What Would You Do in this Case?

I want to share an interesting tooth story with you. But I don’t want to give it away before we dig in, so only highlight this text if you want to get a spoiler: This is a case study all about hypercementosis root canal treatment. Ready to dive in? 

Let’s start with a question.

Tell me, what does this radiograph say to you?

How would you describe this case? Based on what you see, does it change the game for you? Would you do anything differently, clinically, based on what you see? What’s the risk assessment to proceeding with treatment, in your view?

Take a look at it again if you need to!

Let’s start with tooth #19.

Let’s first describe the radiograph with respect to tooth #19. 

Tooth #19 is a very long tooth. It has been restored with a composite, and there is a periapical radiolucency associated with the tooth. 

Other than that, this tooth looks pretty normal to me!

My diagnostic tests revealed that all the probings were within normal limits, the tooth had no response to cold. It was necrotic and tender to percussion. The diagnosis was Necrotic Pulp and Symptomatic Apical Periodontitis #19.  

What else do you see? Is there anything else in this radiograph that would have you think twice, with respect to risk assessment in this case?  

What about the hypercementosis on the distal root? 

What is hypercementosis? Let’s quickly review!

Hypercementosis is the excessive deposition of non-neoplastic cementum over normal root cementum. This alters the root morphology because it goes beyond the physiologic limits of the tooth.

The cause for hypercementosis is not really clear, but most cases appear to be idiopathic. It can be a common finding in the Indian population, or it could be a sign of other systemic conditions like Paget’s disease, Vitamin A deficiency, acromegaly and perhaps even systemic lupus erythematosis, so it’s good to have that awareness if you see hypercementosis in a patient.  

Local factors that could cause hypercementosis include occlusal trauma and inflammation as a result of pulpal or periapical inflammation.

The most frequently affected teeth are the mandibular molars.  Mandibular and maxillary second premolars come in second place and mandibular premolars come in third place.  

A case of hypercementosis treatment.

Usually, hypercementosis does not require any treatment.

But in the case of this tooth, it has gone necrotic and needs either a root canal or an extraction.  Hypercementosis root canal treatment is definitely important in this case!

If you run across a case like this, I want you to be prepared. These teeth are harder to remove than other teeth, and they most certainly are harder to root canal. So if you see hypercementosis on the radiograph, know that it should be considered within your risk assessment process. This might be a case that’s worth referring out to an endodontist.

For this particular case, the hypercementosis is most likely being caused by the inflammation of pulpal origin, since the tooth is necrotic. But this tooth has hypercementosis and is very long.  Both of those factors will impact the ease of instrumentation in this case. And not in a good way! There is a much higher chance of instrument separation at the apex of this root when doing this root canal. 

Be honest with yourself. Would you be able to manage this case with that variable layered on top? There’s no shame in knowing your limits.

An endodontist’s perspective on this tooth story.

I often find that patency and achieving working length is more challenging in cases of hypercementosis treatment. 

I’ve also run across cases like these where everything was going fine, but my final pass with my rotary file was all it took for things to go south, and my instrument separated. Bleh!

So in a case like this, I will use my hand files a lot more, make sure there is a wide glide path for my rotary files, and I will use more EDTA. I may even use some RC Prep, which is something that I don’t really use much of anymore.  

How would you have handled this case? What have you learned from this tooth story? I’d love to hear from you in the comments!

Here are my top takeaways, personally:

First, be aware of the potential complications of cases like these. Do your risk assessment from the get-go, so you keep top of mind the limits of your comfort zone. It’s not that you can’t learn new skills—of course you can! But sometimes the ROI just might not be worth it. Sometimes, it might make the most sense to refer a case like this out to a specialist.

Second, have patience as you get to working length, and have resilience as you achieve patency. These cases can really be tricky!

Third, remember how diverse teeth really are. There are so many possibilities of what you can see inside and outside your patients’ teeth. Bring an open mind and lots of awareness to your procedures, so you can keep your endo safe for your patients and less stressful for you!

I’d love to hear your thoughts and takeaways!

Empower yourself,

Sonia