Rhodium Coated Mirrors

Mirrors used for intraoral photography are not all the same. There are several kinds of mirrors. Standard metal mirrors reflect 55-60% of light. Chromium coated mirrors reflect 65-70% of light and rhodium coated mirrors reflect 75% of light. The manufacturer of the mirror that I use claims that this mirror reflects 99.5% visible light. This increased light reflection is also due to the flatness of the mirror. I usually use a standard mirror, but when want a good photograph, I'll pull out a rhodium coated mirror.

Here is a standard mirror.

This is the exact same photograph using a rhodium plated mirror.

When taking intraoral photographs, the quality of the mirror can make a big difference in the quality of your images.

Pulpal & Periapical Diagnosis

As previously described, endodontic diagnosis is composed of two parts.

A pulpal diagnosis, which indicates the status of the pulpal (nerve & connective tissue inside the tooth), and a periapical diagnosis, which indicates the status of the periapex (tissue around the end of the root).

Pulpal Diagnosis can be accomplished using cold, heat or electric stimulus. Cold testing is the most reliable. Endo Ice is the most convenient, and easy to use product for thermal testing.

The following flowchart will help you with your pulpal diagnosis.



As previously discussed, the new diagnostic terminology defined by the American Board of Endodontics simplifies the periapical diagnosis based upon pain and swelling. The following flowchart can be useful in helping to understand the diagnostic terminology.

New Endodontic Diagnosis Terminology

Endodontic diagnosis can be very confusing. Much of this confusion comes from differences in diagnostic terminology. The diagnostic terminology used from school to school is different. Even endodontic textbooks fail to create a systematic approach to endodontic terminology. The American Board of (ABE), the organization which oversees the board certification of endodontists, even allows for board candidates to describe the terminology they will be using during their board certification process.

Endodontic diagnostic terminology is based on clinical signs & symptoms, radiographic appearance & presence or lack of swelling or drainage. It is easily understood how confusing this can be with so many variables.

In an effort to simplify and unify the endodontic diagnostic terminology, the ABE has recently published a list of pulpal and periapical diagnostic terminology. In our practice we have adopted this terminology and will be using it in our daily practice of endodontics. We will also begin using this terminology in our cases presented in the blog. The following is the new terminology recommended by the ABE.

A complete endodontic diagnosis is made up of two parts:
1. Pulpal diagnosis
2. Periapical diagnosis


PULPAL DIAGNOSIS
Normal pulp – A clinical diagnostic category in which the pulp is symptom free and normally responsive to vitality testing.

Reversible pulpitis – A clinical diagnosis based upon subjective and objective findings indicating that the inflammation should resolve and the pulp return to normal.

Irreversible pulpitis – A clinical diagnosis based on subjective and objective findings indicating that the vital inflamed pulp is incapable of healing.

Additional descriptions:
Symptomatic – Lingering thermal pain, spontaneous pain, referred pain
Asymptomatic – No clinical symptoms but inflammation produced by caries,
caries excavation, trauma, etc.

Pulp necrosis – A clinical diagnostic category indicating death of the dental pulp. The pulp is non-responsive to vitality testing.

Previously Treated – A clinical diagnostic category indicating that the tooth has been endodontically treated and the canals are obturated with various filling materials, other that intracanal medicaments.

Previously Initiated Therapy – A clinical diagnostic category indicating that the tooth has been previously treated by partial endodontic therapy (e.g. pulpotomy, pulpectomy).




PERIAPICAL DIAGNOSIS

Normal apical tissues – Teeth with normal periradicular tissues that will not be abnormally sensitive to percussion or palpation testing. The lamina dura surrounding the root is intact and the periodontal ligament space is uniform.

Symptomatic apical periodontitis – Inflammation, usually of the apical periodontium, producing clinical symptoms including painful response to biting and percussion. It may or may not be associated with an apical radiolucent area. (This category includes what many of us call Acute Apical Periodontitis & Phoenix Abscess)

Asymptomatic apical periodontitis – Inflammation and destruction of apical periodontium that is of pulpal origin, appears as an apical radiolucent area and does not produce clinical symptoms. (This is what many of us have previously called a Chronic Apical Periodontitis)

Acute apical abscess – An inflammatory reaction to pulpal infection and necrosis characterized by rapid onset, spontaneous pain, tenderness of the tooth to pressure, pus formation and swelling of associated tissues.

Chronic apical abscess – An inflammatory reaction to pulpal infection and necrosis characterized by gradual onset, little or no discomfort and the intermittent discharge of pus through an associated sinus tract.


You can see that the pulpal diagnostic terminology has not changed. The periapical terminology is where are the confusion was and that is what they have tried to simplify. If you look closely at the definitions, you will see that the radiographic signs are not part of the periapical definition anymore. That is the reason that a Acute Apical Periodontitis & Phoenix Abscess are now both called a Symptomatic Apcial Periodontitis. Is your head spinning yet? Go back to the top and read it again. We'll have more on diagnosis to help you apply these definitions in your practice.

(Source: www.aae.org/certboard)

Healing Following Apical Surgery

This patient came to our office for treatment in 2005. Tooth #30 was diagnosed with a necrotic pulp and chronic apical abscess. Periodontal probing around tooth #30 was normal. Despite the large lesion into the furcation, this was determined to be an endodontic lesion.

Endodontic treatment was completed.

16 months later, the patient returned with swelling. Orthodontic treatment was underway. The apical lesion had failed to heal, and even gotten worse. Surgery was recommended to evaluate the lesion for possible root fracture.

Large amount of granulation tissue removed from large boney defect.

Biopsy Dx: Periapical Cyst

Following the apicoectomy, a MTA retrofill was placed in all canals. No fractures were found. The orthodontic treatment was discontinued for a period to allow for healing.

The patient came in last week for a nine month recall. The patient is completely asymptomatic, the apical healing is almost complete.
As a review, this is a tooth that failed to heal with non-surgical endodontic therapy. This tooth while loaded occlusally, underwent orthodontic forces, endodontic surgery (without bone grafting) and had significant bone regeneration at nine months.
There are many dentists who would have extracted this tooth without considering the option of endodontic treatment or surgery. Modern endodontic microsurgery provides our patients with another option for maintaining their natural teeth. It should be considered when we are doing our treatment planning.

Upcoming Inner Space Seminar

Our mission statement says, “…we are unconditionally committed to excellence in all we do, we are the endodontic leaders and teachers in our community.” In order to promote the specialty of endoontics and help all dentists perform the highest quality endodontic procedures, we have developed a seminar series entitled, "Inner Space Seminars".

These seminars are free and free from the commercialism that is creeping into all forms of dental education. Don't you get tired of reading articles only to find out the specialist writing the article is selling some dental product? We select topics and speakers that will provide valuable information for the dentists in our community.

4th Canal on Maxillary Molar

This root canal was completed 2 months ago. The patient continued to report pain with no relief. The dentist had also recently worked on #2, placing an occlusal restoration. My examination found #2 & #3 both very sensitive to percussion, normal probings and lingering pain to cold on #2. Since both teeth were very sensitive, the diagnostics become very difficult. My original recommendation was to adjust the occlusion on #3 and re-evaluate in a week. However the patient returned to the office later in the day experiencing severe pain, pointing to the vestibular area above #2 & #3.
My instincts pointed to #3. We performed diagnostic anesthesia on #3 by infiltrating a small amount (approx. 0.25ml) mesial to #3. Within several minutes the pain was gone. It was then determined that the pain was coming from #3 and endodontic retreatment was initiated.

Upon access and removal of gutta percha, no additional canals were visible. Suspecting a fourth canal, I began removing dentin from the MB groove using slow speed handpiece with #2 round bur and ultrasonic instrumentation. A fourth canal was located. The original difficulty in finding this canal was caused by the fact that it was completed covered over by secondary dentin.

The patient was informed of the fine work the general dentist had done in finding and filling 3 canals. There was no way that this fourth canal could be found without the use of the operating microscope.

Since almost all maxillary first molars have a fourth canal, make sure an look closely in the MB groove for the forth canal. This process of searching the MB groove should be done with an operating microscope, to facilitate this process as well as prevent iatrogenic damage to the tooth.