Management of a Necrotic Tooth with Unstoppable Drainage

Authors
Brian Jafine
Suffix
DDS, Cert. Endo
Cite this as: J Can Dent Assoc ;79:d118
Topics
treatment
diagnosis
dental caries
injury
endodontics
 

Presentation

Population

  • Patients with previous extensive restorations (e.g., amalgam or resin restorations, crowns), trauma or recurrent caries with pulp exposure
  • Medically-compromised patients

Signs

  • Swelling (sometimes)
  • Sinus tract (sometimes)
  • Large periapical lesions (sometimes)

Symptoms

  • Pain severity may vary
  • Continuous flow of pus or serous-like fluid
  • Bad taste in mouth (drainage from sinus tract)

Investigation

Fig. 1: Pre-treatment radiograph: large periapical radiolucency associated with two necrotic teeth.

  1. Thoroughly assess the patient’s medical history: diabetes mellitus, bleeding disorders, history of radiation therapy and trauma.
  2. Perform a complete extraoral and intraoral examination:
    • Examine for sinus tract inside or outside the oral cavity. If present, trace radiographically.
    • Examine for swelling and periodontal pocketing.
    • Examine teeth for caries, broken down restorations, crowns with open margins or recurrent caries.
  3. Perform pulp tests (hot, cold and electric) on the tooth in question and surrounding teeth to ensure they are not contributing to the problem.
  4. Perform a radiographic examination:
    • periapical radiographs to check for periapical (PA) pathology and periodontal problems (Fig. 1)
    • bitewing radiographs to check for dental caries
  5. Perform a radiographic examination to investigate:
    • recurrent caries
    • pulp exposures
    • widened periodontal ligaments
    • external and internal resorption
    • calcifications
    • length accuracy, perforations, strip perforations, or possible additional canals after the initiation of treatment
    • pathology in the area around the teeth or in the maxillary sinus

Diagnosis

Based on the clinical and radiographic examinations and the patient’s medical history, a diagnosis of necrotic tooth with unstoppable drainage is determined.

Treatment

Fig. 2: Post-treatment radiograph: treatment involved both non-surgical and surgical endodontic procedures to resolve the unstoppable drainage.

If the patient presents with a fluctuant swelling, consider doing an incision and draining prior to initiating treatment. Then begin instrumentation.

  1. Perform a more thorough cleaning and shaping of the canal spaces to ensure that all necrotic materials have been removed.
  2. Verify length determination (apex locator and radiographs) to ensure that over-instrumentation did not occur. Special care should be taken near the maxillary sinus, since over-instrumentation can lead to persistent drainage.
  3. If a strip perforation or perforation is noted, repair immediately with MTA or equivalent material. If unable to perform this procedure, refer the patient to an endodontist.
  4. Irrigate with NaOCl and leave in the canals and chamber for 10–15 minutes. Dry and place Ca(OH)2 in the canals and close, if drainage stops.
  5. Use negative pressure irrigation, if available.
  6. If all else fails, leave the tooth open, reappoint the next day, lightly instrument, irrigate and dry, and close the canal.
  7. In cases where there is a large PA radiolucency associated with a necrotic tooth and the drainage continues, both conservative and surgical endodontic treatments may be required (Fig. 2). Refer to an endodontist if uncomfortable dealing with this situation.
 

THE AUTHOR

 
 

Dr. Jafine is on staff at the Peel Memorial Hospital in Brampton, Ontario. He also maintains a private practice in endodontics and microsurgical procedures in Scarborough and Bramalea, Ontario. Dr. Jafine was a clinical instructor at the University of Toronto faculty of dentistry for 15 year in both the undergraduate and graduate programs.

Correspondence to: Dr. Jafine, Partners in Endodontics, 709-2075 Kennedy Rd, Scarborough, ON  M1T 3V3. Email: docj@rogers.com

The author has no declared financial interests.

This article has been peer reviewed.

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