Testing the Limits of Endodontic Surgery

This patient came to our office in 2012.  She reported trauma in the early 1970's - when one of her kids accidentally head butted those teeth.  They became infected and a RCT was done in the early 70's.  Original crowns still in place.  Her dentists ever since have pointed out the radiolucency, but for the most part is has been mostly asymptomatic.  Our exam finds #24 and #25 with mild percussion sensitivity, normal probings and class II+ mobility.  We discussed the resorption that appears to have affected the apex of #25.  We discussed options and she wanted to try to retain the tooth, so we decided to attempt an apicoectomy with guarded prognosis.

PreOp #24 and #25 - RCT done about 40 years earlier.

PostOp Apicoectomy

 Because of the resorption at the apex of #25, a traditional root end preparation and filling was not possible with removing too much tooth structure.  In this case, we bonded Geristore on the root apex and tried to "cap" the apex.  Retrofill #24 is MTA.

At one week, the patient reported some pain and throbbing following the treatment with increased mobility. We stabilized the teeth with some bonded resin and recommended Augmentin.

At two weeks, patient reported improvement, but gingival inflammation was present and #25 had a class III mobility.  Teeth were removed from occlusion to remove any occlusal trauma.  We recommended a second antibiotic at that time, Clindamycin.

At three weeks post op, area is feeling better, inflammation/infection has resolved, tissue looks improved and both teeth are class II mobile.

From this point, the patient has remained asymptomatic and we have seen full resolution of PARL.
This is a tooth that would be extracted by most dentist, and by many endodontists, however, apical surgery is too often overlooked as a treatment option.

6 month Re-evaluation.

1 Year Recall

1 Year Recall

2 Year Recall - complete bony healing.

We should not forget how lucky we are to work in a biologic enviroment that is so forgiving and with such ability to regenerate bone.

Single Step Pulpal Regeneration - Success at 6 Months

This 8 yr old patient had trauma 3 yrs earlier on this immature #9.  His dentist bonded it the best he could.  3 yrs later, the tooth is necrotic with symptomatic apical periodontitis.  (non-responsive to cold, pain to percussion, normal probings)  Root apex is >1mm open.  Pulpal regeneration was recommended.

Pulpal regeneration peformed.  Canal debrided with minimal filing, NaOCl irrigation, Saline rinse, EDTA final rinse. Blood clot initiated with MTA coronal plug placed below CEJ (to prevent staining).

Regenerative procedure completed in single step with MTA plug and resin coronal access filling.

Following the treatment, a post operative flareup occurred - requiring antibiotics.  I was concerned that this may be detrimental to the regenerative process. I am continually amazed at the healing capacity of the tooth.  At 6 months, the tooth is aysmptomatic, fully function and canal is closing down.  A dentin bridge is formed just below the MTA barrier.  There is no additional plan for endodontic treatment on this tooth - unless eventually needed for restorative purposes.

For your patients who watch Dr. Oz...

The British Medical Journal is taking Dr. Oz to task over the information he provides on his show. According to an article in the Washington Post, the reserachers examined 40 episodes and found 479 separate medical recommendations. Of those recommendations, they were able to find medical research that supported 46% of his recommendations.  15% of his recommendations were actually contradicted by current medical research and 39% has no medical research available.


Most clinicians in the US have probably had a patient that came with concerns about something they heard from Dr. Oz. A little more evidence that you can't believe everything you read on the internet OR hear from Dr. Oz!

Periapical Cemental Dysplasia

A 42 yr old, white, female presented for evaluation of #22.  She was asymptomatic, with a prior RCT on #22.  A large nodular, irregular, radiopacity found within a large radiolucent area on the periapical radiograph. Tooth is normal to palpation, percussion and probings.

Pre-Op Radiograph

CBCT shows the radiographic findings from multiple angles.

Sagittal slice shows complete obturation with no missed lingual canal.

DX: Prior RCT with possible periapical cemental dysplasia.  Apical surgery recommended with biopsy.

Surgical acess

Removal of calcific nodules

Crypt completely cleaned out to normal bone

MTA retrofill placed.

Biopsy report indicated Periapical Cemental Dysplasia (anterior focal osseous dysplasia)  Recurrence would be unusual, but other areas of dysplasia can arise as well as truamatic bone cysts are also common.

I Don't Always Amputate Roots, But When I Do...

Root amputation is not a commonly performed procedure in my practice, but when it is, I like for it to look like this.  In this case, the tooth is non-mobile - despite the bone loss around the DB root.  While the distal margin is open, it is not carious and patient is not planning to replace the crown at this time.  Pt understands that this procedures extends the life of the tooth.  I explain that the short term prognosis is good. If the tooth does well, then replacement of the crown can be considered.

PreOp and PostOp of DB Root Amputation

DB root is floating - with no buccal bone

DB root removed and contoured to a cleansable form.

Why Most Research Findings Are False

Dr. John P. A. Ioannidis is a Professor of Medicine, Health Research and Policy at Stanford University.  He holds the C.F. Rehnborg Chair in Disease Prevention and is the director of the Stanford Prevention Research Center (SPRC) at Stanford University School of Medicine.  He is a professor of Statistics and one of two directors of the Meta-Research Innovation Center at Stanford (METRICS).

In an article published in 2005, titled "Why Most Research Findings Are False", Dr. Ioannidis explains the increasing concern that most current published research findings are false.  There are many factors that play into this problem such as research design, definitions, outcomes, financial interests, prejudice, and the "chase for statistical significance".  In fact, Dr. Ioannidis states that for many current scientific fields, published research findings may be little more than "accurate measures of the prevailing bias".

Dr. Ioannidis and other methodologists, have pointed out that the high rate of non-replication of research discoveries is based on a convenient, yet ill-founded strategy of claiming conclusive research results after a single study where statistical significance is claimed based on the p-value of <0 .05.="" p="">

Dr Ioannidis is known for defining the proteus phenomenon, which is the greater tendency for the early repeat studies done to contradict the original study.  The proteus phenomenon was named for the Greek God Proteus, who had the ability to change form.

Research findings are less likely to be true in research studies with:
1. Smaller sample size
2. Smaller the effect size
3. Greater the number and lesser the selection of tested relationships
4. Greater the flexibility in designs, definitions, outcomes and analytical modes
5. Greater the financial and other interests and prejudices
6. Hotter the scientific field (more teams interested in studying a field)

While it is impossible to know with 100% certainty what the truth is in any research question, Dr. Ioannidis makes some recommendations on how we can improve the scientific research.

1. Seek better powered evidence (large studies or low-bias meta analysis) with acknowledgment and avoidance of bias.
2. Find ways to evaluate the all the evidence generated by multiple teams studying the same topic.  Find ways to develop and follow protocols as done in randomized clinical trials.
3. Rather than focusing on p-value for statistical significance, improve the understanding of the range of R values - pre-study odds.  This helps us understand the chances that we are testing a true, rather than an un-true relationship.

Dr. Ioannidis is not the only one concerned about the effect of bias in the research.


Pannuchi and Wilkens have said "Bias can occur in the planning, data collection, analysis, and publication phases of research. Understanding research bias allows readers to critically and independently review the scientific literature and avoid treatments which are suboptimal or potentially harmful. A thorough understanding of bias and how it affects study results is essential for the practice of evidence-based medicine."  They go on to discuss how bias can affect a study before, during and after the research is complete.

An article in Radiology by Gregory Sica MD, MPH reviews types of study design, types of selection bias, types observational bias, and suggests some ways to reduce bias in research.

Mullane and Williams ask if bias in biomedical research has become the rule rather than the expectation.  They indicate that bias in research is amplified by competition and difficulty getting funding, pressures for maintaining laboratories and staff, desire for career advancement, and monetization of science for personal gain.  They also mention the increasing body of research publications that cannot be repeated or require corrections or retractions.

Other Resources
Bias in Research (Sandra Burge PhD) - an online learning module from UTHSC San Antonio
Continuum Between Fraud and "Sloppy Science" - Scientific American

Dr. Ioannidis will be the keynote speaker at the Nowzari Symposium on Friday, Nov. 7th 2014 in Beverly Hills, CA.  See you there!

Source:

1.  Ioannidis JPA (2005) Why Most Published Research Findings Are False. PLoS Med 2(8): e124. doi:10.1371/journal.pmed.0020124
2. Pannuchi, C Wilkens, E Identifying and Avoiding Bias In Research. Plast Reconstr Surg. Aug 2010; 126(2):619-625.
3. Sica, G Bias In Research Studies. Radiology. Mar 2006; 238:3.

4. Mullane, Williams. Bias in Research: The Rule Rather Than The Exception. Editors Update. Sep 2013. Issue 40.
5. Moonesinghe R, Khoury MJ, Janssens ACJW (2007) Most Published Research Findings Are False—But a Little Replication Goes a Long Way. PLoS Med 4(2): e28. doi:10.1371/journal.pmed.0040028

Saving a Tooth with Intentional Replantation

Previous posts have discussed the often overlooked surgical option of intentional replantation.  The following case is an example of 3.5 yr success of intentional replantation of a Md second molar.

#31 Prior RCT with Chronic Apical Abscess - with recurring sinus tract.  Radiograph shows the overfill on all canals and large periapical/ furcal lesion.

CBCT shows the extent of the bone loss.

CBCT also shows the root anatomy and the buccal/lingual bone in tact.

At this point, retreatment or surgery are the options to preserve the tooth. With a crown, not needing to be replaced, a long post and overfilled gutta percha - which can be difficult to retrieve, we considered a surgical approach. Since this is a second molar, the buccal bone is too thick to allow for conventional surgical approach (apicoectomy).  After discussing risks of intentional replantation, pt elected to preserve tooth using intentional replantation. 

Tooth extracted atraumatically.  (Crown came off during extraction.)

Apico & retrofill completed chairside

Tooth replanted.

Note the bone levels around the tooth. They are identical to the pre-op bone levels.  Intentional replantation has preserved the natural tooth AND the periodontium.

Internal Bleaching of VITAL Teeth

With the recent advances in regenerative endodontics, we have come to see the pulpal tissue in a new light.  This has encouraged us to treat healthy pulpal tissue in ways that would seem counter-intuitive.  For example, in the treatment of a decayed tooth, with immature roots - when the pulpal tissue is completely healthy, we may try an MTA pulpotomy on a permanent tooth, and give the tooth a chance to finish its development. We are finding new ways to perform apexogenesis procedures. The apexification procedure is becoming a thing of the past. In fact, I haven't performed an apexification in several years.

This new approach to the pulpal tissue has brought up a new questions.  In a mature tooth, with calcific metamorphosis causing discoloration, is it really necessary to perform a root canal before internal bleaching?  Conventional wisdom would say yes.  But our understanding and respect for the pulpal tissue and its capacity to repair itself has changed my view on this procedure.

First off, teeth with calcific metamorphosis are often misdiagnosed as necrotic because they do not respond to thermal pulp testing.  Electric pulp testing (EPT) is required to determine vitality on these teeth.  If these discolored teeth are determined to have vital, normal pulps and periapices - why not perform internal bleaching without RCT?

The following case is an example of this procedure.

History of trauma to #8 with gradual discoloration

Close up of the color difference

Radiograph shows pulpal obliteration - complete calcification

Normal endo access with stain removal under microscope without entering canal.  Glass ionomer barrier placed at the CEJ and Opalescence Endo placed in pulp chamber. Access closed with Cavit and bleach left for 1 week. Fresh bleach reapplied for a second week.

Access filling placed.

Before & After

With no exposure of the canal system on a vital tooth, internal bleaching can be performed WITHOUT prior endodontic therapy.

Insurance Companies Respond to Delta Dental of AZ's Recent Changes

The dental insurance world in AZ is a buzz with the recent changes regarding Delta Dental of AZ.  These changes will force providers into the PPO network, to become exclusive Delta providers or terminate their relationship with Delta Dental of AZ.


There has been contact made with the AZ Attorney General's office regarding these concerns by other dental insurance providers.


Here are a few of the recent letters we have seen regarding their response to Delta. While being an exclusive provider for Delta is not a new concept, it is obvious that other insurance companies see that as anticompetitive and questioning it's legality.

Delta Dental of Arizona Cutting Reimbursements to Arizona Dentists

The Delta Dental of AZ website says, "...dentists are valuable partners in providing quality oral health care and Delta Dental is striving to find the right balance between the dentists, the companies and our enrollees to remain the leading dental benefits provider in our state."  The latest move in striving to find this balance is to reduce the reimbursements to Premier Provider dentists by forcing them into the lower paying PPO dental plan.  In a recent letter from Delta Dental of AZ, I was informed that the Premier Plan, of which I am a provider, is being retired and I have three options:

1. Accept the Delta Dental PPO contract fees
2. Become an exclusive provider - accepting ONLY Delta Dental insurance
3. Terminate my provider relationship with Delta Dental

In order to evaluate the decision of staying with Delta Dental, I decided to look to FairHealthConsumer.org to find out what a "fair" price is for endodontic procedures in my region.

Fair Health is a national, independent, not-for-profit corporation whose mission is to bring transparency to healthcare costs and health insurance information through comprehensive data products and consumer resources. FAIR Health uses its database of billions of billed medical and dental services to power a free website that enables consumers to estimate and plan their medical and dental expenditures.

As a consumer, this is what FAIR health says should be charged for endodontic treatment in my zip code.  If I have no insurance, this is what I should expect to pay.

According to FAIR health, the reasonable cost for a molar root canal in 85206 zip code is $1203.00

According to FAIR health, a typical dental insurance policy should expect the insurance to cover $601.50 of the root canal and I should expect an out of pocket expense of $601.50.

Now looking at the proposed reimbursement for an endodontist doing these three procedures, Delta Dental PPO wants me to reimburse at the following rates.

Molar RCT (D3330) 36% below the FAIR price

Bicuspid RCT (D3320) 41% below the FAIR price

Anterior RCT (D3310) 44% below the FAIR price

At SSE our current fees are BELOW the FAIR health fees for our area.

As a Premier provider with Delta Dental we are reimbursed at:

Molar RCT (D3330) 16% below the SSE Fee

Bicuspid RCT (D3320) 23% below the SSE Fee

Anterior RCT (D3310) 30% below the SSE Fee
If we become a PPO provider for Delta Dental, we will be reimbursed at:

Molar RCT (D3330) 31% below the SSE Fee

Bicuspid RCT (D3320) 42% below the SSE Fee

Anterior RCT (D3310) 48% below the SSE Fee
Looking at those reimbursements, Delta Dental PPO would become the worst reimbursing insurance company that we work with. As a business owner, at what point does it become non-profitable to see Delta patients? How does any business function at a 30-50% discount?  The obvious business answer is that you have to make it up the difference in volume which typically means a decrease in the quality of service.  (does corporate dentistry sound familiar?)

If you are a Premier provider, you may want to look at the numbers carefully.  If you don't contact Delta by written notice, you will automatically become a PPO provider on July 1, 2014!

If you are a general dentist, the Delta PPO want to reimburse you at the following rates:

Molar RCT (D3330) 54% of the FAIR price

Bicuspid RCT (D3320) 52% of the FAIR price

Anterior RCT (D3310) 51% of the FAIR price

As a company, who was initially founded by dentists in California, Washington and Oregon and has become one of the largest dental networks in the country, this move to cut reimbursements by forcing its premier providers into the PPO network does not seem to support the dentist.


If you are a dentist in another state that has been affected by Delta Dental cuts, what has been your experience?

If you are an Arizona dentist, what are you planning to do and how do you think it will affect your practice?

Some other interesting links regarding this pattern of Delta Dental to cut reimbursements to Dentists.

DentalTown Discussion regarding Delta Dental of Washington cutting reimbursements

Dental Warrior Blog reporting Delta Dental of Idaho cutting reimbursements

Delta Dental of Missouri cuts reimbursements

Dental Economics: Things to consider when dropping a PPO