When a definitive diagnosis needs more than a radiograph

By Dr Margot Anderson

Can you make a definitive diagnosis purely on radiographic appearance? Dr Margot Anderson looks at how a more thorough investigation of a suspected fracture helped retain a patient’s tooth

A 69-year-old lady, Mrs K, sought my opinion regarding a symptomatic tooth 46. She had lost a number of molar teeth over the years through fracture, and was very keen to retain the 46, but had been advised by two GPs that the prognosis for this tooth was also hopeless as it was fractured. Mrs K gave a history of mild tenderness to bite sporadically for some months, or maybe even years. She was now aware of a fluctuant swelling on the buccal gingiva.

Clinically, the tooth was tender to percussion: there was 3-4mm periodontal probing circumferentially but no obvious isolated defects. The tooth was non-responsive to cold pulp testing. The appearance of the radiolucency as a “teardrop” – extending the length of the mesial root into the furcation – also made me immediately suspicious of a vertical root fracture. My suspicions were heightened by Mrs K’s history of loss of other teeth through fracture.

Here it is important to note that the diagnosis of an undisplaced vertical root fracture cannot be made on radiographic appearance alone.

After a discussion of the treatment options, Mrs K consented to treatment and a conservative access was made through the existing gold crown. There was no sign of a fracture intraoperatively, and treatment was completed after a dressing of calcium hydroxide. When Mrs K returned, the swelling had resolved, she was comfortable and the canals were clean and dry.

At a six-month review, Mrs K was asymptomatic and excellent radiographic healing had occurred. Needless to say, she was relieved and happy to retain the tooth.