies Dimitrova. 12 months following
treatment, the patient did not have clinical pain or discomfort during
eating and radiographically. The bone defect was repaired almost
completely (Figure 6).
Discussion
Multiple challenges are posed for the clinical practice due to the dynamic characteristics of apical periodontitis. The purpose of an endodontic treatment is to prevent and/or eliminate the pathological process of endodontic origin. Treatment of chronic AP is typically associated with successful long-term results, and if there are any indications of failure, a further surgical treatment is considered. Accidents with worse prognosis include perforations at the furcation due to its proximity to the gingival sulcus which favors bacterial contamination Seltzer. Iatrogenic strip furcation perforation is critical for a good outcome. Aidasani & Mulay [5]. Influential factors of significance to the prognosis for treatment are time, size, and shape of the perforation as well as its location which impacts the potential to control the infection. Frequently, the cause is iatrogenic as a result of the misaligned use of rotary burs amid endodontic access preparation and search for root canal orifices. Aidasani & Mulay [5]. Our aim is to avoid an inflammatory process in the periodontal area with exacerbation and also the development of irreversible bone loss. It should be noted that treatment of a tooth with chronic AP with perforation is a challenge even for experienced endodontists Gorni. Treating such a difficult and complicated case by a fifth-year student is also very challenging. Introduction of bioactive calcium silicate cements in dental practice is an important prerequisite for success in the treatment of compromised cases. Similar conclusions have been confirmed by other authors Camilleri J & Montesin; Mente J & Hage [6-10].
Conclusion
This clinical case is an example of a favorable outcome of treatment of a complicated situation and also demonstrates the correct clinical approach in terms of student learning.
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