Question:
I am a dental PATIENT, 46 years old, female, in generally good health. I
am not a dental professional, but feel I have an interesting case involving
root canal therapy on a molar with three roots. I'll explain the
activities that have taken place since the end of October, 1997, then will
ask my question.
Initially, this tooth was prepared for a crown only. (The
filling(s) in the tooth were deep, but the pulp apparently was still
healthy.) After the tooth was filed down, I began to experience
sensitivity to pressure placed on the tooth, and my dentist felt root canal
therapy was called for. When he began the instrumentation, he found a
"perforation". He mentioned at one point that one of the roots directed
toward the back was extremely narrow. He thought he could eventually fill
the tooth with glass ionomer (sp?) cement, but the tooth simply would not
calm down. After approximately four weeks of observations and placing
several different medications in the tooth, I began to experience pain in
the tooth closer to the apex. He decided to leave the tooth open (but
packed with cotton), and I changed this cotton and rinsed with warm salt
water at least three times a day. This gave me considerable relief within
six hours. At this point, he also put me on 500 mg penicillin three times
a day, for ten days, with one refill (which I've finished).My dentist
explained a procedure he wanted to do - a "section" of the tooth in which
he would split the tooth so that it essentially would resemble two
premolars - I believe the connection of the two roots toward the back and
one toward the front would be severed. He did this procedure, and about a
week later (about a week ago) the soft tissue are between the - now - two
sections of the tooth became slightly inflamed and red. Initially it bled
slightly, and I may have trapped food. At his direction, I'm rinsing with
hydrogen pyroxide now. He is planning to restore the tooth in a week.
Answer:
Yes, sectioning of a tooth is a viable alternative in certain
circumstances. Its also known as hemisection. Many times this is done
when one root is not responding and one half of the tooth (er, root)
must be removed.
In your case, your dentist proposes to save both halves and use this
technique to restore where the root is perforated.
I hope that some other dentists add their input here, because this is
not an area of dentistry where I have much expertise.
I would further recommend that the dentist place a nice temporary
crown on the tooth and wait several months before proceeding. Retake
an x-ray to confirm that the tooth is healing properly.
I would say the reason of your problem started at the time when the
tooth was perforated. And from my experiences, root canal therapy would
only be succesful if your dentist managed to seal the perforation
properly, whether from inside of the root or from outside, for instance
by performing hemisection or apicoectomie, depending on the location of
the perforation.
If it did not happen, the tooth will continue to hurt even if you were
on penicilline and analgesics. Beside the pain, infection will spread
out around the root and its surroundings, leading sooner or later to
tooth loss.
Therefore I suggest not to do the crown right now. I would ask whether
the perforation was closed and whether root canal was done with success.
If, as you once mentioned, one of the canal was too narrow and therefore
obviously difficult to be instrumented, I personally prefer to extract
this part of the tooth in order to get a better surviving chance for the
restoration.
It is not unlikely that a tooth with a "deep" filling following crown
preparation is in need a root canal therapy. In many cases the stress
placed on the tooth during this procedure is enough to send the tooth
over the edge, causing exteme discomfort until root canal therapy is
performed. It is paramount that the root canal procedure be done
properly if the tooth is to be kept. Perforations of teeth are
"man-made" and often do occur during difficult root canal procedures,
particularly when canals are sclerotic (ie. closed) and are difficult
to locate and access. It is possible for the perforation to be sealed
either in the tooth or surgically outside the tooth, but this may
result in a poor prognosis for the tooth. Bicuspidizing or
hemisectioning a molar is a common practice, particularly when a lower
molar exhibits a furcation or bony defect between the front and back
roots. Again, this will the prognosis of the tooth. I would
recommend that since these procedures have been done, I would have a
temporary restoration placed on the tooth and wait for all the
symptoms to subside, making absolutely sure that the tooth was
comfortable and chewing ability has been restored. If not, I would
remove the tooth and look for some alternative means of replacement.
