Monday, September 26, 2016
Thursday, June 16, 2016
Monday, April 11, 2016
|CBCT by J. Morita Veraviewepocs 3De|
The following cases demonstrate the usefulness of CBCT in identifying odontogenic sources of chronic sinusitis. Several radiographic findings are pointed out which help identify odontogenic sources for chronic sinusitis. These common findings seen with high resolution CT imaging include:
- Perforation of the floor of the Mx sinus
- "Halo effect" elevation of the floor of the Mx sinus
- Thickening of sinus membrane adjacent to odontogenic infection
- Air bubbles in the sinus suggested of an acute sinusitis
- Missed (untreated) canals in a previously treated root canal
- Short filled canals in a previously treated root canal
- Iatrogenic damage in a previously treated root canal
Proper endodontic treatment of the dental infection is the first step in addressing the chronic sinusitis of odontogenic origen. If sinus symptoms persist, following endodontic treatment, then referral to ENT is recommended.
Monday, March 28, 2016
"Is this tooth bothering my sinuses?" For years patients with chronic sinus issues have asked this question at the dental office. Unfortunately, there has been a communications gap between diagnostic medicine and dentistry in this overlapping area of practice. Endodontists are experts diagnosing pulpal disease, but not trained in diagnosis of sinusitis. Most otolarygologists (ENT) physicians, and especially rhinologists, are experts in sinus diagnosis, but not trained in evaluating dental and pulpal infection, which may be a source of infection for the sinuses. Most sinus CTs are not including the teeth and rarely are medical radiologists evaluating the teeth in their reads.
In cooperation with Dr. Tim Haegen of the Arizona Sinus Center, a division of Valley ENT, we have been able to help patients with chronic sinus issues. Many of these patients have bounced from ENT to ENT looking for answers, some have had continuous courses of antibiotics and some have had sinus surgery, only to continue to have chronic sinus issues. With some interdisciplinary education between endodontics and otolaryngology, familiarization with each other's diagnostics and terminology and the use of medical and dental CT imaging, we are working together to diagnose and treat the often time overlooked odontogenic sources of sinusitis. The use of 3D imaging between disciplines has helped to bridge the gap of communication between medical and dental specialists trying to help patients with sinusitis and dental infections.
The following case demonstrates how proper understanding of endodontic and ENT imaging, diagnostics and terminology facilitate proper diagnosis and treatment.
This patient presented to Arizona Sinus Center for evaluation of chronic sinus issues. She presented with chronic, unilateral nasal and facial symptoms, along with foul smelling nasal discharge. Nasal endoscopy was performed and findings include:
- Nasal septum - superior deviation to right, mucosa intact, no perforation or crust
- Right inferior turbinate - normal
- Right middle turbinate - edematous
- Right middle meatus - closed; edematous medialized uncinate. Tissue is pulsatile. No purulence or polyps.
- Right posterior choanae - normal
- Left inferior turbinate - normal
- Left middle turbinate - normal
- Left middle meatus - open, no mucopus or polyps
- Left posterior choanae - normal
- Nasopharynx - no masses
|Complete opacification of the right frontal sinus.|
|Partial opacification of the R ethmoid sinuses.|
|Complete opacification of R maxilliary sinus, superior septal deviation to the right, bilateral opacified concha bullosas.|
- Nasal Obstruction
- Deviated nasal septum
- Frontal sinusitis, chronic
- Maxillary sinusitis, chronic
- Ethmoidal sinusitis, chronic
- Dental caries, unspecified
- Disturbances of sensation of smell and taste
With these radiographic findings and clinical impressions, the patient was then referred to Superstition Springs Endodontics for evaluation and definitive treatment of the maxillary molars #2 and #3. Due to the complete opacification of multiple sinuses along with bony erosion of the medial orbital wall, the possibility of endoscopic sinus surgery was discussed. Discussion included risks of failure to treat the infection within the sinuses as well as failure to remove the source of the infection, which in this case has to include the dental source of infection.
|Pt presents for endodontic evaluation of #2 and #3 following ENT identification of possible dental abscess adjacent to Mx sinus.|
|Endodontic retreatment with microscope locates the previously missed MB#2 canal.|
|MB#2 canal is debrided and irrigated with NaOCl.|
|PostOp radiograph shows all 4 canals have been properly treated.|
|PeriApical RadioLucency (PARL) seen at apex of MB root - which had a missed canal on initial treatment.|
|6 month recall following endodontic retreatment shows healing of the PARL.|
After 6 months, extraction of tooth #2 and retreatment of tooth #3 has shown periapical healing. The potential odontogenic source of the sinus infection has been eliminated. Since the Mx sinus continues to show opacification, the patient is referred back to Dr. Haegen for continued sinus evaluation and treatment.
Why See An Endodontist?
|Dental Operating Microscope used by endodontists|
A common reason for root canal failure on Mx molars is inadequte cleaning, and often completely missing the MB#2 canal. Endodontists using an operating microscope are able to find and treat the MB#2 (4th canal) more effectively and efficiently. Endodontist are also trained to perform endodontic microsurgery when traditional endodontic therapy is unsuccessful.
When endodontists and otolaryngologists work together, they can provide the best care for patients with odontogenic sinusitis.
Wednesday, March 16, 2016
This patient came to Superstition Springs Endodontics in June 2009. Her general dentist had started RCT on #3 but was unable to locate the MB canal(s). A perforation was made during the efforts to find the MB canals. We have taught the generalists in our community that the most successful and fulfilling way to practice endodontics depends upon careful case selection. Proper case evaluation can:
- prevent lost chair time without reimbursement
- prevent loss in patient confidence
- prevent clinician frustration
The Endodontic Case Assessment Form from the AAE, can help clinicians determine the difficulty level of treatment - before therapy is started. This is how this case should have been classified - prior to starting treatment.
The treatment for this tooth was RCT completion and repair of the iatrogenic damage using Mineral Trioxide Aggregate (MTA).
Fortunately, with good repair materials, the prognosis for a tooth like this is still good. A 7 year recall finds the tooth in full function and asymptomatic.
However, proper case selection will make your practice of endodontics more fulfilling, less stressful and ultimately, more successful.
Monday, February 1, 2016
Tuesday, January 5, 2016
Endodontic surgery on maxillary molars is usually limited to the MB and DB roots - through a buccal approach. Surgical treatment of the palatal root often requires a palatal surgical approach, and is therefore rarely done. In this particular surgical case, due to the root anatomy and size of the periapical lesion and osteotomy, all three roots were accessed through a buccal surgical approach.
Wednesday, December 2, 2015
Thursday, September 10, 2015
With the advancement of pulpal regenerative therapies, we have come to appreciate and respect the healing capacity of the pulp. While MTA and new bioceramic materials are allowing us to create better coronal seals, we now have new treatment options to replace the traditional apexification and apexigenesis procedures. While pulpal regenerative procedures were first applied to necrotic immature teeth, usually affected by trauma, this has led to the development of new vital pulp therapies on carious, immature teeth.
Caries removed, pulp chamber cleaned out, MTA placed against the amputated pulp tissue, with resin restoration.
The following case demonstrates a MTA pulpotomy on a vital, healthy pulp with carious exposure.
This 8 yr old presented in 2012 with deep caries on an immature #19. The pulp tested vital, but his dentist expected pulpal exposure. He was also reporting night time pain, which typically is associated with irreversible pulpitis.
9 month re-eval finds the tooth a symptomatic and functional. Apices continue to develop normally.
2 year recall reveals a symptomatic tooth with full function. Roots have continued to develop to normal length and thickness. Coronal protection recommended.
3 year recall finds tooth a symptomatic and functional. Root development is complete and appears normal.
While previous apexigenesis procedure have been used to keep the pulp alive in order to complete root development, these new materials seem to give a better prognosis and are an exciting advance in the development of vital pulp therapies.
Tuesday, June 16, 2015
Now you are probably wondering what that title means? As we all know, posterior teeth often get craze lines (surface cracks) in the enamel due to truama, large restorations, heavy occlusion or parafunctional habits. When these craze lines go past the enamel and into the dentin, we refer to them as cracks. Coronal cracks are very common in adult teeth. Seeing a coronal crack in a tooth should prompt you to question the occlusal forces, parafunctional habits, size the existing restoration, the vitality of the tooth and then the need for coronal coverage.
This patient came to our office in early 2010. She was reporting throbbing pain to temperature that had been bothering her for a couple of weeks. She also reporting biting pain. Diagnostics found #3 was normal to cold test, normal to probing, mild pain to percussion, pain to biting pressure. DX; #3 reversible pulpitis with symptomatic apical periodontitis and cracked tooth syndrome. We decided to treat endodontically before a crown would be placed.
Upon accessing the pulp, we found a stained crack on the mesial and smaller crack on the distal. Pt was informed that these cracks would not be completely removed, and would affect the long term prognosis for the tooth. The patient, understanding that the prognosis is guarded, elected to preserve the tooth as long as possible by completing the RCT and placing a crown.
RCT was completed and returned to GP for coronal coverage.
5 year recall of the tooth finds it fully functional and asymptomatic. Note the fine margins of the crown which play a key role in the success of this treatment. Some patients will elect to retain a natural tooth with a crack, understanding the guarded long term prognosis, rather than extract and replace it immediately.