AMERICAN BOARD OF ENDODONTICS
CASE HISTORY REPORT
Case Report Number: TWO Candidate Number: 70103
Patient Age: 52 Date Case Started: 6-12-01
Patient Sex: Female Date Case Finished: 7-9-01
Date of Last Recall: 7-1-04
A. Tooth # (1 - 32): 13 B. Procedure Category: EMERG
CHIEF COMPLAINT: "The inside of my mouth is swollen".
C. MEDICAL HISTORY: 53 year old Female Caucasian. Patient in good health, No reported medical
conditions or diseases. Allergic to Penicillin and Sulfa Drugs, BP 109/74 Pulse 84.
D. DENTAL HISTORY: Patient reports spontaneous pain in area of tooth #13 which started two weeks
prior to today's emergency appointment. Pain has stopped but she now has swelling adjacent to the tooth
#13. Her general dentist saw her first, took a PA radiograph and made an initial diagnosis of an endodontic
problem and scheduled an emergency, same day appointment for the patient with our office. No reported
HX of Myofacial Pain Dysfunction Syndrome.
E. E. CLINICAL EVALUATION: (Diagnostic Procedures)
Exam: Radiographic examination shows a prior silver cone endodontic treatment. Patient cannot recall date
of original treatment. No extraoral swelling is present but swelling of the buccal mucosa is noted adjacent to
#13. Afebrile. #12 and #14 are asymptomatic and unremarkable clinically. Negative exam findings for Non-
Odontogenic pain. Good oral hygiene noted. No periodontal pockets greater than 3 mm.
Tests: Tooth 12 13 14
Dry Ice WNL RCT WNL
Palpation WNL + WNL
Percussion WNL ++ WNL
Bite Stick WNL + WNL
Mobility 1 2 1
Radiographic Interpretation: A PA radiolucency approximately 7 mm in diameter is present at the apex
of #13 and extending to the mesial aspect of #14 mesial buccal root. PBM crown present. Prior silver cone
endodontic treatment is present. No evidence of redecay radiographically.
F. PRE-TREATMENT DIAGNOSIS: Pulpal: Previously Treated.
Periradicular: Acute Periradicular Abcess.
G. TREAMENT PLAN:
Recommended: Emergency: Incision and Drainage, informed consent obtained.
Definitive: Conventional Retreatment.
Alternative: Extraction and replacement.
Restorative: Bonded alloy buildup.
H. CLINICAL PROCEDURES: Treatment Record
Date: 6-12-01 Operations:Incision and Drainage
Emergency endodontic consultation and treatment. Clinical exam, film x-ray scanned and reviewed of tooth
#13, clinical tests, medical and dental history taken and reviewed. Treatment plan was presented to patient
which included (1) incision and drainage of periradicular abscess, (2) Conventional retreatment of failing silver
cone after intraoral swelling controlled. Risks, benefits and alternatives presented and understood. Patient
accepted treatment plan. Profound anesthesia was achieved by local infiltration of 72 mg of Lidocaine 2% with
1:100,000 epinephrine. An incision was made at apex of #13 and drainage achieved with manipulation of
incision site using an endodontic spoon. Rubber dam drain was placed and stabilized with one, interrupted 4/0
silk suture. Patient was monitored until drainage subsided and scheduled for 3 day drain removal. Post op
instructions including medication instructions and instruction in placement of clean gauzes were given verbally
and in writing. Post op PO medications prescribed: Erythromycin 500 mg x 28 capsules, 2 stat then 1 Q6H till
gone, Hydrocodone with Acetaminophen 5 mg/500 mg x 15 tablets, Take 1 Q6H prn severe pain and
Ibuprofen 400 mg Q6H for eight doses. Antibiotics given to treat any bacterial component to swelling and anti-
inflammatory to treat any inflammatory component.
6-12-01 PM Post op followup phone call, patient is comfortable, taking medications and has stopped draining.
6-13-01 AM Next day Post operative followup phone call. Patient is comfortable, taking medications and is not
6-15-01 Drain removal. Topical anesthetic applied to incision, suture clipped and drain removed. Patient is
asymptomatic with buccal swelling diminished. Post op drain removal instructions given. Patient scheduled for
Single Visit Endodontic Retreatment.
7-9-01 Single Visit Endodontic Retreatment. Asymptomatic with sinus tract present. Profound anesthesia
achieved by local infiltration of 72 mg of Lidocaine 2% with 1:100,000 epinephrine. Rubber dam placed,
Access made through crown. Silver cones exposed, loosened and removed with ultrasonic instrumentation.
Length determination achieved, "Standardized" instrumentation and obturation were performed. Bonded alloy
buildup placed. Final radiograph shows slight sealer excess present. POI given. 2 week fistula re-evaluation
7-10-01 AM Followup call, pt comfortable and asymptomatic.
DIAGNOSIS ( If different post-treatment) Pulpal: N/A
HISTOPATHOLOGIC DIAGNOSIS (If biopsy) Periradicular: N/A
CANAL WORKING APICAL
(M,D,B,L, etc) LENGTH SIZE* OBTURATION MATERIALS AND TECHNIQUES
B 16 .360 "Standardized" Obturation Technique
L 17.5 .360 "Standardized" Obturation Technique
*Size of the largest instrument used at the apex
I. POST-OPERATIVE EVALUATIONS: (Last recall recorded must be 1 year minimum)
Date: 7-17-01 Sinus tract still present. Asymptomatic. Scheduled for 4 week followup.
Date: 8-21-01 Sinus tract healed. Asymptomatic. Six month re-evaluation scheduled.
Date: 7-1-04 Digital x-ray taken and reviewed. Asymptomatic. Soft tissues WNL. No periodontal pockets
greater than 3 mm. PA radiographic shows sealer excess gone and bone fill present in the original radiolucent
area. Percussion and bite stick tests WNL. Outcome: HEALED.
AMERICAN BOARD OF ENDODONTICS
CASE HISTORY REPORT