Endodontic treatment of the mandibular first molar

Endodontics ENDODONTIC TREATMENT OF THE MANDIBULAR FIRST MOLAR A. NOR)IAN CRANIN, D.D.S., ~ AND SAMUEL L. CRANIiN',D.D.S., ~* BROOKLYN,N. Y. ANY authors have emphasized the inestimable importance of the manTM It is the cornerstone of the dental arch; it maintains proper maxillomandibular relationships, and it preserves correct mesiodistal and inferosuperior positions of all teeth adjacent and opposed to it. Despite the fact that the value ~f the first molar is so well established, it is the most commonly lost tooth. The loss of this tooth, espeeially its early removal, leads to permanent crippling of the mastieatory apparatus (Fig. 1). This article is presented to illustrate a method of treatment of seriously involved first molars, t t is written to encourage more practitioners to undertake eases such as those presented herein. Certainly, pulp canal therapy can be a rewarding operation to both patient and doctor. Although the efforts expended on seemingly hopeless teeth are fraught with trouble, pain, and trauma, these problems seem ephemeral when the advantages of retaining the tooth become manifest. Among the criteria to be considered before undertaking such treatment are the age and health of the patient, the bone support and strategic value of the afflicted tooth, and the operability of the canals. Since all the illustrative cases included in this article had elements which caused them to be considered questionable, treatment was undertaken with patients aware of all contingencies. Conservative therapy can be effective if meticulous technique is employed. Despite the fact that root end curettage was not practical, the treatment of these teeth was completed successfully under conditions which ordinarily would have required apicoectomy.'~ Many workers have stated that the most important phase of endodontic treatment is the mechanical d6bridement and cleansing of the canals/, ~ None of the cases presented were treated with locally instilled antibiotics. The oldest one was completed four years ago; the most recent was finished five months previous to the preparation of this article.

M dibular first molar tooth.

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The clinical and diagnostic pictures which these patients presented are given in tabular form in Fig. 2 for comparison of the accompanying symptoms and signs. In each instance, the etiology is clear: carious involvement of the dental pulp. Clinical findings also had much in common. Patients suffered from malaise, elevated temperatures, marked pain, and cellulitis. Roentgenographically, there were areas of periapical rarefaction, interradicular (bifurcation) involvement, and cemental necrosis. According to Cahn, s the rarefied !

Fig. 1.

osseous areas shown in the accompanying radiographs are due to hyperemic decalcification. This is a readily reversible pathologic process which is eorrectible by the elimination of the infection source. In each instance it will be seen that prompt recalcification of the intact medullary matrix is effected.

Case Reports Case 1.--The patient, a 12-year-old, well-developed, well-nourished white boy, presented the signs and symptoms noted in Fig. 2. He had noticed a fullness of the cheek two days before, but had a t t r i b u t e d it to a blow received in a football game. On the day he was first seen, he awakened with great pain, swelling, and trismus. A f t e r a diagnosis of acute dentoalveolar abscess was made, incision and drainage in the l e f t buccal sulcus were performed under general anesthesia. The pulp chamber was opened through the occlusal surface. Penicillin, 800,000 urdts, was i n j e c t e d intramuscularly. A beeehwood creosote t r e a t m e n t was sealed into the pulp chamber. Three days of parenteral antibiotic t h e r a p y brought a remission of constitutional symptoms. F o r t y - e i g h t hours later, No. 2 K e r r files were introduced into the canals, a f t e r which formocresol dressings were inserted. Four more visits were required to complete the sterilization. Canals were gradually widened, using a p r o p r i e t a r y organic tissue solvent. Dry formocresol points were used between visits. The canals were filled w i t h silver points and silver cement (mesiobuecal and mesiolingual) and gutta-percha points and chloropercha-Mynol (distal).* Four months later~ when it was ascertained chat the result was successful, the final restoration of the tooth was completed (Fig. 3). Case 2.--This patient, an ll-year.old, well-developed, well-nourished white girl, was referred with the chief complaint of pain and swelling of the right lower mandible. E x a m i n a t i o n revealed an acute dentoalveolar abscess of the right p e r m a n e n t first molar. When the buccal gingiva was palpated, exquisite pain was elicited and some thick, foulsmelling exudate was expelled from the crevice. A f t e r the pulp chamber was opened, the p a t i e n t experienced immediate relief. Beechwood creosote and iodine were sealed into 9 *Chloropercha-Mynol is a crean~y paste mixture prepared in the authors' offices at the time of pulp canal filling. It consists of baseplate gutta-percha, chloroform, eugenol, creosote, thymol, iodoform, bismuth substrate, zinc oxide, and rosin.

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the tooth and seventy-two hours later, when therapy wa~ resumed, No. _l Kerr reamers were introduced halfway down the length of the canals. Some ddbridemeut was carried out and formocresol dressings were inserted. A t the third visit No. 2 reamers and files were introduced to the apices, and chlorinated soda was employed. Two f u r t h e r visits were devoted to enlarging the canals, which were finally filled with gutta-percha [minis and ehloropercha-Mynol. This p a t i e n t was observed for several months, and when s~eeess seemed assured the final restoration was constructed (Fig. 41). 0a,se & - - T h i s patient, an 1S-year-old student nurse, complained of pain in left molar tooth. Examination revealed ~L well-developed, well-nourished young in no acute distress, with pain caused by the mandibular left first; molar tooth. genographieally, there appeared to be two largo periapical radiolucent areas, as apical resorption.

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Fig. 5.----(~ase a.

Fig. C,..--Case 4. During the first visit, the pulp chan~ber was opened and beeehwood creosote and iodine were inserted as a dressing. Twenty-four hours later tile p a t i e n t had a soft, nontender swelling of the cheek. Temperature was normal. Penicillin, 800;000 units~ was ad ministered intranmseularly, and proper home care was prescribed. The following day the p a t i e n t complained of great pain. Her swelling had become firmer, and rectal temperature was 102 ~ F. There were many t e n d e r palpable cervical lymph nodes. She was admitted to the Nurses' Infirmary of The Mount Sinai tIospital. Meperidine, 75 rag. every four hours, was prescribed for pain. The following morning she developed severe urticaria. Penicillin therapy was discontinued, and 5{etieortcn was administered by mouth. The pulp chamber was opened and some drainage was established. Two days later tetracycline, 250 rag. four times daily, was prescribed. A f t e r four days this caused complete remission of all symptoms. Local therapy was then resumed. Four visits were spent preparing the canals, and formoeresol was used as the dressing. The canals were filled with ehloropereha-Mynol and gutta-percha points. Three months later a east crown restored the tooth to function (Fig. 5). (Ja~e 4 . - - A 14-year-old, well-developed, well-nourished schoolgirl was referred to our office with the chief comphdnt of a swollen and painfu! " g u m . " lr revealed an acute dentoalveolar abscess involving the mandibular left first molar. I t was

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caused by a mesial carious exposure of the pulp. The carious area extended subgingivally to the alveolar crest. The pulp c h a m b e r was opened and instructions were given for home care u n t i l the local symptoms h a d abated. The caries were t h e n removed, the mesial gingival tissues were cauterized, and a copper b a n d was fitted and cemented. Creosote a n d iodine was t h e n sealed into the pulp chamber. The second t r e a t m e n t consisted of partial reaming of the canals with No. 1 Kerr reamers. Formoeresol dressings were used. A t the time of the t h i r d visit, 1%o. 2 K e r r reamers and files were used w i t h chlorinated soda. F o r t y - e i g h t hours later, the p a t i e n t presented a recurrence of pain and swelling. She h a d an oral t e m p e r a t u r e of 100.80 F. Aqueous penicillin, 600,000 units, was given i n t r a m u s c u l a r l y and home care was outlined f o r her. W h e n the tooth was opened, p u r u l e n t d r a i n a g e was noted. The canals could not be dried, even by repeated placement of a b s o r b e n t points. Formocresol was sealed into the canals. F o r t y - e i g h t hours later, when the seal was removed, the exudative phenomenon was much diminished. F e v e r and local symptoms had abated. Three more visits were required for e n l a r g e m e n t of the canals a n d sterilization. The canals were filled w i t h chloropercha-MynoI and g u t t a - p e r c h a points. F o u r months l a t e r the copper b a n d was removed and a cast crown was constructed to complete the r e s t o r a t i o n (Fig. 6).

Summary Four cases of acute dentoalveolar abscess of the mandibular first molar tooth in youthful patients are presented. A chart of pertinent symptoms (Fig. 2) is included to facilitate an overall case evaluation. Each case presented was considered to have a hopeless or questionable prognosis at the time of treatment. Results, both clinical and roentgenographic, appear to be satisfactory. The oldest case is now four years old. Conservative therapy may be recommended in such cases. Mechanical d~bridement, rather than chemotherapy, is to be stressed for successful results.

Conclusions Despite questionable prognoses in severely abscessed mandibular first molars, root canal therapy may be employed successfully in their treatment. Apical necrosis, periapical rarefaction, interradicular osteolysis, and hyperemic decalcification need not discourage the conscientious operator. Remincralization can be encouraged by following the tenets of sound endodontic procedure.

References 1. Eichenbaum, I. W., and Dunn, N . A . : Pulp M a n a g e m e n t in the Mixed Dentition, J. Am. Dent. A. 47: 511~ 1953. 2. McCoy, J . D . : Applied Orthodontics, ed. 4, Philadelphia, 1935, Lea & Febiger, pp. 27-28. 3. Strung, R. H . W . : A Textbook of Orthodontia~ ed. 3, Philadelphia, 1950, Lea & Febiger, p. 34. 4. Hemley, S.: F u n d a m e n t a l s of Occlusion, Philadelphia, 1944, W. B. Saunders Company, pp. 87, 152, 200, 258. 5. Luks, S.: Root Canal Therapy, J. Am. Dent. A. 41: 184, 1950. 6. Grossman, L. I.: P o l y a n t i b i o t i c T r e a t m e n t of Pulpless Teeth, J. Am. Dent. A. 43: 277, 1951. 7. Stewart, G. G.: Chemomechanical P r e p a r a t i o n of Root Canals, ORAL Svr~., ORAL MEn., AND ORAL PATH. 8: 993, 1955. 8. Cahn, L.: P a t h o l o g y of the Oral Cavity, Baltimore, 1941, Williams & Wilkins Company; personal communication. 2120 OCEA~ AVE.