October 20, 2010

PIPS Root Canal – Case Study #1

NOTE: Final Fill photos of PIPS cases found at the end of the blog “New service to our patients: Laser Root Canals!”.

Day 1

Periapical x-ray(#4) taken today by Lisa with a lead apron and was reviewed by Dr. Mark Kraver.

Reviewed health history, Chief complaints include: gingiva feels swollen, points to tooth #4. Pt. reports visiting this office in 2007 and was aware that she needed a root canal at that point. However due to finances has put it off and taken antibiotics when she has felt any swelling. Pt. also reports having a ct scan taken elseware recently which revealed a possible small cyst in her left maxillary sinus. Pt. says she is going to see the ENT for this on Thursday this week. Pt. appears very nervous/anxious
Clinical and radiographic findings included: #4 periapical pathosis- moderately defined, moderately sized (~2mmX2mm) periapical radiolucency with a possible root tip from the extraction of #5, #4 non-vital tooth, no response to cold, asymptomatic, parulus present, TMJ appears normal, Oral Cancer screening WNL
ASSESMENT: #4 necrotic tooth
PLAN: pulpectomy, endo
Risks, benefits and alternatives have been discussed,  Treatment plan accepted. Next Visit: Endo

Scratches on the x-rays are from well used phosphorous plates.  The Bold text are the actual notes written in the patient’s chart and the plan text are our comments.

Informed Consent, Reviewed health history, #4 has Parulus,   Entry and excavation revealed necrotic pulp tissue. Treatment preformed included #15 file, Gates Glidden,  Acoustic Streaming, TWO CANALS FOUND joining into ONE canal, Peridex irrigation, calcium hydroxide paste, cotton pellet, IRM,  Occlusal Reduction,  Topical anesthetic 20% lido/4% Tetra/2% phenylephrine with 1 carpule (68mg/1.7ml) of 4% Articaine w/1:100000 epi infiltration, Pt informed not to eat food, bite or chew on lips or tongue while anesthetic is still working.   Risks, benefits and alternative discussed. Next Visit: Endo

Pt. informed that this treatment is temporary and will need to follow-up soon with either a root canal, post and crown or an extraction.  There is no way to know how long this treatment will last and that the tooth may fracture or have recurrent decay or have another toothache if definative care is not completed.

Day 3

Pt. presents with C/C swelling near tooth #4. Reviewed health hx. Mild vestibular space swelling noted, no lymphadenopathy, no trismus, slightly tender to palpation. Antibiotic prescribed (Amoxicillin 500mg X30 to take 2 tabs P.O. now and 1 tab P.O. q8hr until gone. NV: endo

Day 10

Informed Consent, Reviewed health history, Root Canal Treatment using Rubber Dam,  ONE CANAL, Endo gripper, Apex Locator, File-Eze EDTA canal prep, Water irrigation,  Er:YAG with eye protection, Photon induced acoustic streaming, PIPS 400u/14.0mm laser tip, (R14, 50?s, 20mJ, 15Hz, 0.3W),  Water irrigation, EDTA, #40 @ 19.5mm, Periapical (3), resin coated GP w/ EndoRez, IRM, Occlusal Reduction, Treatment was tolerated well. Topical anesthetic 20% lido/4% Tetra/2% phenylephrine with 1 carpule (36mg/1.7ml) of 2% Mepivacaine/1:20,000 NeoCobefrin infiltration, Pt informed not to eat food, bite or chew on lips or tongue while anesthetic is still working.  Next Visit: post/Crown

The patient has been informed that a final restoration will be needed whether it be a filling for an anterior tooth or full coverage crown for more badly damaged tooth.  If this final restoration is not done in a timely manner then the tooth may be lost from possible recurrent decay, endodontic leakage, and /or fracture.

Day 13

Pt. presented with C/C: “I have white pus draining out my gums”. Pt. reported pressure-like discomfort associated with #4 over the weekend. Reviewed medical history. Post-op Exam revealed draining fistula mid-buccal to #4 through gingiva. Gutta percha placed in fistula and PA taken tracing it back to #4 which RCTX was completed on this past Friday. RCTX WNL.  Pt. is to be seen this Friday for re-eval. NV: re-eval

This “white pus” was the EndoRez that was expressed out the apex into the draining sinus track and now is completely gone.

Gutta percha inserted into the healing parulus to see if it was to point to another tooth.  It didn’t.  She should heal well and we will post the recall x-rays when we get one.