Tooth Story #14: Another Good Root Canal Recall on the Books
November 30, 2018
Treating Symptomatic Apical Periodontitis and PCO (Pulp Canal Obliteration)
December 21, 2018
A couple of years ago, I had a very upset patient. The reason? I was the second specialist that he was seeing for the same tooth. This patient was actually referred to me by a Periodontist, and the patient was NOT happy that he had to have the same tooth evaluated AGAIN!!
It was my first patient on a Monday morning, and having an unhappy patient first thing in the morning is not my favorite way to kickstart a week. When you greet them with a cheery, “Hi, good morning! How are you?,” you don’t really expect a negative response. So what’d he say? “Not good at all.”
His Chief Complaint
The patient’s chief complaint was that his dentist told him had a bump on his gum and had an infection. He had no pain and he didn’t even know that he had a deeper problem. Check out his preoperative radiographs…
On the radiograph, I see a curvy mesial root and a periapical radiolucency around tooth #15. He had no pain to percussion and did not have a response to cold. Clinically, I saw that the teeth in the upper left quadrant have been restored with crowns and that a sinus tract was present over area #15.
That was a little clue for me… because whenever, I see a sinus tract, I always trace it. 100% of the time.
Tracing a Sinus Tract to the Source of the Infection
Tracing a sinus tract is such an amazing diagnostic tool since it will trace right to the source of the infection. All I do is take a size 25 gutta percha and put it right through the sinus tract until it stops. Sometimes, I need to use a periodontal probe to create a glide path before I place that gutta percha. (Keep in mind that my patient is usually not numb for this. However, they usually do very well, as long as you give them a little warning as to what’s coming. You’ll want to let your patient know that this step will be a little tender.) In this case, the sinus tract traces right to the apex of tooth #15.
He was Frustrated with His General Dentist
Unfortunately, this patient was so upset with his general dentist that he did not want to go back to him for any further care. Why? He felt that his dentist should know how to make the right diagnosis to get him to the right specialist. The patient was losing faith in the dentist that he had been loyal to for so long. (And he didn’t feel like it was fair to have to pay for two evaluations, since his general dentist didn’t diagnose the problem accurately.)
You know, I know many dentists who don’t like to do endo at all in their practice. However, that doesn’t mean that they should simply forget about the diagnostic aspect of endo.
Diagnostics are something that we do in our practices everyday, and it can have a HUGE impact on our all of our patients. In this sense, we are doing endo all the time and are just not realizing it.
This case is sooo simple to diagnose. When you simply do a cold test, you will find out that the tooth is necrotic. The necrotic pulp is the source of the infection and the draining sinus tract. Because this is a primary endodontic lesion, that sinus tract should be gone within a week of doing the root canal. This patient had a Necrotic Pulp with Chronic Apical Periodontitis, and all it needed was a root canal.
Always Look for the Sinus Tract
Some other things to keep in mind when it comes to sinus tracts — they are usually incidental findings. Most patients don’t know they have them because there is very little pain associated with them. So, make sure that you look for them and DON’T prescribe an antibiotic when you see one.
I really want to high five this Periodontist!!! He saved this guy’s tooth by not doing any crazy surgery to try and fix it. He recognized that it was a primary endo lesion and not a primary perio lesion. I can’t tell you how many times I have seen a tooth like this AFTER a periodontal surgery has already been performed to treat it.
So, do your patients a favor and run through the diagnostic tests BEFORE you ever refer a patient out.
Remember, we, as specialists, are here to confirm your diagnosis, but it’s also important to keep the shuffling around of your patients to a minimum. If you have a question, call us and perhaps discuss it with us before you make a referral so that you can save your patients time and money (and so they will come back to your practice as happy campers).
The Take Away
The reason I write some of these blogs is so that you can see what a specialist sees, and so I can give you a different perspective — your patient’s perspective. (I’m always grateful for those who give me feedback so that I can better my practice, and I hope you feel the same!)
That said, there are two lesson here:
Lesson 1: When you see a sinus tract, embrace it… because it’s your friend. It’s there to give you a clue, to tell you exactly where the infection is coming from, and it’s saving your patient from having any pain at all.
Lesson 2: Make sure you can confidently diagnose your patients’ pain, even if you don’t like to perform root canals. When you can diagnose correctly, you help your patients get the treatment they need…and they keep trusting you as a clinician.
Need some help with diagnosis? Download my free Pulpal & Periapical Diagnosis Checklists!
-Sonia
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33 Comments
Sonia
How does a cold test confirm a necrotic tooth?
Tony
Sonia, thanks for sharing this. I see these a lot in general practice, and am quite happy to take up the GP trick you describe.
I’ve sometimes struggled to describe to patients what happens if they simply “ignore” the lesion along the rationale “it doesn’t hurt so why do I need treatment”.
So do you have any good summary I could tell my patients what the outcomes might be if ignored?
Best wishes,
Mark Friend
Tony,
Hmmm, I hope that I am interpreting your question correctly. Not having a response to a cold test typically means that the tooth is no longer vital, hence necrotic. Just be careful that your patient feels cold on their teeth. Every now and then I will get a patient who never responds to cold on any of their teeth. So, make sure you find out THAT patient’s normal. For example, if the tooth in question is #15, then also do a cold test on tooth #2 and see how it responds (so long as it has not been treated with an RCT). If it responds to cold, well then, #15 should also respond to cold. If it doesn’t then you know that there is an issue, a necrotic pulp.
Mark,
I love to show my patients the problem and talk about it. I show them the “lesion” and tell them that this is their bone disappearing and pulling away from the tooth because it doesn’t like the infection inside the tooth. If they wait, the bone loss will get worse. The goal of the root canal is to change the environment back into health and to get that bone back. So, now they know what benefit they will also get from the root canal. If that doesn’t work, you can remind them that there are other ailments (i.e. clogged arteries, cancer, etc) that don’t cause pain but still need to be treated.
Hope this helps,
Sonia
Very interesting talk….
So glad you’re following! Stay tuned for more…
-Sonia
Very informative….in your article you have mentioned that dont prescribe antibiotic when u see a sinus tract..wats your rationale behind this…
Hi there!! I only give an antibiotic when a patient is swollen, has a fever, lymphadenopathy or is really tender to percussion due to infection (indicating that they are experiencing a flare-up). Usually, when a sinus tract is present, they have no pain and since they are already draining, I feel that the sinus tract IS the antibiotic. Instead, perform treatment, that is the best medicine.
-Sonia
Hey Sonia,
How long sinus track stays after root canal treatment? I had 4 canals done 5 years ago and my dentist missed one canal and last week sinus track showed up. Yesterday dentist have done gutta-percha test and infection was near 5th canal. He fixed that canal. X ray looking good and my dentist is happy. How long takes to heal for sinus tract?
Thanks you!
Hi!! I usually see a sinus tract healing up after about 1-2 weeks. However, sometimes it does depend on how much bone loss exists under that tissue. But, for the most part, it has been about 1-2 weeks in my experience.
-Sonia
Thank you so much Sonja for sharing this , so only rcttt , do you finish it in one visit or two visits ?? And do you apply any canal medication in this situation ??
Thank you
Did you give any intracanal medicament? How long the medicament to be kept for adequate asepsis?
Can you discuss perio/endo problems and how to diagnose? Thank you.
Rahul,
Hi there. I typically leave my calcium hydroxide in the tooth for 3-4 weeks.
-Sonia
Mary Ann,
I will definitely add that to my list of blogs to write. Thank you for the recommendation.
-Sonia
Hi,
So I’ve had a sinus tract for 20 years over my front tooth! Had extreme pain and abscess 20 years ago – antibiotics cleared it but apparently not the abscess! Dentist yesterday said root canal was needed – struggling to come to terms with this thought as I have had it for 20 years with no pain and no repercussions that I am aware of (tooth is necrotic). What would you suggest?
Get your root canal, you will be so happy. From what I can tell from the limited information, this is what you sound like you need.
-Sonia
Hi, have you ever had the GP point break inside the bone defect? How would you treat , if something like if it happened
I am sorry that I don’t know what you mean by that.
-Sonia
I had a root canal followed by an apico on #19. Within three weeks I developed a sinus tract lesion that has been draining for over five weeks. My surgeon says this is normal when the bone is healing. My regular dentist says it isn’t and wants to have the tooth pulled because it’s a sign of infection. It doesn’t hurt. My question is: Can I have a sinus tract draining as part of the healing process?
Michele,
I feel that I don’t have enough information to really answer this question. I would think that it would take a few weeks, even a month for the drainage to show signs of healing. Hopefully, it is getting better, but I would let your surgeon follow up on this. Good luck.
-Sonia
Sonia, I have a patient with a failed root canal on #15. She has gone through root canal twice and continues to have pain. Upon CT scan it was found that she has a fracture in the root canal with infection and the tooth is near the sinus- next steps are tooth extraction w implant or bridge, current treatment are antibiotics and pain meds until extraction. Any additional thoughts on treatment?
Maria,
This is a tough one to comment on without actually seeing the imaging myself. If there is a true fracture and what you are seeing is definitely not beam hardening on the CT, then it sounds like you have no other choice. I cannot tell you if an apico would work here without more information.
-Sonia
Hi Sonia,
I’m doing my dental internship now, thank you for your sharing.
Could I know what’s your SOP during diagnosis of a tooth?(more often a deep caries tooth)
Will you perform heat test? If yes, which method do you prefer?
Thanks a lot!
Kai,
My SOP for diagnosis: probing, palpation, percussion, bite stick cold. I don’t really test heat, but if I do I use a hot water bath under the rubber dam.
-Sonia
Hi! I was told by my Endodontist that I have an infection and a sinus tract he did a root canal and prescribed antibiotic. Why do you say no antibiotic?
The sinus tract will not go away with an antibiotic. When you remove the infection from the tooth, the sinus tract goes away on its own and there is no need for an antibiotic. If it keeps coming back, that is a sign that there is something wrong. I hope that helps you.
-Sonia
Hello!
My dentist diagnosed a sinus tract on a back molar. He referred me to an endo , but my consulatation appt is two weeks away. Is it okay to wait that long without treatment ? Is there anything I should be doing between now and then ?
Thank you
Marie,
That sinus tract is your friend and is keeping you from having any pain. You should be fine until your appointment from how you are describing it to me.
-Sonia
I was just recently diagnosed with a sinus tract. They thought I had skin cancer or possibly a cyst on the outside of my jaw. They started to remove it but found out it was a sinus tract. I had 2 failed root canals over 20 years ago. I have been referred to the Oral and maxillofacial surgery dept and am waiting to hear back. I am very nervous on the amount of damage this may have caused. Thoughts?
~Angie
Angela,
Unfortunately, I don’t have enough information here to weigh in. I would need to evaluate you completely myself in order to give you a proper assessment. I hope you understand.
Thanks.
-Sonia
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