I recently did a case of a mid-age woman where she came with pain and swelling around her first lower right molar. Tooth no. was 46 to be precise. While taking the radiograph I noticed she had periapical abscess and calcified canals.
The case which I thought to be a simple RCT procedure, soon turned out to be filled with challenges. This case tested my clinical knowledge and patience both at the same time.
Periapical abscess is an infection that spreads to the tissue surrounding the tip of the tooth’s root. Due to that swelling, pain and resorption of alveolar bone starts happening. While treatment began, I noticed the root canals were calcified, it meant the canals were narrowed due to deposition of hard tissue in it. Calcified canals are hard to irrigate and clean because the normal pathway is partially or completely obscured. The third and most common complication I encountered was a ledge formation. A ledge was formed in the lingual canal. It is created by the files on the wall of the root canal while doing the treatment. Hence the case became more challenging. A ledge is an artificial deviation created in the wall of the root canal where the instrument no longer follows the original canal path.
Why do ledges form?
- It can occur due to severely curved canal
- Calcified canals
- Using larger or stiff instrument too early
- Inadequate lubrication and irrigation.
So I manage the ledge by taking small per-curved files of no. 8,10 and 15 and I did simple watch and winding motion in clock-wise direction while maintaining adequate lubrication and irrigation while using liquid EDTA gel and saline rinse. Once the canal was bypassed, I enlarged it while preserving the original anatomy. After that I filled the canal with calcium hydroxide which is an intracranial medication. I did this to treat the periapical abscess.
What are your clinical takeaway in this case? What other complications did you noticed while doing dental procedures.
MBH/PS