Lichen Planus - A Review

Lichen planus is a fairly common condition that affects the oral mucosa. This idiopathic condition is believed to be an immunologically mediated.

The name likely comes from the appearance of the lesion which resembles that of a lichen. A lichen is a symbiotic organism composed of an algae and fungi.

There are medications that may induce a reaction in the oral mucosa that appears like the idiopathic form of lichen planus. The medication induced form of the this condition is referred to as "lichenoid mucositis" or "lichenoid dermatitis".

Lichen planus can cause skin lesions as well as oral lesions. Skin lesions are usually purple, pruritic, polygonal papules. Skin papules may exhibit Wickham's straie (lacelike network of white lines).

Oral lesions may be reticular or erosive.

Reticular lichen planus is most common. It usually causes no symptoms. Wickham's straie are seen throughout. The lesions may "wax and wane" over time. It is commonly seen in the buccal mucosa, but also seen in the tongue, gingiva, palate and vermillion border.

Appearance of reticular lichen planus in oral mucosa.

Erosive lichen planus is more symptomatic. It appears as atrophic, erythematous areas with ulceration. White straie are also seen in the periphery of the lesions.

Diagnosis can usually be made on clinical findings alone.

No treatment is usually recommended for reticular lichen planus. Antifungal therapy can be helpful if a candidiasis infection occurs.

Erosive lichen planus is usually treated symptomatically with topical corticosteroids and frequent follow up care.

The malignant potential of lichen planus has not been resolved. If the possibility for malignant transformation exists, it appears to be small and associated with erosive lichen planus.

Interlacing white lines, known as Wickham's straie are the characteristic feature of lichen planus.

(Source: Neville, Damm, Allen, Bouquot. Oral & Maxillofacial Pathology, 680-685, 2002.)

Saving the Natural Tooth with Intentional Reimplantation

Intentional reimplantation is the intentional removal (extraction) and reimplantation of a tooth. This technique can be useful for teeth that cannot be treated with traditional endodontic surgery. This strategy can be particularly helpful in lower second molars where proximity to the mandibular nerve and thickness of the buccal bone make endodontic surgery difficult.


This patient presented for treatment of tooth #18. It had previous endodontic treatment 15 years earlier. The patient presented with some intraoral swelling and intermittent pain that was worsened with pressure and biting. Class II mobility and deep buccal probing were found along with the obvious periapical radiolucency and apical resorption. The tooth was diagnosed as: Prior RCT with chronic apical abscess. The large access cavity weakening the mesial tooth surface was noted and discussed as well as the possibility of a root fracture.

Treatment options discussed included:
1. Retreatment and look for fracture
2. Apicoectomy and look for fracture
3. Intentional reimplantation and look for fracture
4. Extraction

Due to the conical root structure, closeness to the mandibular canal, and probable root fracture, we decided to perform and intentional reimplantation.
Tooth was removed atraumatically and no root fractures were found.

Immediate root resection, retropreparation and retrofill with MTA was performed.
Patient was given PenVK 500mg for 5 days.
Patient was informed of the guarded prognosis following this procedure. Long term follow up will be required to determine the success.

6 year recall of the patient finds the tooth completely functional and asymptomatic. While there are many who would not have considered saving this tooth, the intentional reimplantation procedure has saved this patient thousands of dollars and allowed him to retain his natural tooth.

Strengthening the future of endodontics

In the May 2009 issue of the Journal of Endodontics (JOE) two very important topics have been addressed that are shedding light on what the future of endodontists may look like.
One of the articles is : Update on Imbalanced Distribution of Endodontists: 1995-2006, by H. Barry Waldman and George A. Bruder.
The other, is the letter from AAE president Dr. Louis Rossman addressing the issue of ”Super generalist”.
Before I get into the importance of these two articles, let me point out some very important facts that have changed the economics of dentistry in the USA.
A) In the past 40 years the caries rate has dramatically gone down which has resulted in less number of patients requiring dental treatment due to less number of carious teeth.
B) At the same time, more dentists are practicing longer and opting for delayed retirement.

C) Today’s ratio of dentists to population is 58 per 100,000 which is very high compared to golden age of dentistry in 1960-70s, when this ratio was 49 per 100,000.

D) Today there is an oversupply of dentists in the USA. The areas where there is a shortage, namely the rural areas and the inner-cities, have been chronically underserved, and less than 5 % of graduating dental students have shown an interest practicing in these areas, over the years.( Refer to many articles published in the Journal of Dental Education). [Unfortunately ADA has not taken a strong leadership position on this issue, and I do not see any foreseeable action on their part regarding the oversupply of dentists in the USA. The article “Future of Dentistry” published in the JADA Vol.133,Sep 2002 , 1226-1235, calls this oversupply problem, “maldistribution of dentists.” The problem here is that no entity can make these dentist move from supersaturated metro areas to rural and inner-city area where there is a shortage thus oversupply of dentist in USA will not go away for years to come. ]

E) The student loan debt for an average graduating dental student has tripled in the past 15 years, to $ 180,000. ( 2006 statistics)

F) Dental insurance companies are taking advantage of these oversupply trends, by reducing reimbursement rates per procedure, further eroding the profits for dentists.

G) Three new dental schools have opened in the past 3 years, one in California, and two in Arizona, adding to the number of dentist coming into the marketplace.

As a result of the above, there has been a significant and growing economic pressure on the general dentistry market over the past 20 years causing erosion of profits and decrease in “busyness”, which will continue for years to come.

Which brings me back to the two articles in May 2009 issue of JOE.
Based on the above facts, it is obvious why we are seeing more and more “Super generalists”. The general dentists are under pressure to keep whatever comes in, in-house, and are tempted to do procedures they are not well trained for, to make money and pay their office overhead, student loans and make some profit.

That is why we are seeing an explosion of “retreat-odontics” by endodontists, re-treatment of failed implants by periodontists, re-dos of botched full mouth reconstruction by prosthodontist and more lawsuits and state dental board actions, all emanating from the “hungry general dentist syndrome.”
With all this happening on the general dentistry side, it is obvious that all specialists, including endodontists are negatively impacted. Less referrals are made to us, and when the referral is made, it is a retreatment of a case that is already problematic, or maybe beyond help, requiring extraction.
(This explains why some endodontists are getting into implant therapy.)

The other article by Waldman and Bruder, highlights the problem that we endodontists need to address or face financial and clinical extinction in the next 10 years.
A 48.5% increase in the number of endodontist in the USA from 1995-2006 is recipe for disaster, considering the facts discussed above, along with the emerging “super-generalist” phenomenon.

In my opinion these should be some of the steps, we as endodontists must take to correct this emerging threat:


1) Reduce the number of endodontic residency positions immediately.
( This step was taken by the dermatology residency programs in early 1990s. As a result of that bold move more than a decade ago, today dermatologists are prospering and there is no oversupply of them nationwide.) Some chairpersons can do this now without any pressure from dental school deans or administration, and they need to act now.
The others who are under pressure not to do this, can raise the money that the dental school will lose from reducing the number of residents, from their past endodontic alumni.
2) Accept residents with a minimum of 5 years general dentistry practice experience after graduation from dental school. (Today’s cases referred to an endodontist, are very complex and require a good knowledge of endo, perio and restorative treatment.)

3) Make teaching at a dental school for 12 days a year (which could be once a month per year, or 12 days in a row or any other combination of days, as long as it is 12 days a year) a mandatory requirement for Diplomate status re-certification. This will address the endodontist shortage in the faculty at dental schools and increase exposure of the undergraduate students to endodontists. Endodontics should not be taught by general dentists to undergrad students.

4) Get involved in teaching the general dentists, by discussing cases they should, and cases they should not do.

Action is needed and is needed urgently. Otherwise one day we will look back and will be forced to admit that “We have met the enemy and he is us.”

I welcome your comments,
Robert Salehrabi, DDS

Loss of Tooth Structure - by Mark Montana DDS

This week's Inner Space Seminar, sponsored by Superstition Springs Endodontics, was presented by Dr. Mark Montana. Dr. Montana is a highly recognized prosthodontist practicing out of Tempe, AZ.

Dr. Montana's presentation reviewed the many causes of loss of tooth structure including: attrition, abrasion, ablation, abfraction, caries & erosion. Recognition of the etiology is paramount to proper treatment planning and long term success.

In the following video excerpt, Dr. Montana discusses the multifactorial etiology that is commonly associated with the loss of tooth structure.




Dr. Montana talked about bruxism and how that diagnosis is often misused as a "catch all" to describe loss of tooth structure. The following video excerpt is a case presentation of a patient with severe bruxism.



The following additional excerpts are available:

Attrition

Corrosion/Erosion

Mark S. Montana DDS

2147 E. Southern Ave.

Tempe, AZ 85282

480 820-2901

Resorption of Calcium Hydroxide Paste

Calcium Hydroxide is widely used in endodontics for a number of purposes. Its antimicrobial properties are attributed to its high pH (basic), destructive effects on bacterial cell walls and ability to dissolve organic tissue. It is used routinely as an intracanal medicament. It is also used for apexification, apexigenesis, treatment of root resorption.

Ca(OH)2 used in endodontics is made with Ca(OH)2 powder, a vehicle and a radiopacifier. Most common radiopacifiers are barium sulfate, bismuth or compounds containing iodine or bromine. While radiopacifiers make the calcium hydroxide more visible radiographically, some radiopacifiers are known to resorb at a slower pace, sometimes making it difficult to see the subtle changes.

While the control of a paste material at the apex of a canal can be very difficult, the resorptive properties of calcium hydroxide make it a very forgiving material. Extrusion of calcium hydroxide past the apex of a tooth is not uncommon. In fact, there are some who would recommend deliberate extrusion in the case of a large, chronic periapical lesion to help in the healing of such a lesion.



Calcium hydroxide (Ultracal - Ultradent - 35% Ca(OH)2 with barium sulfate) was used during treatment of this tooth to control exudate prior to obturation. A significant amount was extruded past the apex in close approximation to the maxillary sinuses during the endodontic treatment.




14 months later, the patient returned for treatment of #14. Our recall radiograph of #15 shows complete resorption of Ca(OH)2. The patient had no complaints and is in full function.



Sources:

Hasan Orucoglu, Funda Kont Cobankara, "Effect of Unintentionally Extruded Calcium Hydroxide Paste Including Barium Sulfate as a Radiopaquing Agent in Treatment of Teeth with Periapical Lesions: Report of a Case", Journal of Endodontics, July 2008 (Vol. 34, Issue 7, Pages 888-891)

The Evolution of Implant Success

The 7th Annual Spring into Dentistry seminar was held on March 6th, 2009 in Mesa, AZ. The guest lecturer was Dr. Robert London of Seattle, Washington. Dr. London is currently a clinical professor and director of graduate periodontics at the University of Washington. Prior to his work at UW, Dr. London was director of graduate periodontics at NOVA Southeastern and at University of Southern California.
Dr. London's presentation was entitled, "Enhancing Dental Outcomes".

While a good portion of his presentation had to do with implant treatment planning and preparation of implant sites, he made some comments that I found fascinating.

He used an analogy of a pendulum to describe the acceptance of dental implants into mainstream dentistry. Early on, there was some resistance to accepting them into everyday practice. Like the swinging of a pendulum, treatment with dental implants then became the solution to every situation. Now that the pendulum has swung to both extremes, we are now hopefully settling somewhere in the middle.

He also discussed the changing definition of success with implants. Early on, successful implant therapy meant osseointegration. If the implant was not loose, it was considered a success. In endodontics, success has always been defined very strictly as the complete resolution of signs and symptoms and complete healing of bone. With two such different definitions of success, it is no wonder that there has been misinterpretation regarding the treatment outcomes of the two different treatments.

Dr. London pointed out that what was once considered a successful implant (osseointegration alone) may no longer be an acceptable treatment outcome. Successful implant therapy now requires getting the implant to integrate in the right position, where it can support a prosthesis and look like a natural tooth. This is a major difference from simple osseointegration.

Dr. London stressed how important it was to have an interdisciplinary approach to dental treatment so all specialties are included in the best treatment approach for each patient.

We were pleased to have Dr. London come and share some of his expertise regarding periodontal bone grafting and implant treatment. We hope that the balanced approach to endodontics and implants which he described continues to gain momentum.

Longevity of dental implants vs. natural teeth

Longevity of natural teeth surpass the dental implants.
February 16, 2009

A lot of marketing has been done in the past few years to present dental implants as a better choice than a tooth that can be retained with endodontic therapy.

This has resulted in many un-necessary extractions, increase in implant failures, associated lawsuits and complaints to the states board.

Recently the academic community in the fields of periodontics and prosthodontics have come out with some evidence-based recommendations regarding natural teeth vs. dental implants.
For those of you who may be interested, here are some quotes from these articles:


Periodontology 2000
Lundgren D, Rylander H, Laurell L
Vol 47, 2008: 27-50
“It is well documented that properly treated natural teeth with healthy but markedly reduced periodontal support, are capable of carrying extensive fixed prosthesis for a very long time, with survival rates of about 90%,provided the periodontal disease is eradicated and prevented from re-occuring.”
“Based on assumptions that implants perform better than periodontally compromised teeth, teeth that could be saved and used as support, are extracted and replaced with implants, sometimes on doubtful indications.”
Peri-impantitis (loss of at least 2 mm of marginal bone) at one or more implants have been found to occur in 16-28% of implant patients after 5-10 years and with higher prevalence among patients with multiple implants.
“The natural tooth should not be considered an obstacle but a possibility, whether or not the treatment is to include implant placement.”
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Journal of Clinical Oral Implant Research
Holm-Pedersen P, Lang N, Muller F
University of Copenhagen
2007, 18(suppl) 15-19
“Oral Implants when evaluated after 10 years of service do not surpass the longevity of natural teeth even of those that are compromised, for either periodontal or endodontic reason. “
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Journal of Oral Rehabilitation;
2008,35 (suppl.1) 2-8
Consensus statements and recommendations of the European Conference on Evidence-based Reconstructive Dentistry: Implants and/or teeth

(Gathering of major European researchers and clinicians who were periodontists and prosthodntists )

Some of the recommendations were:
Implants do not have a better prognosis than teeth with reduced marginal bone support.
Dentist should not recommend extraction of these teeth.
There is no evidence available to support an aggressive approach in early extraction of teeth, to preserve bone for later implant placement.
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Journal of Prosthodontics ; 2008, Volume 17: 345-347
Editorial : Inconvenient truths by George Zarb,DDS ( Dr Zarb is one of the pioneers of the field of implantology)

“The integrity of purpose and scientific rigor that characterized the original osseo-integration clinical research has been largely discarded as passe’.”

“Partnership with commercial enterprise now dominate continuing education.”

“New lecture circuit celebrities keep being recruited to promote osseo-integration's newer and expanded promises, albeit it falls significantly outside the technique’s initial oral ecological context.”

“We risk overlooking safety, simplicity and prudence in our clinical judgment.”

“The risk of yet another anarchic phase in treatment decision making has resurfaced."
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I think these statements speak for themselves.
I welcome your comments.
Robert Salehrabi,DDS

Your Endodontist as a member of your Restorative Team

Your endodontist can be a valuable member of your restorative team. You can rely on your endodontist to support and reinforce your appropriate treatment plan.

As an endodontist, I want to see two things happen for my patients:
1. Endodontic therapy be successful
2. Patients value and retain their natural teeth

1. Endodontic therapy be successful:
Everyone knows that successful endodontic therapy requires proper coronal restoration. Without adequate restoration, even the best endodontic therapy will fail. As endodontists, we are invested in the successful treatment of the tooth, therefore, we will always encourage the patients to have their endodontically treated teeth properly restored. That means uncrowned posterior teeth and teeth with large restorations getting coronal coverage to protect them from cracks and fractures and current crowns/bridges with leaking margins/decay replaced to prevent coronal leakage. When a patient leaves my office, I make sure to let them know that they need to protect the root canal against bacterial leakage and occlusal forces. If our patients have been educated correctly, they will return to your office and ask for their new crown or bridge.

This patient came into my office today hoping for a root canal and a filling to preserve this bridge. I encouraged the patient to place a new bridge to prevent coronal leakage following endodontic treatment.

2. Patients value and retain their natural teeth:
I frequently see uncrowned posterior teeth with large restorations, craze lines & cracks. These teeth, especially in patients who are bruxers or have severe patterns of occlusal wear, are at risk of splitting the tooth. I encourage them to talk to their dentist about crowns to protect those teeth before they are damaged and become non-restorable. I hate to tell patients that they need an extraction because the tooth has split in half.




The general dentist has the primary responsibility for treatment planning. Your endodontist can play an important part of your restorative team by helping to educate your patients on the importance of proper restoration following endodontic treatment and the importance of proper restoration to prevent cracks/fractures.

The Endo Blog Welcomes a New Contributing Author - Dr. Robert Salehrabi

I would like introduce and welcome a new contributing author to The Endo Blog, Dr. Robert Salehrabi of Advanced Microscopic Endodontics (Aurora, CO). For quite some time I have considered the idea of adding additional authors to help provide more frequent postings, give additional clinical expertise and perspective and share the workload associated with the blog.

Dr. Salehrabi started his education at University of Massachusetts. He earned his DDS with a minor in Oral Medicine from State University of New York (Buffalo). His endodontic specialty training was completed at University of Southern California.

While a full time member of the USC endodontic faculty, Dr. Salehrabi became well known for his research. His work entitled "Endodontic Treatment Outcomes in a Large Patient Population in the USA: an epidemiological study." (JOE 2004 Dec:30(12):846-50) has been recognized as one of the most important endodontic research articles published in 2004. In a groundbreaking study to evaluate the long term treatment outcomes of non-surgical endodontic treatment, over 1.4 million root canal treatments done by specialists and generalists alike were evaluated. This study provides the clinician with useful tools for clinical decision making and assessment of tooth prognosis.

Dr. Salehrabi has presented endodontic lectures internationally as well as seminars throughout the United States.

While currently in private practice in Aurora, Colorado, Dr. Salehrabi maintains his teaching position as an associate clinical professor in the Department of Advanced Endodontics at USC.

Welcome Dr. Salehrabi!

Root Canals Save Your Natural Teeth

Occasionally I will use the images posted on the endo blog to aid in communication with patients. Whether trying to explain the healing of an abscess or show the patient how their tooth is cracked or fractured, a picture is worth a thousand words. Access to the internet in the operatory allows the endo blog to serve as a useful educational tool with patients. These images designed for patient education are written in lay terms will be labeled "patient education". Feel free to use them in your discussions with your patients. (click on the image for a larger, high resolution image)