A 72-year-old male presented for a comprehensive exam with a chief complaint that the tooth on the upper right side had had a root canal done twice, but he was still in pain. He was wondering if there was a possible sinus infection. Health history included a pacemaker, Warfarin, and thyroid cancer.
Testing of the upper right side was, for the most part, inconclusive, aside from some 6 mm pockets in the upper right quadrant. Radiograph was WNL . A potential sinus infection was discussed, along with the possibility of a periodontal abscess. The patient was placed on antibiotics, referred to an ENT, and had scaling and root planing done on the upper right quadrant.
The report from the ENT was negative. The symptoms persisted and, in fact, started to worsen. The likelihood of a vertical root fracture was then discussed with the patient. He was referred to an endodontist who took a CBCT scan.
Evaluation by the endodontist showed a very small direct, vertical 9 mm drop on the lingual with radiolucency on the lingual root in the scan about halfway down . Given the history of the double root canal, symptoms, and radiographic evidence, it was concluded that the patient had sustained a vertical root fracture on the lingual root of tooth No. 4. Prognosis was poor, and the tooth was removed with discussion regarding replacement options.
This case is a classic example of how elusive diagnosing these types of teeth can be and how critical a comprehensive assessment is to produce the most accurate diagnosis.