Monday, April 11, 2016

Dental Computed Tomography (CBCT) to Identify Dental Sources of Maxillary Sinusitis

CBCT by J. Morita Veraviewepocs 3De
As endodontists, the use of CBCT (Cone Beam Computed Tomography) has allowed us to cross this barrier and diagnose dental pathology which is adversely affecting the maxillary sinuses.  These images also allow us to communicate more effectively with patients and physicians who are trying to manage and treat these chronic sinus issues.  In order for dental and medical specialists to work together, new paths of communication must be developed.  CBCT (3D imaging) is helpful in bridging the communication gap between dentistry and medicine.

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:

  1. Perforation of the floor of the Mx sinus
  2. "Halo effect" elevation of the floor of the Mx sinus
  3. Thickening of sinus membrane adjacent to odontogenic infection
  4. Air bubbles in the sinus suggested of an acute sinusitis

CBCT (J. Morita Veraviewepocs 3De) demonstrates a large periapical radiolucency around the buccal roots of #15.  The sagittal view shows elevation in the floor of the sinus (halo effect).  Coronal view shows arrow pointing to a missed mesio-buccal canal causing the endodontic infection. Air bubbles seen in the maxillary sinus are indicative of an acute sinusitis. Endodontic retreatment is required BEFORE sinus treatment.  Failure to address the odontogenic source of the sinus infection will result in recurrent sinus infections.

CBCT (J. Morita Veraviewepocs 3De) demonstrates a large periapical radiolucency around the mesio-buccal root.  The sagittal and coronal views both show elevation in the floor of the sinus (halo effect) as well as perforation of the floor of the sinus.  Endodontic treatment is required BEFORE sinus treatment.  Failure to address the odontogenic source of the sinus infection will result in recurrent sinus infections.
CBCT (J. Morita Veraviewepocs 3De) demonstrates a large periapical radiolucency around the buccal roots of #3.  The sagittal and coronal views both show elevation in the floor of the sinus (halo effect) as well as perforation of the floor of the sinus.  Endodontic treatment is required BEFORE sinus treatment.  Failure to address the odontogenic source of the sinus infection will result in recurrent sinus infections.
Fortunately, these high definition images also identify the problems with previous endodontic treatment and the solutions to remove the odontogenic source of infection.  These common endodontic findings include:
  1. Missed (untreated) canals in a previously treated root canal
  2. Short filled canals in a previously treated root canal
  3. 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?

"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.

Molar #2 and #3 have periapical radiolucency (PARL), one of which is dehiscent into the maxillary sinus and buccal gingival sulcus.  This may be the most important diagnostic information in the CT scan.  Too often, radiologists and otolaryngologists are not looking at this part of the scan - if it is even included in the field of view.
Following evaluation, the following impressions were recorded.

  • 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 diagnosis, including CBCT, determines that tooth #2 has a prior root canal with a root fracture and extraction is recommended.  Tooth #3 has a prior RCT with apical abscess - caused by a missed MB#2 canal during the initial root canal treatment.  Retreatment of the root canal #3 is recommended.

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
The endodontists at Superstition Springs Endodontics are experts in endodontic diagnosis and have extensive experience with CBCT.  In addition, endodontists are specially trained to perform the most difficult endodontic cases.  Maxillary molars, most closely associated with the maxillary sinus, almost always have 4 canals.
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

Preventing Root Canal Perforation by Case Selection

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:
  1.  prevent lost chair time without reimbursement
  2.  prevent loss in patient confidence
  3.  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

Congressman Paul Gosar to Speak at 2016 Spring Into Dentistry Seminar on Feb. 19th

This year's Spring Into Dentistry Seminar will feature Congressman (and Dentist) Paul Gosar from Arizona's 4th Congressional District.  We are excited to have him as our guest speaker and hear about his unique perspective as a dentist and a congressman.  We hope you can join us!

Tuesday, January 5, 2016

Apicoectomy on Mx Molar - All Three Roots Through A Buccal Approach

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.

Surgical PreOp
Root resection of all three roots using a buccal approach
Retrofills with MTA
Post-Op radiograph
1 year recall. Patient fully functional and asymptomatic.  Radiographic healing evident.

Wednesday, December 2, 2015

Thursday, September 10, 2015

Success with Vital Pulp Therapy

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.
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.

Caries removed, pulp chamber cleaned out, MTA placed against the amputated pulp tissue, with resin restoration.

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

5 Year Recall on a Cracked Tooth

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.

Monday, June 8, 2015

Are Dental Implants Forever?

In previous posts, we have discussed the differences between implants and root canal therapy.  We have made the argument, which is still seen playing out in many of our dental journals, that implants and root canals are not really alternative treatments.  If a tooth is restorable (no root fracture, stable periodontium) then maintaining the the natural tooth is the ideal treatment.

At Superstition Springs Endodontics, we work with the best dentists in the east valley, who understand and help their patients understand the value of the natural tooth. However, many patients get information from other sources that give them the impression that implants are just like teeth, but never get cavities, periodontal disease or any of the other challenges we have in maintaining our natural teeth. This view is not the whole story and doesn't help patients understand the unique challenges that implants have.

Those who propagate the idea that implants are a better and hassle-free version of natural teeth will use implant research to argue that an implant is more successful than traditional restorative dentistry.  Many patients and some dentists are convinced that dental implants are without complication and have unlimited lifespan.  It is not until recently that we have begun to see articles addressing the "Failure of Dental Implants" (JADA Aug 2014, p.835-842.)  Terms such as "ailing" implants and "reimplantation" are new on the scene.

However, an article in the Journal of Clinical Periodontology by Cairo et. al. reviewed the quality of reporting of randomized clinical trials in implant dentistry from 1989 - 2011.  Their systematic review found that the implant trials were mainly parallel trials, single center trials.

Methodological flaws noted were:
Random sequence generation only 37% of the time
No information given regarding allocation concealment 75% of the time
Correct sample size calculation only 12% of the time
Blinded examiner only 42% of the time

While these methodological flaws affected the reporting of these studies, they also noted that the quality of these studies only partially improved over time.  They found that allocation concealment was at a high risk of bias, there was a lack of reporting characteristics of drop-outs, and lack of CONSORT adherence.

The authors concluded that with these methodological flaws, and failure to adhere to CONSORT, the statistically significant results reported in this body of implant studies, caution is suggested in data interpretation and generalization of outcomes.

It is also noted that many of the methodological flaws seen in implant research are also found in endodontic research, dental research in general, and all throughout medicine as well. However, we should expect and demand that the quality of the research published and used to make treatment recommendations should be improving over time.


Greenstein, G. Cavallaro, John. "Failed Dental Implants: Diagnosis, Removal and Survival of Reimplantations" JADA 2014. 145(8), 835-842.

Cairo, F., Sanz, I., Matesanz, P., Nieri, M., Pagliaro, U. "Quality of Reporting of Randomized Clinical Trials In Implant Dentistry. A Systematic Review on Critical Aspects in Design, Outcome Assessment and Clinical Relevance"  J. Clin Periodontol 2012. 39(Suppl. 12), 81-107.

Friday, June 5, 2015

Medicare Opt-In or Opt-Out Delayed Again

CMS has delayed the enforcement of the new Medicare rule until June 1, 2016.  The deadline for enrollment has been moved back to Jan 1, 2016.

For more information from ADA, click here.