ENDODONTIC RETREATMENT OF A MANDIBULAR FIRST MOLAR WITH SYMPTOMATIC APICAL PERIODONTITIS: A CASE REPORT*Martariwansyah*Mahasiswa Peserta Program Dokter Gigi Spesialis Ilmu Konservasi Gigi Fakultas Kedokteran Gigi Universitas Padjadjaran

Case Summary : A 24-year-young male patient complaining of discomfort in his tooth #36, which had already been endodontically treated one year ago. Six month later, a filling became looseand got the temporary filling. After standing for a long, he began to experience moderate pain at percussion especially when used chewing. There was no sign of swelling or sinus. He never take any medication to relieve the pain. Intra Oral examination found the old cavity with the temporary filling (fig.1), Pulp sensitivity test was negatif. At the mesial side was sensitive to percussion. Periapical Radiographic analysis showed of tooth was periapical lesion at mesial apical root (fig.2).Diagnosis : Tooth 36 previously treated; symptomatic apical periodontitis. Treatment planning : Endodontic retreatment and placement of indirect onlay composite Figure2. Periapical Radiographic analysis showed of tooth was periapical lesion at mesial apical root ((July 3rd 2014Figure 1.the old cavity with the temporary filling (July 3trd 2014)

Removing Gutapherca : After giving local anaesthesia with Xylocaine(Dentsply Maillefer) 2% with adrenaline (Epinephrine) 1:80,000 the tooth was isolated with rubber dam and clamp (Hygenic) (Fig.3). The access cavity was refined with an Endo Access bur number A0164 DM (Dentsply Maillefer) and Remnant restoration material was removed. When exposing the pulp chamber floor, a lot of debris, sealer and gutta-percha (GP) were observed. There was appearance of two master cones in the mesial side (one mesio buccal and one mesio lingual), and one in the distal side (fig.4). The retreatment was done after removing the GP using Hand files Instrument without solvent (fig 5.). GP was removed using light apical pressure and passively rotated clockwise until the working length with Hedstroem File Colorinox 25mm #25 (Dentsply Maillefer). The pulp chamber was thoroughly rinsed with 2.5 % sodium hypochlorite solution (NaOCl) . After removing GP on the distal and mesial canals carefully examined using an endodontic probe. X-rays are taken to verify that cleaning fiilling material completed. (fig.6)

figure 4. Exposing the pulp chamber floor, a lot of debris, sealer and gutta-percha were observedFigure3. the tooth #36 was isolated with rubber dam and clamp (Hygenic)

Figure 6. X-rays are taken to verify that cleaning fiilling material completed

Figure 5.Gutta-percha was removed using light apical pressure and passively rotated clockwise until the working length was reached with Hedstroem File Colorinox 25mm 25 (Dentsply Maillefer)

Preparation : Instrumentation was performed again according to the pre-enlargement technique, which preparing the middle-coronal third with ProTaper Rotary Shaping File 19mm SX and subsequent preparation of the apical third. The initial coronal preparation was carried out with the ProTaper Next (PTN) (Dentsply Maillefer) X1 file, which has a 0.17 tip size and a 4% taper. Using Glyde (Dentsply Maillefer) as intracanal lubricants to aid preventing blockage during cleaning and shaping (fig.11). The file was used in a brushing motion to approximately two-thirds of the estimated working length with frequent NaOCl irrigation. The file was withdrawn from the canal frequently to clean the flutes and to recapitulate with a #10 K-File to ensure canal patency was maintained. Once the coronal preparation was completed, the working length (WL) was gotten by electronic measurement with an apex locator, ProPex PiXi (Dentsply Maillefer) (fig 7.) and Creating smooth and reproducible apical glide path using PathFile(Dentsply Maillefer) #16, #19 rotary instruments to the full WL (fig.8).Taking the radiograph to confirm full WL (fig.9). Canal preparation was continued to WL. the PTN X1 and X2 file with the same brushing motion, again with regular irrigation and recapitulation. The next stage was to gauge the apical diameter of the canals and thus determine the finishing PTN (Dentsply Maillefer) X3 file (fig.10) which has an ISO 30 tip size and 6% taper. After shaping was completed, theEndoActivatorwas used to agitate the 2,5 % NaOCl (fig.11). After rinsing out the NaOCl with sterile water, the canals were irrigated withchlorhexidin (CHX) 0.2 % followed byGlyde (Dentsply Maillefer)) to remove smear layer (fig12). All canals were dried with paper points (fig 13). Calcium Hydroxide paste (Non setting) was placed into the canal with a lentulo spiral paste carrier and the access cavity was closed with ciprospad (Dentsply Maillefer) as temporary filling. The intracanal dressing was changed weekly for two weeks. In the Final appointment, the calcium hydroxide dressing was removed, the canals were rinsed, and each of the three canals was gauged again using hand K-files to confirm a full WL. The canals were irrigated again, dried with sterile-paper points and taking a radiograph photo to confirm fit of the master cone (fig.14). Once the master GP cone is fit, the canals were obturated with GP master cones (X3, size 30) (Dentsply Maillefer) and AH Plus Sealer (Dentsply Maillefer) using the lateral condensation technique (fig.15 a.b). Access cavity was sealed with SDRSmart Dentine Replacement (Dentsply Maillefer). When the patient was reviewed after one week, there was not any abnormality detected radiologically and clinically (fig.16). Following this, a indirect onlay composite was cemented using SmartCem2 (Dentsply Maillefer) (fig.17 a, b). Finaly, taking radiograph for confirm the cementing onlay.(fig.18). One week observation after the treatment was done (fig.19)

Figure 8. Creating smooth and reproducible apical glide path using PathFile(Dentsply Maillefer) #16, #19 rotary instruments to the full working length

Figure 7. The working length was gotten by electronic measurement with an apex locator, ProPex PiXi (Dentsply Maillefer)

Figure 10. Determining the finishing ProTaper Next (Dentsply Maillefer) X3 fileFigure 9. Taking the radiograph to confirm full working length

Figure 11. theEndoActivatorwas used to agitate the 2,5 % NaOCl

Figure 12. Glyde (Dentsply Maillefer))as lubricant and chelating agent to remove smear layer

Figure13. All canals were dried with paper points

Figure 14. taking a radiograph photo to confirm fit of the master cone (Sept 22nd 2014).

Figure. 15 a. The canals were obturated with gutta-percha master cones (X3, size 30) (Dentsply Maillefer) and AH Plus Sealer (Dentsply Maillefer) using the lateral condensation techniqueFigure15b. obturated canal

Figure 16. Taking a radiograph to evaluate obturation (Sept 22nd 2014).Figure.17 a. a indirect onlay composite was cemented using SmartCem2 (Dentsply Maillefer). Lateral view

Figure 18. Taking a final radiograph to evaluate cementing (Sept 29th 2014).Figure.17 b. indirect onlay composite was cemented using SmartCem2 (Dentsply Maillefer). Occlusal View

Figure 18.b. One week observation after the treatment was done (lingual view) (Oct 10th 2014

Figure 18.a. One week observation after the treatment was done (occlusal view) (Oct 10th 2014

DiscussionThe conventional retreatment is always the first treatment option in the cases of endodontic failure 1,2. Endodontic treatment failure has been associated to persistent infection of canals: unsatisfactory shaping or cleaning procedures, incomplete root canal filling, iatrogenic errors or leakage of temporary/post-endodontic restorations are common factors that may impair an acceptable microorganisms eradication3. Furthermore, Inadequate obturation of the root canal invites failure as surely as does inadequate filling of a coronal cavity4. For this case, the endodontic failure was caused breakdown coronal sealing. Recontamination of the root canal system by coronal leakage will occur through: sealer dissolution by saliva; percolation of saliva in the interface between sealer and root canal walls (particularly if smear layer is present) and/or between sealer and gutta-percha5. Microorganisms penetrate into the canal after filling, there is a higher risk that the treatment will fail 6,7. How high the risk of reinfection will be is dependent on the quality of the root filling and the coronal seal 8.If the root canal had been unsealed at some point during the treatment, enteric bacteria are found more frequently than in canals with an adequate seal between the appointments. Pinheiro et al. reported a significant positive relationship between the absence of a coronal restoration and the presence of streptococcus spp. And candida spp. in the root canal 9. In 2004, Adib et al.attempted to identify the bacterial flora in root-filled teeth with persistent periapical lesions and a history of coronal leakage. They found the predominant group of bacteria was Gram-positive facultative anaerobes of which staphylococci followed by streptococci and enterococci were the most prevalent. Their results also showed a polymicrobial flora existed (with the number of species recovered per tooth ranging from six to 41 species) when the canal was poorly root filled 10. In addition, In the root canals of teeth with technically inadequate root fillings and asymptomatic periapical lesions, but with an acceptable coronal restoration, one or more obligate anaerobes are usually found and the situation is similar to the infected but previously untreated teeth 11,13 Symptomatic Apical Periodontitis represents inflammation, usually of the apical periodontium, producing clinical symptoms involving a painful response to biting and/or percussion or palpation. This may or may not be accompanied by radiographic changes (i.e.depending upon the stage of the disease, there may be normal width of the periodontal ligament or there may be a periapical radiolucency). Severe pain to percussion and/or palpation is highly indicative of a degenerating pulp and root canal treatment is needed 14.Root canal retreatment aims to eliminate or to substantially reduce the microbial load from the root canal to enable effective cleaning, shaping and filling of the root canal system 15 . This procedure can uncover residual necrotic tissues or bacteria that may be responsible for persistent periapical inflammation, and allow further cleaning and refilling of the root canal system 16. The relative difficulty in removing gutta percha varies according to the obturation technique previously employed and further influenced by the canals length, cross sectional dimension, curvature and internal configuration. Dividing the root into thirds, gutta percha may be initially removed from the canal in the coronal one-third, then the middle one-third, and finally eliminated from the apical one-third 17. Various instruments have been used for gutta-percha (GP) removal, including endodontic hand files, enginedriven rotary files, ultrasonic tips and files, and heat carrying instruments. Chemicals are sometimes used as solvents 18, 19 . Removal of GP using hand files with or without solvents is time-consuming, especially when the filling materials are well condensed 20. Gutta-percha is usually removed with Hedstrom files alone or in combination with Gates Glidden drills (GGdrills) with or without solvents 21. Remaining filling debris has been assessed by radiography 16.In the present case report, endodontic retreatment was necessary because of the presence of periapical lesion, as a consequence of an improper former root canal therapy performed one year ago. Removal of sealer and gutta-percha from inadequately prepared and filled root canal systems is essential in root canal retreatment because it is likely to uncover remaining necrotic tissue or bacteria that may be responsible for periapical inflammation and posttreatment disease 22. Removal of GP using hand files without solvents because from the radiographic analysis the proper root canal obturation is inadequate in this case. Gutta-percha from the distolingual, mesiobuccal and mesiolingual canal was removed with Hedstroem hand files instruments for retreatment under copious irrigation with sodium hypochlorite and EDTA solution. An important method to remove gutta percha, especially when the canal has been overextended vertically and underfilled laterally, is to utilize the hedstroem displacement technique. The gutta percha is first thermosoftened with heat and then a 15, 20, or 25 hedstroem file is passively rotated clockwise into this mass. Let the gutta percha cool and harden within the blades, and upon withdrawing the hedstroem file, oftentimes the entire mass of gutta percha will be removed as well 17, 22. Finishing of the root canal with cemomechanical preparation was done by using some irrigants and ProTaperNext files. The retreatment was performed in this case in two appointments. Between the two appointments, calcium hydroxide was placed as medication in the root canals for two weeks, in order to kill the microorganisms undestroyed by the irrigation protocol and neutralize remaining microorganisms in the root canal 23. In this case, a postoperative radiographic was taken to evaluate the quality of the performed endodontic retreatment and to confirm the presence of three canals in relation to mandibular left first molar.In summary, the microorganisms causing the initial infection persisted in poorly treated root-filled teeth with periapical lesions. In theory, if these root canals are retreated adequately under a strict treatment regimen, the success rate should be as good as endodontic treatment of the previously untreated teeth with apical periodontitis.

Reference1. Lopes HP, Siqueira JF Jr., Elias CN. Retratamento endodntico. In: Lopes HP, Siqueira JF Jr. Endodontia: biologia e tcnica. Rio de Janeiro: Guanabara Koogan; 2004. p. 727-85.2. Moiseiwitsch JR, Trope M. Nonsurgical root canal therapy treatment with apparent indications for root-end surgery. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1998;86(3):335-40.3. Ricucci D, Siqueira Jr JF. Recurrent apical periodontitis and late endodontic treatment failure related to coronal leakage: a case report. J Endod 2011;37(8):11715.4. Schilder H, D.D.S.Filling Root Canals in Three Dimensions.JOE Volume 32, Number 4, April 20065.Siqueira JF Jr, Ras IN, Lopes HP, Uzeda M (1999) Coronal leakage of two root canal sealers containing calcium hydroxide after exposure to human saliva. Journal of Endodontics 25, 146.6. Bystrm A, Happonen R-P, Sjgren U, Sundqvist G (1987)Healing of periapical lesions of pulpless teeth after endodontic treatment with controlled asepsis. Endodontics and Dental Traumatology 3 , 5863.7. Sjgren U, Figdor D, Persson S, Sundqvist G (1997) Influence of infection at the time of root filling on the outcome of endodontic treatment of teeth with apical periodontitis.International Endodontic Journal 30, 297306.8 Saunders WP, Saunders EM (1994) Coronal leakage as a causeof failure in root canal therapy: a review.Endodontics DentalTraumatology 10, 10589. Pinheiro ET, Gomes BP, Ferraz CC, Sousa EL, Teixeira FB, Souza-Filho FJ. Microorganisms from canals of root-filled teeth with periapical lesions. Int Endod J 2003; 36: 11110. Adib V, Spratt D, Ng YL, Gulabivala K. Cultivable microbial flora associated with persistent periapical disease and coronal leakage after root canal treatment: a preliminary study. Int Endod J 2004; 37: 54251.11. Cheung GS, Ho MW. Microbial flora of root canal-treated teeth associated with asymptomatic periapical radiolucent lesions. Oral Microbiol Immunol 2001; 16: 3327.12. Peciuliene V, Balciuniene I, Eriksen HM, Haapasalo M. Isolation of Enterococcus faecalis in previously root-filled canals in a Lithuanian population. J Endod 2000; 26: 5935.13. Sundqvist G, Figdor D, Persson S, Sjogren U. Microbiologic analysis of teeth with failed endodontic treatment and the outcome of conservative re-treatment. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998; 85: 8693.14.American Association of Endodontists.Endodontic Diagnosis. ENDODONTICS: Colleagues for Excellence.2013;9-1415. Stabholz A, Friedman S (1988) Endodontic retreatment-case selection and technique. Part 2. Treatment planning for retreatment. Journal of Endodontics 14, 60714.16. Schirrmeister JF, Hermanns P, Meyer KM, Goetz F, Hellwig E (2006d) Detectability of residual Epiphany and gutta-percha after root canal retreatment using a dental operating microscope and radiographs-an ex vivo study. International Endodontic Journal 39, 55865.17. Ruddle CJ: Nonsurgical endodontic retreatment. Cda journal, 2004;418. Wilcox LR, Krell KV, Madison S, Rittman B (1987) Endodontic retreatment; evaluation of gutta-percha and sealer removaland canal reinstrumentation. Journal of Endodontics 13, 4537.19. Lewis R, Block R (1988) Management of endodontic failures. Oral Surgery, Oral Medicine and Oral Pathology 66, 711121.20. Sae-Lim V, Rajamanickam I, Lim BK, Lee HL (2000) Effectiveness of ProFile.04 taper rotary instruments in21.Dalton BC, Orstavik D, Phillips C, Pettiette M, Trope M (1998 Nov) Bacterial reduction with nickel-titanium rotary instrumentation. J Endod.; 24(11):763-7.22. Friedman S, Stabholz A, Tamse A. Endodontic retreatment-case selection and technique. Part 3: retreatment techniques. J Endod. 1990;16:543-4923. Soares JA, Leonardo MR, Tanomaru Filho M, Silva LAB, Ito IY. Effect of biomechanical preparation and calcium hydroxide pastes on the anti-sepsis of root canal systems in dogs. Journal of Applied Oral Science 13, 93-1009