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Case Conference: Endodontic Management of a Mandibular Second Molar

This case is submitted by Dr. Jacqueline Lopez Gross, from the University of Toronto

The case resolution follows the the case conference questions.

Case Presentation

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Case Resolution



  1. I would also like to see the opposing tooth (if any) or its condition to see the occlusion.
    There is bone loss on the m and D. of 37
    I would question if the cost is worth the benefit of doing an endo, post and crown on a second molar on a fifty year old male with perio issues.
    Longevity or prognosis of the 36 will be better with 37 extracted due to elimination of perio problems.
    There was no discussion of the condition or missing teeth of the whole mouth.
    Great presentation of exam, diagnosis and treatment but a narrow focus on one tooth only.
    As you will discover, in private practice cost is a large factor on treatment.

    • Jacqueline Lopez Gross

      Hi Noah, Thank you for your comment. We considered the periodontal status, however the patient did not present any clinical signs of periodontal disease and he was undergoing active orthodontic treatment. Even though the patient was in his 50’s, having ortho treatment shows how motivated was he about his teeth.

      Unfortunately I don’t have fast access to a bitewing, but the opposing tooth was present. Extraction of 37 was discussed as an option and I should have elaborate more about it during my presentation.


  2. Third root was not visible at any angulation but lateral canal could be seen on mesial root, mid mesial can be present if working with microscope can be seen then.
    Nsrct is the first step and see if pt is asymtomatic and most important is to rule out a crack as pt presented with pain in biting too. Cbct could be used to asses vertical fracture.

    • Jacqueline Lopez Gross

      The third root was identified due to the radiopaque area and PDL between distal and medial roots. CBCT confirmed the variation in the anatomy. Indeed, a 2D periapical radiograph has several limitations. Thank you for your comment!

  3. Very informative, thank you!

  4. Dr. Sheryl P. Lipton

    Hey Noah:
    Thank you for your comments and for noticing the bone loss around tooth 37.
    I totally agree with you that looking at the “big picture” is important, however when a patient shows up at your office in severe pain, it is incumbent upon the practitioner to alleviate the pain that day–in this case either with extraction or endodontic therapy (pulpectomy or more at the emergency appointment). Perhaps a pulpectomy at the emergency appointment and then a full examination at the subsequent appointment.
    I assume that you are a younger practitioner. One day you will realize that a 50 year old still has many years to live with average life spans extending beyond 80 years. Yes, there is bone loss on the radiograph. But from one radiograph at one point in time, you do not know if the bone loss is progressing or if it is stable and been at this same level for many years. You state that “extraction of 37 will eliminate the perio problems”. Of course extraction removes the perio problem, but it also removes the tooth. Why not recommend perio treatment before extraction, or at least give the patient the option?
    (The mobility of the tooth was not discussed by the presenter, nor were the pockets).
    I can tell you that I have more bone loss in my mouth than the tooth presented in this case presentation and would be very unhappy to extract that tooth if it was mine. Oftentimes, teeth with a large amount of bone loss will show minimal mobility and you will see this as your career continues. Some of your patients will choose to ignore your recommendations to extract a tooth and you may see 20 years down the road that a tooth that you condemned is still functioning and, in fact, may never be lost. In this case, rather than extraction, periodontal therapy might be suggested in conjunction with endodontic therapy and the patient should and must be presented with all options. Would you seriously extract that 37 if it was your tooth? Patients often make their decisions based on our “preferences” when presenting treatment options. I stick with the “do unto others” principle.

    • Jacqueline Lopez Gross

      Thank you Sheryl for your comment. I briefly mentioned that periodontal pockets were not present and that the teeth were stable. I should have elaborate more about it certainly!

      I agree with you, even though extraction was discussed with the patient as a treatment option, I would not recommend it in this situation and his age was never an issue: 50 years old healthy patient, with ortho treatment, motivated and compliant.

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