This is an example of palatal root surgery.
Tooth #14 was retreated 1 month prior to this film. Regretfully, I lost apical control of my obturation on the palatal root and this tooth was symptomatic (biting tenderness).
Pre-op
MTA in MB1, MB2, isthmus, and DB
MTA in the palatal root
Post-op
5 days post-op at suture removal
18 months follow-op
Trigeminal neuralgia (TN), also called tic douloureux, is a chronic pain condition that affects the trigeminal nerve. The disorder causes extreme, sporadic, sudden burning or shock-like face pain that lasts anywhere from a few seconds to as long as 2 minutes per episode. These attacks can occur in quick succession. The intensity of pain can be physically and mentally incapacitating.
The presumed cause of TN is a blood vessel pressing on the trigeminal nerve as it exits the brainstem. This compression causes the wearing away of the myelin sheath. TN may be part of the normal aging process or can also occur in people with multiple sclerosis, or may be caused by damage to the myelin sheath by compression from a tumor.
TN is characterized by a sudden, severe, electric shock-like, stabbing pain that is typically felt on one side of the jaw or cheek. The attacks of pain, which generally last several seconds, come and go throughout the day. These episodes can last for days, weeks, or months at a time and then disappear for months or years.
The intense flashes of pain can be triggered by vibration or contact with the cheek (such as when shaving, washing the face, or applying makeup), brushing teeth, eating, drinking, talking, or being exposed to the wind. The pain may affect a small area of the face or may spread. The bouts of pain rarely occur at night, when the patient is sleeping.
The attacks often worsen over time, with fewer and shorter pain-free periods before they recur.
TN occurs most often in people over age 50, but it can occur at any age. The disorder is more common in women than in men.
There is no single test to diagnose TN. Diagnosis is generally based on the patient’s medical history and description of symptoms, a physical exam, and a thorough neurological examination by a physician.
(Source: www.nih.gov)
For a dentist, it is imperative to recognize symptoms and make an appropriate referral to a neurologist.
CASE
58 year old healthy white female was referred for an evaluation of pain in the maxillary right area. She reported spontaneous pulsating, stabbing like pain lasting for seconds to minutes in the area of tooth #3 occurring several times a day. This pain was also brought on by brushing her teeth around tooth #3, during eating and occasionally when washing her face.
Pre-op
Previous root canal on tooth #3 was done years ago. Clinically, tooth #3 tested WNL to percussion and palpation, and no response to cold. Perio probings no more than 4mm. Radiographically, normal periapical areas, untreated DB and possibly MB2 canals.
Post-op
Endodontic retreatment was completed, DB and MB2 were located and treated as well.
This lady was happy for exactly one week (no pain at all).
She came back two weeks later reporting “electric shock” like sensations, and feeling worse: pain was more severe and more often. A neuralgia was then suspected.
This patient was diagnosed with Trigeminal Neuralgia and placed on Trileptal (form of Tegretol) 300 mg BID by her neurologist after which her symptoms went away.
79 years old petite indian woman was referred for an evaluation of tooth #19. Her medical history included a hypertension and type II diabetes controlled by medications. She reported no pain, occasional bad taste and discomfort when eating. Clinical examination revealed periodontal probings right to the apex of a distal root of #19, and 4mm or less around the mesial root.
Pre-op
Treatment options:
1. Extraction and tooth replacement
2. Root canal treatment and distal root amputation.
Post-op
After root canal treatment was completed on the mesial root, dual cure core resin was placed into the distal root and a root amputation was completed.
When considering a root amputation, one must evaluate the face type, the musculature (how strong are the masseters, angle of the jaw, etc.), occlusion. This procedure may not work for a 30 y/o with bradycephalic face, however in older individual with weaker muscles of mastication, it can last a lifetime.
