CASE REPORT „ 203

Michael Hülsmann, Edgar Schäfer Problem-based endodontic treatment planning: A case report

Michael Hülsmann, Key words management, prevention, problems, root canal treatment, systemic diseases Prof Dr Dept. of Preventive Den- tistry, Periodontology and Root canal treatment may present a considerable number of different challenges of widely differing Cariology, University of Göttingen, severity. Problems occurring during root canal treatment frequently require modifications of treat- Robert-Koch-Str. 40, ment and the use of specific materials and instruments. Some of these problems can be prevented D-37075 Göttingen, Germany by thorough case selection and proper treatment planning. Others can be managed more easily and successfully if their possible occurrence is anticipated; and strategies, instruments and materials for Edgar Schäfer, Prof Dr Central Interdisciplinary immediate management are available. Thus, diagnosis-related and problem-oriented treatment plan- Ambulance in the School of Dentistry, Waldeyerstr. 30, ning (and preparation) is recommended. The following case report presents an example for problem- D-48149 Münster, Germany based endodontic treatment planning and treatment. Correspondence to: Michael Hülsmann, Dept. of Preventive Dentistry, Periodontology and Cariology, history must be taken or recruited for each patient University of Göttingen, „ Introduction Robert-Koch-Str. 40, prior to detailed treatment planning to avoid com- D-37075 Göttingen, As pointed out in previously published textbooks and plications during endodontic treatment in patients Germany Tel: +49-551-3922855 reviews1-3, problems during endodontic treatments with health risks. Not uncommonly, it may also be Fax: +49-551-3922037 Email: michael.huelsmann@ mainly arise due to the complex anatomy of the root necessary to contact the general physician of the med.uni-goettingen.de canal system and due to limitations of the materials patient once the medical history has been evaluated and devices used for root canal treatment. Besides to ensure an adequate interdisciplinary treatment these problems, another aspect has to be carefully approach. taken into consideration before initiating any treat- The present article illustrates a case present- ment; namely, the systemic aspects of the patient to ing several severe technical problems compounded be treated. by a complex medical history of the patient. Thus, In industrialised countries, a rapid rise in the per- besides detailed treatment planning from the endo- centage of elderly people can be observed; and at dontic point of view, it was necessary to take into the same time, these elderly and old patients main- account the relevant treatment modifications that tain their own teeth longer than in previous decades. were required due to the multiple systemic problems Thus, the chance that a patient with severe health of the patient. problems and/or a considerable list of medications being taken daily requires endodontic treatment is substantially increased nowadays. „ Case report Therefore, endodontic treatment planning should include accurate knowledge about systemic In 2012, a 48-year-old woman was referred to the diseases, as there are numerous overlaps between Department of Preventive Dentistry for the treat- general medicine and dental medicine4. The general ment of a painful second maxillary premolar.

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Diagnosen N18.3G Chronische Niereninsuffizienz – Stadium III „ Dental history E21.1G Sekundärer Hyperparathyreoidismus M32.9G Systematischer Lupus erythematodes mit Beteiligung von Organen I10.00G Hypertonie als Folge von sonstigen Nierenkrankheiten The patient reported that she had received root canal M81.80G Osteoporose M85.40G Solitäre Knochenzyste treatment on several teeth from 1995 to 2000. On M79.00G Rheumatismus L40.0G Psoriasis vulgaris tooth 15 an apicectomy had been performed in J32.0G Chronische Sinusitis maxillaris 1991. All further information were non-contributory. D12.6G Polyposis coli M19.87G Arthrose: Knöchel und Fuß For some time, she had experienced intermittent G56.2RG Sulcus-Ulnaris-Syndrom Z94.0G Zustand nach Nierentransplantation pain on tooth 15, mainly on percussion and biting,

Aktuelle Probleme vom 10.09.2014: Z.n. NTX, SLE not requiring any medication with analgesics.

Anamnese vom 10.09.2014 01/14 starke Fingergelenksarthralgien, unter oralem Prednisolonstoß deutliche Besserung, seit dem 23.08. Schmerzen in den Schienbeinen (“Schienbeinkantensyndrom”?) li > re, unter Eisanwendung besser, unter „ Intraoral findings 50 mg Prednisolon deutliche Besserung, schnelle Dosisreduktion mit Rezidiv, wegen abendlich diskreter Knöchelödeme selbstständig abendlich 5 mg Furosemid eingenommen. Nach schneller foscher Gehbewegung • Tooth 14: Restored with an intact ceramic fused- inzwischen ubiquitäre Muskel-, Gelenk- und Sehnenschmerzen. Keine Kopfschmerzen, keine offensichtlichen neurologischen Ausfälle. to-metal crown. Thermal sensitivity testing was non-responsive, probably due to the crown. Fig 1 The physician‘s report on the medical status of the patient with a considerable • Tooth 15: The tooth also was restored with a number of systemic problems. The details of this list of medical problems are presented in detail in the text below. crown. Probing depths were within regular limits (2–3 mm), while mobility and palpation did not Fig 2 Panoramic radio- graph from 2012. show any problems. The tooth was tender to per- cussion, sensitivity testing was non-responsive. • Tooth 16: Sensitivity testing was non-responsive, all other findings were within normal limits, and no tenderness to percussion or palpation was present. • Tooth 17: Missing. • Tooth 18: Caries and symptom-free tooth. „ Medical history „ Additional clinical findings According to her physician, the patient reported on multiple systemic problems (Fig 1): No signs and symptoms of involvement of the maxil- • In 1996, sixteen years ago, she had received a lary sinus could be detected at the time. kidney transplant (her actual state was chronic kidney insufficiency degree III). „ Radiographic findings • She suffered from a systemic lupus erythema- tosus. • Tooth 15: The panoramic radiograph (Fig 2) • She reported osteoporosis, not requiring treat- revealed an insufficiently root canal-treated right ment with bisphosphonates. second maxillary premolar, the canal was prob- • She also reported: ably obturated with sealer and a silver cone. The – rheumatic disease with acute symptoms, which tooth showed a straight but wide root canal had been successfully relieved with predniso- and also a wide apical opening of the root canal lone; without any signs of an apical constriction. Only – dermatological problems (psoriasis vulgaris); one root with a single root canal was visible. The and tooth was apicected without a retrograde fill- – chronic maxillary sinusitis. ing and a large apical radiolucency was present (Fig 3). The patient asked for eventual extraction of the • Tooth 16: Insufficient root canal filling with silver painful tooth as she was concerned about her trans- cones, radiographically associated with a peri- planted kidney. apical lesion.

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Fig 3 (a) Preoperative radiograph of tooth 15 showing a large apical lesion and unclear apical borders of the apicected root. (b) The silver cone has been bypassed. (c) Silver cone and root canal filling material have been removed without signs of apical extrusion.

• Tooth 46: This tooth also presented with a poor necrosis of the jaws (BRONJ)5. A higher risk has been endodontic treatment and an apical inflamma- reported for systemic treatment with bisphospho- tory lesion. nates than for oral admission. Short-term interruption of medication due to the extended half-life period of up to 10 years is not indicated5. In general, non- „ Diagnoses surgical root canal treatment should be preferred The following diagnoses were made: over surgical treatment (apicoectomy, extraction) • Tooth 16: Asymptomatic apical periodontitis in in order to avoid problems in bone healing. Place- an insufficiently root canal-treated tooth. ment of implants is discussed controversially. Local • Tooth 15: Symptomatic apical periodontitis asso- anaesthesia should be performed with epinephrine- ciated with a previous apicoectomy without ret- free anaesthetics. For root canal treatment, careful rograde filling and poor endodontic treatment. placement of the rubber dam clamp and avoidance • Tooth 46: Asymptomatic apical periodontitis of any overinstrumentation are mandatory. Thus, associated with an insufficient root canal treat- the patency technique should be avoided and root ment. canal filling techniques with the lowest risk of ap- ical extrusion of filling materials should be preferred. Only for high-risk patients, these are those taking „ Treatment planning bisphosphonates for more than 3 years and/or those When discussing a treatment plan and making a final receiving bisphosphonates intravenously, a single- decision for further treatment, the systemic diseases shot antibiotic prophylaxis (amoxicillin 2 g) is recom- of the patient and her concerns about her kidney mended before treatment of non-vital teeth5. transplant had to be considered as well as the dental The prognosis of root canal treatment in persons problems associated with tooth 15. It was decided with osteoporosis seems to be fair, but only a few to attempt non-surgical endodontic retreatment studies with limited numbers of cases are available6. of teeth 16 and 15, eventually with extraction of To summarise; in the present case, no contraindi- tooth 15 with subsequent replacement by a dental cation for non-surgical retreatment of tooth 15 was implant or a three-unit bridge. present, and retreatment seemed to be the prefer- A second apical surgery of tooth 15 was not able option as compared to surgical treatment (api- taken into consideration as a treatment option due coectomy or extraction), although presenting with a to unclear prognosis and the refusal of the patient. number of severe problems to be addressed.

„ Systemic considerations Kidney transplant

Osteoporosis A kidney transplant is associated with lifetime immune suppression and therefore requires life- Osteoporosis may present severe problems in bone time antibiotic prophylaxis during any invasive den- healing, especially when being treated with bispho- tal treatment resulting in bacteraemia7. Treatment sphonates, termed as bisphosphonate-related osteo- procedures causing transient bacteraemia, like root

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canal treatment, should be avoided during the first the intake of azathioprine. However, restrictions or 3 months after transplantation7. It would have been modifications of the root canal therapy are not indi- beneficial if the endodontic problems of the patient cated. had been addressed before transplantation. Single- shot antibiotics (2 g amoxicillin) were prescribed „ Psychological considerations 30–60 minutes before beginning of the treatment for each appointment. The patient reported on phases of general unwell- ness, which she related to her kidney transplant as well as to her dental problems. There was a general Maxillary sinusitis impression of some degree of depression, which to Clinically and radiographically no correlation its full extent became more obvious only during the between the endodontic problems associated with course of treatment. The patient denied the intake tooth 15 and the reported problems with the maxil- of medicines for anxiety, depression or other mental lary sinus could be established. health conditions, such as tricyclic antidepressants.

„ Systemic lupus erythematosus „ Dental/endodontic considerations

Lupus erythematosus is a rheumatic disease with a Tooth 15 presented with the following problems: compromised autoimmune system, affecting inter- • Restorability: The ceramic fused-to-metal crown nal organs. Younger women are more frequently presented with acceptable margins and did not affected than men. Typical for the disease is a change necessarily require removal. For financial reasons, between active and inactive phases. Some case the patient preferred non-removal and prepar- reports indicated a possible association between sys- ation of the access cavity through the prosthetic temic lupus erythematosus and periodontal disease, crown. She was informed about the risk of sepa- although convincing evidence is lacking up to now8. ration of the crown during access cavity prep- aration or during removal of the core material, and eventually of carious dentine or the need to Rheumatism remove the crown in case of unforeseen difficul- No valid or evidence-based information on interac- ties of endodontic treatment, such as a necessary tions between rheumatic and endodontic diseases is search for a previously undetected root canal. It present in the endodontic literature. As such inter- could not be outruled completely that an insuf- actions have been described for periodontal dis- ficient amount of remaining dental hard tissue ease9 comparable interactions cannot be out ruled would prevent restoration of the tooth with a completely for endodontic diseases. This refers both new crown. to reactions onto changes in the balance between • Periodontal support: Probing depths and tooth microbial aggression and host defence as to reac- mobility were within normal limits, tions against materials and medicaments used during • Root canal filling: Based on the radiographical root canal treatment. appearance, the root canal filling consisted of any Rheumatoid arthritis is the most common dis- kind of sealer and a poorly adapted silver cone. ease of the spectrum of rheumatic disorders and a As the type of sealer was unknown, no prognosis rapid periapical bone loss during root canal treat- on the ease of removal could be made. It was ment of a patient suffering from rheumatoid arthritis estimated that removal of the silver cone should has been reported10. The authors assumed that this be possible without major problems, as the cor- unusual bone loss was due to the medication of the onal part of the cone extended into the coronal patient with azathioprine. Thus, when planning root third of the root and sufficient space was present canal treatment in a patient suffering from rheu- besides the cone. A certain risk of separation of matoid arthritis, the anamnesis should include the the cone due to long-term corrosion could not be current medication of the patient – and particularly excluded completely.

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• Previous apicoectomy: Among the most frequent „ Prognosis reasons for persisting apical pathosis following apicoectomy are undetected and untreated root Due to the number of different dental/endodontic canals, cracks in the apical root dentine and problems in combination with the systemic prob- improper (or missing) retrograde obturation11,12. lems, the prognosis for tooth 16 was estimated as The latter was definitely confirmed radiograph- being uncertain, and for tooth 15 as being poor. ically, while the first two could not completely Only few data on the prognosis of non-surgical be excluded. It was estimated that intracanal retreatment of apicected teeth with persisting peri- inspection using the dental operating microscope radicular inflammation are present, showing success (DOM) would present further details13. rates between 60% to 70%29-31.

As for the presence of a large neo-foramen at the „ Treatment resection site and the missing retrograde filling, a high risk of apical extrusion of the present (infected) Treatment started with retreatment of tooth 15. obturation material was likely to appear, as well as of The patient was informed that single-shot antibiotic irrigant and the new obturation material during non- medication was mandatory for each appointment. surgical retreatment. Severe complications of extru- Following isolation with rubber dam and prep- sion of sodium hypochlorite have been described aration of the access cavity through the prosthetic in the literature14, therefore it was decided to use a crown, the core material was carefully removed with- low-concentrated 1% solution and additionally to out touching (and weakening by notching) the silver use saline, ethylenediaminetetraacetic acid (EDTA), cone. As no carious dentine was found, the crown and 2% chlorhexidine (CHX). was left in place. The access cavity was thoroughly For determination of endodontic treatment cleaned and disinfected with 3% sodium hypochlo- length, correct electronic measurement was rite. The silver cone was located and bypassed for unlikely15-18. The treatment plan included radio- some millimetres with an endodontic probe and a graphic determination of working length in combi- micro-opener under the dental operating micro- nation with visual control using the DOM. scope. Using ultrasonics at a low level of intensity, Due to the size of the lesion and the diameter the cone was finally loosened and removed. of the apical opening, proper (tight) obturation was In a crown-down approach, the filling material, expected to present major problems. On the other an unidentifiable non-setting paste-type sealer, was hand, the reduced length of the straight and large carefully removed using hand instruments, micro- root canal could facilitate precise operations under openers and micro-debriders, and low-intensity the dental operating microscope even in the most ultrasonic irrigation with 1% sodium hypochlorite. apical part of the root. A biocompatible material such Finally, the irregular apical border of the root was as mineral trioxide aggregate (MTA)19-25, or newly visible in a large-diameter apical opening. Beyond developed bioceramics (e.g. Biodentine [Septodont, the root, a large bone cavity with granulomatous Saint-Maur-des-Fossés, France], TotalFill Root Repair tissue was visible and some pus discharged. Then Material [FKG, La Chaux-de-Fonds, Switzerland])26 the bone cavity was irrigated with saline to remove was selected for obturation of the apical part of the any extruding remnants of the obturation material. root canal after placement of an external matrix with Following final irrigation with copious amounts resorbable collagen, preventing extrusion into the of EDTA, chlorhexidine, alcohol and 1% sodium bony lesion27,28. hypochlorite, the root canal was medicated with Finally, there was a certain probability of unknown calcium hydroxide and temporised with an adhe- extent that the microbial biofilm had already estab- sive restoration. The patient returned the follow- lished on the outside of the root, thus not being ing day with pain, requiring emergency treatment accessible by intracanal disinfection or antibiotic with copious irrigation and renewal of the dressing. treatment. In this case, prognosis would be poor As the situation did not improve, for the following and extraction of the tooth necessary. days the medication was replaced by a dressing with

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Problem-oriented treatment planning facilitated the operative procedures as necessary instruments and materials already were prepared and available in short time. The 1-year radiographic control (Fig 6) revealed continuing apical healing, clinically the tooth was completely asymptomatic.

Fig 4 Radiograph from 2015: 3 years after initiation of „ Discussion endodontic treatment the periradicular bone shows evidence of progressing healing. The reported case presented with a number of dif- ferent problems, ranging from problems in systemic CHX. Parallel to treatment of tooth 15, endodontic health to psychological and complex dental prob- retreatments were performed on teeth 16 and 46. lems. Most of these problems could be addressed in During the following months, repeated exchange a timely fashion, resulting in less complicated treat- of the medication and redisinfection were necessary ment and good healing of the lesion. due to repeated low-degree flare-ups, not requiring Many systemic medical problems have been analgesics or antibiotics. Nevertheless, the patient’s reported to interfere with endodontics, among these attitude to retention or extraction of the tooth are coronary heart diseases, diabetes, joint implants, changed from appointment to appointment, reflect- osteoporosis and many more32,33. ing her overall psychological instability and her fear In an ageing population, it is particularly im- to lose the organ transplant. Finally, in the beginning portant to explore exactly the patients’ medical of 2014, one and a half years after treatment initia- history to identify any relevant medical problems tion, she decided to have the tooth extracted and in time. In the present case, osteoporosis, a kidney was referred to an oral surgeon. transplant, rheumatic disease, an autoimmune dis- One and half years later, in summer 2015, she ease (lupus erythematosus), and a possible involve- returned with the tooth still in place, but in a clearly ment of the maxillary sinus had to be taken into improved mental state, being more optimistic on her consideration and regarded in the treatment plan. general health and the chances to retain the tooth 15, The osteoporosis in the present case was of minor which had been completely asymptomatic for more significance as the patient was not medicated with than a year (Fig 4). Clinically, percussion was nega- bisphosphonates. Nevertheless, extraction (rep- tive and probing depths still within normal limits. The resenting a higher challenge for the compromised radiograph revealed signs of apical healing. bone than root canal treatment) could be avoided. The tooth was reopened and the apical bone cav- Using a combination of radiographic length deter- ity, still present and visible through the DOM, was mination and visual control, the endodontic work- irrigated with saline. The bone cavity was filled with ing length was strictly limited to the root canal and a resorbable material (Bioresorb, Resorba, Nürnberg, overinstrumentation and irritation of the periradicu- Germany) up to the most apical extension of the lar bone was prevented. root, creating a barrier with some resistance for the Regarding the renal transplant, it has to be taken root canal filling material. The root canal was obtu- into consideration that patients with allogeneic rated under the DOM with TotalFill (FKG) in a thick- organ transplantation are usually on lifelong immu- ness of 4–5 mm and the coronal part of the root nosuppressant medication (e.g. cyclosporine A, canal filled with sealer (AH plus, Dentsply, Konstanz, steroids), in order to prevent rejection of the for- Germany) and injectable gutta-percha (Beefill, VDW, eign organ by the body1. This medication is asso- Munich, Germany) (Figs 5a–f). The access cavity was ciated with a considerable reduction of the body’s restored with composite, which 6 months later was immune defences against pathogens. Against the replaced by a new ceramic crown. background that numerous dental treatment pro-

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Fig 5 (a) Bony cavity beyond the apicected root tip. (b) Irrigation of the bone cavity. (c) Application of resorbable collagen into the bone crypt. (d) Application of TotalFill bioceramic repair material. (e) Obturation of the middle and coronal parts of the root canal with injectable gutta-percha. (f) Postobturation radiograph. cedures are associated with transient bacteraemia, systemic medications with immunosuppressants are of major clinical relevance. Therefore, for any treat- ment procedures that could be associated with tran- sient bacteraemia (extraction, endodontic proced- ures, periodontal probing, root planning and scaling, root canal preparation, PDL injection) a prophylactic administration of antibiotics is indicated in immuno- suppressed patients34. The antibiotics of choice are aminopenicillins, preferably amoxicillin (adults: 2 g; Fig 6 children: 50 mg/kg body weight). The oral antibiot- One-year recall radiograph showing excellent healing. ics should be taken 1 hour before the treatment as a ‘single shot’34. If the patient is allergic to peni- to one-third of patients) compared to control sub- cillin, the patient’s physician should be consulted, jects35. Thus, optimal treatment approaches should as the antibiotic of second choice, clindamycin, is include frequent dental recall appointments as oral contraindicated in patients with a renal transplant. infections and periodontal diseases could compro- It is of outmost importance to keep in mind that mise the success of an organ transplant36. medicaments which are eliminated renally, such as Extrusion of the present root canal filling material, clindamycin, acetylsalicylic acid and non-steroidal infected debris, irrigant and new filling material was anti-inflammatory drugs and antibiotics with pro- likely to occur due to the wide apical opening of the nounced nephrotoxic properties (e.g. sulfonamides, root. Therefore, preoperative single-shot antibiosis aminoglycosides) are absolutely contraindicated in was mandatory for each appointment in order not patients with a renal transplant1. to put the transplant at risk. Moreover, patients with a renal transplant have The impact of rheumatic diseases on endodon- a significantly higher incidence of oral lesions (up tic diseases and on respective treatment until now

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has not been clarified. A recent publication has „ Conclusion reported on possible interactions between perio- dontal and apical disease and rheumatoid arthritis9, In conclusion, this case report demonstrates the but it remains unclear whether these findings can complexity of endodontic treatment in a medically be generalised. It can be stated that the patient pre- comprised patient presenting with a severely com- sented with clearly improved general health 2 years promised tooth. Problem-related treatment plan- after treatment initiation, including retreatment of ning and treatment resulted in tooth retention and three insufficiently root canal-treated teeth with healing of the apical lesion. However, whether the apical lesions. Nevertheless, causality should not medical status of the patient improved during the be claimed. treatment period causality cannot be confirmed. 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