Dentistry/Root Canal, then apicoectomy, now inflammation
QUESTION: Hi Dr. Teig,
I had a root canal performed on my #9 tooth. It failed and my endodontist then recommended an apicoectomy.
I saw another endodontist for a second opinion and had a CBCT scan performed. The second opinion was indeterminate as to whether re-treatment by root canal was feasible or if an apicoectomy was in fact required.
The CBCT scan report concluded "Tooth #9: apical inflammation. It appears there is continued apical inflammation at the apex of tooth #9, perhaps due to the loss of buccal cortication or there may be a very slight overfill of the tooth. The tooth appears sound and there are no contraindications to apical surgery or other treatment. The apical inflammation may be foreign body reaction and may also resolve with anti-inflammatory therapy."
I elected to have the original endodontist perform the apicoectomy. That was completed about 1 month ago. Every thing seemed fine up until 2 days ago when inflammation reappeared.
I saw my endodontist yesterday, who prescribed me clindamycin and said that this inflammation could be part of the normal healing process. She suggested I take the clindamycin and if the inflammation does not improve, call back in a week; if the inflammation does improve, I should come back for a follow-up in another month, rather than the typical 6-month post-apicoectomy follow up.
What would you suggest I do to try to figure out what is going on with my tooth? More imaging, a consult with a different doctor, or something else? Neither endodontist seemed to have much explanation for why the initial root canal failed; neither did they have anything but confidence that an apicoectomy would be successful.
ANSWER: Dan - Your situation is a very common one. The cause of recurrent inflammatory reactions or infection are often unknown. Sure there are obvious reasons in some teeth that display such a reaction, but often, common reasons for failure are incomplete cleaning of the nerve canal during the root canal treatment. Poor packing of the filling material in the nerve canal can leave a space for bacteria or even small drops of blood to percolate. In addition, there are microscopic defects in the tooth walls. Microscopic canals branch off the main nerve canal and small pieces of the infected nerve tissue can exist there and be a stimulant for causing a root canal tooth failure. There are also microscopic fractures in a root that also be a site for failure.
So the main cause of a problem is not always known. CBCT, MRI, CT scans and simple dental xrays have all been used to diagnose the cause of recurrent problems with root canal teeth. In my experience, when the true cause of a failure of a root canal treatment, even though the cleaning of the canal and the filling of the canal seems immaculate, is unknown, the apicoectomy is a method, if done by a skilled and knowledgeable surgeon to cut off the tip of the root, the site of most failures.
So I am impressed by the success of apicoectomy if the doctor performing it is a skilled surgeon and takes the time to completely clean the bone surrounding the infected portion of the root, along with cutting off that piece of the root tip and sealing the new end of the nerve canal created by cutting off the root tip. Unfortunately, most apicoectomy failures occur when doctors are not completely skilled in surgery and perform incomplete apicoectomies. Why? My feeling is that they are not true surgeons and are unsure of the extent of cleaning of the region needed. This often is the result of doctors who are not knowledgeable in the anatomy of the area and are hesitant in being aggressive enough to completely clean the area.
So should you have any apicoectomy? Yes if the doctor doing it is a skilled surgeon and not just an endodontist, who only occasionally does surgery.
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QUESTION: Thank you for the answer, Dr. Teig.
To be clear, an apicoectomy was performed on me about 1 month ago.
I was healing well until 3 days ago when inflammation reappeared.
Given that I have already had an apicoectomy, would you suggest now finding a skilled oral/maxillofacial surgeon, and not just an endodontist, to try to plan further treatment?
Are there any clear diagnostic steps to determine the cause of inflammation post-apicoectomy? Would another CT scan provide evidence of an incomplete apicoectomy?
thank you again for your time, and I appreciate the answers.
Dan - failure of apicoectomies can be due to a number of factors. The most common cause is the doctor's failure to create a complete seal into the nerve canal after the apicoectomy. There are no clear diagnostic tests. Direct exam often will disclose the cause, but sometimes the cause is not a simple manner. A CT scan would not be a diagnostic tool to arrive at the cause, unless the doctor who did the apicoectomy made a mess.
So, in my opinion, the only method to arrest the problem is to do a redo of the apicoectomy by a skilled surgeon. Even with that, there is no guarantee of success.