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. ENDO (Lond Engl) 2016;10(4):203–211 204 Hülsmann and Schäfer Problem-based endodontic treatment planning: A case report 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. ENDO (Lond Engl) 2016;10(4):203–211 Hülsmann and Schäfer Problem-based endodontic treatment planning: A case report 205 abc 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