Endodontics · patient case question
What is the most appropriate management of tooth #30?
Patient case: An old root filling and a sharp cusp
Patient: Two patients
Chief Complaint: Patient A: “This tooth is tender and there is a bad taste.” Patient B: “I have had a sore on my tongue for two weeks.”
Background: Patient A, 48 years old: tooth #30 was root treated twenty-two years ago and obturated with SILVER POINTS. Patient B, 57 years old: the distolingual cusp of #32 fractured a fortnight ago and has not been treated.
Findings: Patient A: a periapical radiolucency at both roots of #30, a sinus tract on the buccal, tenderness to percussion, and a defective coronal restoration. The canals appear negotiable coronal to the points. Patient B: a sharp fractured cusp edge, and an ulcer with a slightly rolled margin on the lateral border of the tongue lying directly against it.
Show answer and explanation
Correct answer: A. Non-surgical retreatment — remove the silver points and obturate with gutta-percha
- A. CORRECT. The governing rule is that ORTHOGRADE (non-surgical) retreatment precedes any surgical approach whenever the canal can be renegotiated. Silver points seal poorly for a structural reason — they are round and canals are not, so the seal depends on a cement that washes out over time — and they CORRODE in the presence of tissue fluid, releasing cytotoxic silver corrosion products. The periapical lesion here reflects persistent intracanal infection, and that infection can only be eliminated from inside the canal. Remove the points, clean and shape thoroughly, disinfect, obturate with gutta-percha and sealer, and re-establish a proper coronal seal.
- B. Apicoectomy is reserved for cases where orthograde retreatment has FAILED or is genuinely impossible — a non-negotiable canal, a separated instrument that cannot be bypassed, an obstructive post that cannot be safely removed, or a lesion persisting after adequate retreatment. Raising a flap while leaving infected canal contents in place treats the symptom and leaves the cause. The recall makes exactly this point: retreat with gutta-percha first, and only then consider apicectomy.
- C. A symptomatic tooth with a sinus tract and an expanding periapical lesion requires treatment, not observation.
- D. The tooth is restorable and has not yet had appropriate treatment. Extraction is premature and replaces a treatable tooth with a more expensive problem.
Note: Technique: expose the coronal end of the point and grasp it with Steiglitz forceps or engage it with an ultrasonic tip; a Masserann kit or a Cancellier extractor is used when the point is fully embedded. Handle carefully — corroded silver points are brittle and fracture readily. Both gutta-percha and silver points can achieve high clinical success, so the presence of silver points ALONE, in an asymptomatic tooth with no periapical lesion and a sound coronal seal, is not by itself an indication to retreat.