Friday, May 29, 2009

Saving the Natural Tooth with Intentional Replantation

Intentional replantation is the intentional removal (extraction) and replantation 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 replantation 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 replantation.
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.

Tuesday, May 12, 2009

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

Friday, May 1, 2009

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:



Mark S. Montana DDS
2147 E. Southern Ave.
Tempe, AZ 85282
480 820-2901