APLAN MILESTONE

2
Anish Amin
 PAIN HISTORY
 Male, 26 years old

 Patient previously seen by another dentist for an exam

 Reason for attendance: Emergency appointment due to pain

 Presenting complaint: Hole in back tooth causing pain and discomfort

 History of presenting complaint: “A hole in my back tooth, It’s happened for a while but
stating to feel it more often, pain is a constant 6/10, I’m avoiding eating on that side. I’m
sleeping okay and taking ibuprofen ”
SOCRATES TO ESTABLISH DIFFERENTIAL
DIAGNOSIS
 Site: LR6

 Onset: Since a week

 Character: Constant dull ache previously the pain was not constant

 Radiation: No radiation, localised to the area

 Association: No associations noted

 Time: Pain is mostly constant not fixed to a particular time

 Exacerbations or Relieving factors: Exacerbated by eating, sweets and relieved by

pain killers but only for a while

 Severity: 6/10
 MEDICAL HISTORY

 Patient suffers acid reflux, but does not take any medication
or seen a GP regarding this
 Medications: Nil, other than ibuprofen for the pain
 Allergies: Nil
 SOCIAL
HISTORY
 Smokes e-cig daily, for the last 3 years

 Greater than 14 units per week

 Occupation: Construction worker

 DENTAL HISTORY

 Irregular attender

 Heavily restored dentition, missing teeth

 Not anxious with dental treatment

 Brushes 2-3 times a day, using ETB, Fluoride toothpaste, No

interdental cleaning, Occasional mouthwash

 Occasional snacking, drinks a lot of fizzy drinks

 CLINICAL EXAMINATION
INTRA-ORAL
EXTRA-ORAL EXAMINATION
EXAMINATION  All soft tissues: No issues
 Lymph Nodes: Not swollen noted
and tender  Generalised plaque
 TMJ: No issues noted
 Generalised calculus
 Swelling/Tenderness:
 Tooth wear: Severe erosion
Tender on right hand side of
and attrition
cheek, near the mandible
BPE

2 1 1
1 2 2
SPECIAL
INVESTIGATIONS
 Tooth in question: LR6
 Upon presentation, disto-occlusal cavity dressed with
ledermix and temporised with GIC
 No sinus tract present
 Occlusal wear facets from attrition and erosion
 No tenderness to palpation
 Mobility: (no mobility)
 Sensibility testing
 (+) exaggerated response to Endofrost (previous dentist
conducted this during examination stage)
 Percussion testing
 (+) response to apical percussion upon seeing me
 Radiographs
 Peri-apical radiograph taken of LR6 to assess for any
pathology
 PRE-OP
RADIOGRAPH
RADIOGRAPHIC REPORT
 To assess for root morphology, caries, peri-
apical pathology, and bone levels
 Diagnostically acceptable
 Teeth present LR4, LR5, LR6
 Mild horizontal bone loss
 LR6:
 PDL widening present around apices
of mesial and distal roots of LR6
 Distal and coronal radiolucency,
distal radiolucency extends past
2/3rds into dentine resulting in
reduction of distal pulp horn
 No large curvature present in the
roots, no sclerosed canals
 Severe
erosive facets
seen
occlusally

PRE-OP L
PHOTOGRAPHS R
Underlying
caries visible,
buccal cusps
completely
worn out

Disto-occlusal
GIC placed
upon
presentation
 DIAGNOSIS

DIFFERENTIAL DIAGNOSIS:
1) Dentine Hypersensitivity – during
examination stage DEFINITIVE DIAGNOSIS:
2) Cracked tooth syndrome
Irreversible pulpitis with symptomatic
3) Reversible pulpitis acute apical periodontitis
4) Irreversible pulpitis
5) Apical periodontitis

TREATMENT
OPTIONS
1. Leave and accept
2. Root canal treatment
followed by a definitive
indirect (Band 3) or direct
restoration (Band 2). NHS
or specialist referral
3. Extraction of tooth
under local anaesthetic
TREATMENT
TREATMENT DEFINITVE
REVIEW
UNDERTAKEN TREATMENT
2. Root canal treatment 1. Indirect restoration Patient still has a long open
(metal crown or onlay) course of treatment requiring
followed by a definitive OHI, supragingival PMPR,
restoration (NHS) 2. Direct restoration diet advice, a few restoration
(indirect/direct) (composite/amalgam) and XLA of the UR4. For the
LR6 yearly PA’s and special
testing to assess healing and
Patient chose: success of RCT
2. Direct composite
restoration over indirect *advised patient to speak to
options mainly due to GP regarding acid reflux due
to significant wear on teeth*
financial constraints
 TREATMENT IN
DETAIL
1st Visit 2nd Visit 3rd Visit
1. Since pulp was showing some signs of vitality I 1. Confirmation with working length radiograph 1. Patient returned to complete restoration
decided to use an IANB supplemented with a • D: 20mm, MB: 21mm, ML: 20.5mm 2. GIC removed under rubber dam to
buccal infiltration of articaine to ensure patient 2. Apex locator to accurately identify working length pulpal floor
is comfortable • D: 19.5mm, MB: 20mm, ML: 19mm 3. Composite restoration placed in thin
2. Isolation carried out with a rubber dam 3. Shaping to WL of all 3 canals layers to respect any shrinkage stresses
3. GIC removed with a fast handpiece and 4. Master GP placed in all 3 canals and another 4. Radiograph taken to assess margins of
remaining caries removed with rosehead. radiograph taken to assess whether GP extrudes out restoration
4. Once complete caries removal carried out of apex
5. Access cavity preparation and location of 5. Tubliseal applied to apical third of GP points
canals. MB, ML and D canal found 6. Cold lateral condensation technique used
6. Preparation of 2/3rd of canals by radiographical 7. Excess GP points removed using heated
length using WaveOne Gold instrument, packed down to base of pulp chamber,
7. Copious irrigation with sodium hypochlorite pulp chamber cleaned with US
and recapitulation with a 10 file 8. Temporised with GIC
9. Post op radiograph taken to confirm extent of GP
 RADS: TREATMENT IN
WORKING LENGTH PA
DETAIL
MASTER CONE FIT PA POST OBTURATION PA

o Diagnostic o Diagnostic o Diagnostic

o Teeth present: LR6, LR5
o 25 file reaches apex of distal canal
o Est WL from PA:
o D canal: 20.5mm, MB canal: 21, ML
canal: 20mm
o Verified with apex locator:
o D canal: 19.5mm, MB canal: 20, ML
canal: 19mm
o *Radiograph deleted for WL PA for Mesial
canals
o Teeth present: LR6, LR5, LR4
o WaveOne primary GP points reach working
length and no extrusion out the apex.
o No adjustments made to cone before
placement
o No voids, good apical seal
o Teeth present: LR6, LR5, LR4
o GP is well condensed, no voids or perforations
present
o D canal GP is slightly short of apex but
o Coronal radiopacity indicative of GIC
restoration
 FINAL POST-OP RADIOGRAPH
FOLLOWING DEFINITIVE RESTORATION

RADIOGRAPHIC REPORT
 To assess for root morphology, caries, peri-
apical pathology, and bone levels
 Diagnostically acceptable
 Teeth present LR4, LR5, LR6
 Mild horizontal bone loss
 LR6:
 Well condensed GP
 No voids
 Distal 1mm short of apical
constriction but no perforation of
constriction present
 Coronal radiopacity indicative of
composite restoration
 No distal overhang present,
restoration well sealed to tooth.
POST OP
TOOTH
CHART

LR6 root treated and

DO composite placed
 POST-OP
PHOTOGRAPHS

AFTER OCCLUSAL
ADJUSTMENT AND
POLISHING
 REFLECTION

What went well?

 Shaping process and identification of working length went well with minimal assistance
needed.
 Despite the stress of the situation, I was able to correct the coronal perforation while
making the access cavity and continued with the procedure."
 Use of mouth prop during long appointments prevented post-op trismus and facilitated
access to the tooth.
 Improving speed with rubber dam use and happy with final restoration.
 Good conversation with patient regarding prognosis, risks of not having indirect
restoration, and treatment consent process.
 Photography skills helped identify areas for improvement and allowed for objective
evaluation of work.
REFLECTION - CONTINUED

What didn’t go well?

 Difficulty identifying canals as they were presented buccally, leading to perforation of

the lingual aspect of the crown.
 Treatment required three visits due to struggling to complete it in a timely manner, an
area for improvement.
 Need to develop a habit of removing GP points cleanly to avoid compromising the bond
of the core and restoration.
 GP point distally was shorter than the master cone PA, something to be more aware of
in the future.
 Difficulty with fitting the endo ring PA holder around the clamp.
 REFLECTION - CONTINUED

What I learned from this case?

 Canals may not always follow textbook versions due to wear and attrition, but I learned
about the laws of orifice location which I now apply to access cavities.

 "To assess perforations during access cavity preparation, I can use my apex locator. If
beeps, it’s probably external tissue and therefore a perforation.

 I learned not to use a normal PA holder for working length radiographs, as the patient can
bite down on files. Instead, I use GP to assess WL with a normal PA holder.
 REFERENCES

 Krasner P, Rankow HJ. Anatomy of the pulp-chamber floor. J Endod. 2004

Jan;30(1):5-16. doi: 10.1097/00004770-200401000-00002. PMID: 14760900.

 Ng YL, Mann V, Gulabivala K. Tooth survival following non-surgical root canal

treatment: a systematic review of the literature. Int Endod J. 2010
Mar;43(3):171-89. doi: 10.1111/j.1365-2591.2009.01671.x. PMID: 20158529.
THANK YOU!