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Clinical Response To A Vacant Post Space: Case Report

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VICTOR FERNANDO LAMAS LARA
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24 views

Clinical Response To A Vacant Post Space: Case Report

Uploaded by

VICTOR FERNANDO LAMAS LARA
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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CASE REP ORT

Clinical response to a vacant post space

G. Fishelberg
University of Medicine and Dentistry of New Jersey, New Jersey Dental School, Newark,
NJ, USA

Abstract

Fishelberg G. Clinical response to a vacant post space. International Endodontic Journal, 37, 199^204,
2004.

Aim To report a case demonstrating a radiolucency developing adjacent to an un®lled


post space.
Summary A mandibular left ®rst molar was root ®lled before post-space preparation.
The tooth was restored coronally but the post space was left empty, and 14 months
later, pain and furcal radiolucency developed. Cleaning, shaping, medicating and ®lling
the post space resulted in the resolution of symptoms and healing of the radiolucency.
Key learning points
 Post space should be prepared under conditions of asepsis.
 A post space must not be allowed to remain empty when a tooth is restored.

Keywords: post space, radiolucency, un®lled.


Received 29 October 2002; accepted 27 August 2003

Introduction

The consensus of investigators performing leakage studies is that restorative materials,


cements and canal ®lling materials leak (White et al. 1995, Siqueira et al. 1999). Dyes and
bacteria have been shown to penetrate root-®lled teeth through the apical foramen and
coronal opening in as little as 24 h (Gish et al. 1994), and while the clinical relevance of such
studies may be in doubt (Wu & Wesselink 1993), most practitioners strive to improve the
prognosis of their endodontic cases by working to minimize both coronal and apical leakage
(Ray & Trope 1995). Most studies advise retreatment after 3 months of saliva contact with
gutta-percha (Magura et al. 1991).
The creation of a post space decreases the amount of ®lling material in the root canal.
Some investigators feel that this may leave the apical seal susceptible to leakage (Metzger
et al. 2000), and researchers have also speculated on the threat of leakage around posts
(Metzger et al. 2000).

Correspondence: Dr Gerald Fishelberg, DDS, University of Medicine and Dentistry of New Jersey, New Jersey
Dental School, 110 Bergen Street, PO Box 1709, Newark, NJ 07103, USA (Tel.: ‡1 973 972 4690; fax:
‡1 973 972 0328; e-mail: ®shelge@umdnj.edu).

ß 2004 Blackwell Publishing Ltd International Endodontic Journal, 37, 199^204, 2004 199
Figure 1 (a) A periapical radiograph arrowed to indicate a furcal radiolucency. (b) A periapical radiograph
arrowed to indicate a vacant post space.

200 International Endodontic Journal, 37, 199^204, 2004 ß 2004 Blackwell Publishing Ltd
The case presented in this manuscript illustrates signs and symptoms associated with a
vacant post-space preparation, where new infection or reactivation of residual microorgan-
isms led to the development of a lesion. The report serves to reinforce the message that
root canals should be densely ®lled after preparation and that vacant space may lead to
clinical failure.

Report

A female patient, aged 34 years, was seen in an Endodontic of®ce for evaluation of pain and
swelling associated with a mandibular left ®rst molar. Discomfort began 10 days before,
when the tooth became uncomfortable on chewing. Tenderness progressively became
worse to touch, and the pain increased to a severe level. The patient relayed that root canal
treatment had been performed 14 months before and a crown was placed soon after the
completion of root ®lling.
A periapical radiograph revealed a furcal radiolucency (Fig. 1a) adjacent to an un®lled post
space (Fig. 1b); the apices of the tooth exhibited an intact periodontal ligament space.
Clinically, the tooth was tender to percussion and palpation in the midroot area, not the
apical area. There was no signi®cant pocketing or communication to the radiolucent area
through the sulcus.
A rubber dam was applied, and an access opening was made through the crown. No
anaesthetic had been administered. Cement was removed from the chamber with a spoon
excavator, and an empty distal post space was irrigated with 5.25% sodium hypochlorite
solution (CVS Woonsocket, RI, USA) and instrumented with Hedstrom ®les (Dentsply
Maillefer, Tulsa, OK, USA). As soon as the post space was irrigated, the patient reported the

Figure 2 A periapical radiograph arrowed to indicate the obturated post space.

ß 2004 Blackwell Publishing Ltd International Endodontic Journal, 37, 199^204, 2004 201
Figure 3 A periapical radiograph arrowed to indicate bone ®lling in the furcal area.

immediate relief of all symptoms. The canal was dried with paper points (Dentsply Tulsa,
Tulsa, OK, USA) and calcium hydroxide (Sultan, Englewood, NJ, USA) mixed with sterile
water was placed in the chamber with a plastic instrument (Union Broach, York, PA, USA),
before packing it into the post space with a Luks Plugger (Union Broach). The crown was
temporized with Cavit (ESPE America Inc., Norristown, PA, USA).
Seven days later, the post space was re-instrumented and ®lled with gutta-percha
(Dentsply Maillefer) and sealer (Roth Root Canal Cement, Roth Co., Chicago, IL, USA),
by a combination of cold lateral and warm vertical compaction (Fig. 2) with a heated no. 3
Luks plugger. IRM (Dentsply Caulk, Millford, DE, USA) was used to ®ll the chamber, and the
patient referred back to her general dentist for a new crown.
At 9-month recall (Fig. 3), the tooth was asymptomatic and there was no communication
from the sulcus into the furcation. The bone had ®lled in between the roots, and the apical
areas appeared to have remained normal (Fig. 4).

Discussion

This case demonstrates that complications may arise from an un®lled post space. Leakage
of saliva along crown margins may have resulted in accumulation or reactivation of
microorganisms in the post space. Alternatively, post-space preparation may have been
undertaken without proper isolation, allowing the pooling of saliva in the empty channel.
Although a lateral canal was not demonstrated, it is likely that seepage of irritants to the
furca resulted in the development of pathosis. Emergency treatment resulted in immediate
alleviation of clinical symptoms. The patient was advised that as coronal leakage was likely,
the entire root canal system should be re-treated, but in the absence of symptoms after the

202 International Endodontic Journal, 37, 199^204, 2004 ß 2004 Blackwell Publishing Ltd
Figure 4 A periapical radiograph arrowed to indicate normal periapical bone.

emergency visit and apparently healthy apical tissues, the patient and the referring dentist
requested that the root canal not be re-treated. After ®lling of the post space, a recom-
mendation for a new crown was made. Cement was placed in the chamber to seal the
gutta-percha from future leakage.
The interesting question that we must ask is: why did the apical regions of the tooth
remain healthy in the apparent presence of prolonged contact between microorganisms
and gutta-percha more coronally? Are current methods of assessing the leakage of root
®llings appropriate and valid (Wu & Wesselink 1993)?
The conclusions of Ricucci et al. (2000) suggest that the problem of coronal leakage may
not be of such great clinical importance as implicated by numerous in vitro studies, provided
instrumentation and root ®llings are performed carefully. The history of the case suggests
that careful treatment should include preparing post channels under conditions of asepsis
and not leaving them empty as potential reservoirs for infection.

Conclusion

A vacant post space, un®lled for a prolonged period of time, may allow the accumulation of
bacteria suf®cient in numbers to cause pathology to develop in the adjacent bone.
Post channels should be prepared under conditions of asepsis and should not be left
empty.

Acknowledgements

The exceptional technical assistance of Mr Richard Merkel and Dr Edward Millward is


gratefully acknowledged.

ß 2004 Blackwell Publishing Ltd International Endodontic Journal, 37, 199^204, 2004 203
Disclaimer

Whilst this clinical article has been subjected to Editorial review, the opinions expressed,
unless speci®cally indicated, are those of the author. The views expressed do not
necessarily represent best practice, or the view of the IEJ Editorial Board, or of its af®liated
Specialist Societies.

References

Gish SP, Drake DR, Walton RE, Wilcox L (1994) Coronal leakage: bacterial penetration through
obturated canals following post preparation. Clinical Practice 125, 1369±72.
Magura ME, Kafrawy AH, Brown CE (1991) Human saliva coronal microleakage in obturated root canals:
an in vitro study. Journal of Endodontics 17, 324±31.
Metzger Z, Abramovitz R, Abramovitz I, Tagger M (2000) Correlation between remaining length of root
canal ®llings after immediate post space preparation and coronal leakage. Journal of Endodontics
26, 724±8.
Ray HA, Trope M (1995) Periapical status of endodontically treated teeth in relation to the technical
quality of the root ®lling and the coronal restoration. International Endodontic Journal 25, 12±8.
Ricucci D, GroÈndahl K, Bergenholtz G (2000) Periapical status of root-®lled teeth exposed to the oral
environment by loss of restoration or caries. Oral Surgery, Oral Medicine and Oral Pathology 90,
354±9.
Siqueira JF, Jr, RoÃcas IN, Lopes HP, de Uzeda M (1999) Coronal leakage of two root canal sealers
containing calcium hydroxide after exposure to human saliva. Journal of Endodontics 25, 14±6.
White SN, Furuichi R, Kyomen SM (1995) Microleakage through dentin after crown cementation.
Journal of Endodontics 2, 9±12.
Wu MK, Wesselink P (1993) Endodontic leakage studies reconsidered. Part I. Methodology, application
and relevance. International Endodontic Journal 26, 37±43.

204 International Endodontic Journal, 37, 199^204, 2004 ß 2004 Blackwell Publishing Ltd

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