An Interesting Case with Isolated Extreme Bone Loss

One of my senior citizen patients came into my office recently with some interesting developments. He has been a patient for 6 years and has had a lot of dental work including crowns, root canals and dental implants.
 
He was complaining of soreness on his lower left side on his first molar. The second molar had a root canal and crown done several years ago and looks healthy in every respect. The first molar had developed a bone defect that goes 80% of the way down the root on the distal (away from the midline toward the back of the mouth), where there was no sign at all on the x-ray that is only 1 year old. My fear is that there is a fracture on the root and the tooth may not be restorable.

Analysis and Treatment

First I referred him to my oral surgeon to do a CT scan and see if there is a fracture on the tooth. Nothing showed up on that.
 
He had another issue on another tooth that required root canal treatment. At the root canal specialist, this tooth was also inspected and checked out vital (alive). His recommended treatment is to have a surgical scaling done in the area. This requires that the periodontal surgeon will flap the gum tissue back and expose the defect. This provides great visibility and access in the deep area to thoroughly clean out the defect an performed localized scaling and root planing. Without the flap surgery there is a fear that plaque and calculus (calcified tartar) may be left behind impeding the desired healing.
 
Even though nothing was noticed on the CT scan, there is still a chance of a root fracture that could not be picked up. It is possible that a root fracture can be seen during the flapping procedure and that would change the prognosis of this tooth to hopeless.
 
If the discomfort and bone loss does not resolve, the tooth would be indicated for an extraction and an implant. This patient would really like to save this tooth, and I don’t blame him.