Deep Cavity on Necrotic Molar, RCT Needed?

[Mo24078]

Hello all,
I had a deep cavity on my No.18 molar on the mesial-buccal surface. Two weeks ago, my dentist removed all the decay without administering any anesthetics; he could tell just by looking at the tooth that it was necrotic and I felt no pain during the procedure. In that process of decay removal, the pulp chamber was exposed but there was no bleeding; more signs that the pulp was non-vital. He did an amalgam filling on that tooth and told me that I should take a periapical x-ray every year to see if there is a radiolucency at the tip of the root and therefore need for root canal surgery. Post treatment, the tooth is a bit sensitive and painful to percussion and I have had one episode where it was aching for 30 minutes but I have no issues or pain when biting or chewing with it or with hot and cold fluids. From my own research, when a tooth has become necrotic like this, RCT is a must but my dentist, who has 30 years of experience, suggested otherwise and told me to just monitor it yearly and that it might never need RCT. Is he right in his assessment or should an RCT be done to save the tooth?

 

[Dr M]

Good day

A necrotic pulp can transition at any time to acute abscess formation. If the pulp was exposed like you mentioned, and the tooth was grossly carious to begin with, a root canal treatment is definitely a MUST. If left untreated, an abscess can form, which can cause severe pain and then later spread to adjacent spaces.
That being said, before a root canal is performed on this tooth, it should be evaluated if the amalgam filling that was done, is forming an accurate seal. The caries on the molar went sub-gingival and if the restoration is not sound, microleakage after root canal therapy will result in the ultimate failure of the root canal as well.
If the long term prognosis of the tooth is not that great due to questionable root canal therapy, it might be a better option to rather look at other treatment alternatives.

 

[honestdoc]

I agree with Dr M. I'm sorry to say the 30 year plus experienced dentist is wrong to leave it. It is a source for infection. To restore this tooth may be costly and unpredictable. Your options are to do a root canal, core bu, and crown or to extract it.

 

[Mo24078]

Good day

A necrotic pulp can transition at any time to acute abscess formation. If the pulp was exposed like you mentioned, and the tooth was grossly carious to begin with, a root canal treatment is definitely a MUST. If left untreated, an abscess can form, which can cause severe pain and then later spread to adjacent spaces.
That being said, before a root canal is performed on this tooth, it should be evaluated if the amalgam filling that was done, is forming an accurate seal. The caries on the molar went sub-gingival and if the restoration is not sound, microleakage after root canal therapy will result in the ultimate failure of the root canal as well.
If the long term prognosis of the tooth is not that great due to questionable root canal therapy, it might be a better option to rather look at other treatment alternatives.

Thank you for your detailed response Dr M.
I have two follow up questions if you don't mind,

- My main dilemma is Covid right now as I'm almost 80 years old. Do you believe it's a viable strategy to wait till it the tooth gets painful to go the endodontist? I'm just trying to buy as much time as I can in hopes of getting a vaccine. Is this something that has to be done absolutely right away?
- When you say the restoration has to be checked to make sure it's sound, what are some ways/tools dentists have to check such a thing? Is it just visual inspection?

Thanks once again.

 

[Dr M]

Good day

You can wait until symptoms arise and then go for the RCT, but I would not put it off for too long. It is just important to note, that even though you might not have any symptoms on the tooth right away, I would advise 6-monthly peri-apical xrays of the tooth, to rule out any infection. Sometimes a tooth can remain asymptomatic, but when you take a radio-graph you can clearly see abscess formation. And we don't want this to spread. I have seen patients that are of a more " advanced age ", where the nerve was necrotic and all the canals in the roots were sclerosed or " calcified " , and then they never ever have any symptoms or infection on the tooth. But this is not always the case and shouldn't be considered the norm.
To check the restoration, a dentist can use a probe to make sure the margins of the restoration are sound, with no void or gaps, and with a peri-apical radiograph, you can also see if all decay was removed or not.