Monday, December 27, 2010
This video is made of individuals slices 1.0mm thick with 0.25mm interval between each slice.
Thursday, December 16, 2010
Monday, November 29, 2010
Post-Op films shows the MTA repair in the furcal area. Note the large lesion around the mesial root.
At 6 months, furcal and periapical lesion are improving and the tooth is functional.
At 18 months, the lesion continues to improve, tooth is completely asymptomatic and functional. Proper endodontic treatment and repair with MTA has retained a tooth that many would have considered "hopeless" or non-restorable based on the amount of furcal bone loss.
Wednesday, November 17, 2010
Superstition Springs Endodontics is excited to introduce cone beam technology (CBCT) into their practice of endodontics. The decision to incorporate this technology has come after a extended review of the technology, research and clinical applications of CBCT in endodontics.
Dr. Edward Carlson was among the first endodontists in Arizona to incorporate the operating microscope into his practice of endodontics almost twenty years ago. Just as the operating microscope has become an indispensable tool in the practice of endodontics, we expect CBCT to become integral part of endodontic diagnosis, treatment & evaluation.
As Superstition Springs Endodontics, we are specialists in saving teeth. The CBCT is another diagnostic tool to allow us to make important decisions about saving teeth. Doctors and patients who are committed to saving natural teeth, will be able to benefit from this new technology.
The clinical applications of CBCT in endodontics include:
1. Aid in endodontic diagnosis
2. Canal morphology
3. Evaluation of root fracture
4. Evaluation of internal root resorption
5. Evaluation of invasive cervical resorption
6. Presurgical assessment
7. Evaluation of non-endodontic pathology
8. Assist with implant planning for non-restorable teeth
We look forward to sharing cases using this new technology.
The first case to share is the case of a fractured tooth. This patient had a fall and hit her face 5 months ago. #8 was damaged and had to be removed and replaced with an immediate implant. #9 continued to give her symptoms and mobility.
Now it is obvious with a regular radiograph that there is a problem with this root. The tooth exhibited class II mobility.
The coronal view (left) shows the similar view to the standard radiograph, however, the sagittal view (right) shows how the fracture has sheared off toward the palate, well below the level of palatal bone. The ability to see this fracture from the sagittal view allows us to make a determination of the restorability of this tooth.
Previously, we would have had to remove the fractured portion of the tooth and visualize the depth of the fracture. The CBCT allows us to visualize this without the need to disassemble the tooth. This tooth has been recommended for extraction and the CBCT scan can also be used to help in the treatment planning of the new implant.
Stay tuned for more applications of CBCT in our endodontic practice.
We have selected a CBCT manufactured by J. Morita. J. Morita has been a leader in development of cone beam technology. The Veraviewepocs 3De is a focus field cone beam with incredible resolution, ideal for the practice of endodontics.
Wednesday, November 10, 2010
I mentioned an inexpensive light that can be used for transillumination. Thanks to Dr. Nathan Saydyk for his research, this light has been discontinued and replaced with the new Browning 2120 Microblast Pen Light with Bore Light Adapter. This is a flashlight used for firearm inspection and cleaning that can be used for transillumination.
Monday, November 1, 2010
Cracks in teeth are findings, not a diagnosis. Proper pulpal and periapical diagnosis as well as the location and extent of a crack are needed to determine a proper treatment plan. The problem with cracks in the tooth are the possibility for future bacterial penetration, which leads to inflammation and disease.
With these considerations, many teeth with cracks can be saved. Keys to saving teeth with cracks are:
1. Early detection and treatment
2. Proper endodontic diagnosis
3. Proper determination of the location and extent of a crack
The following case of a cracked tooth was recently treated at Superstition Springs Endodontics.
This patient presented with mesial decay on #14 causing discomfort. The tooth was normal to percussion, probing and no response to thermal test. DX: Necrotic pulp w/ normal periapex. A crack was noted on the distal marginal ridge. RCT recommended.
Removal of decay and access revealed the crack extending down the distal wall.
Closer examination finds that the crack ends near the level of the CEJ. Pt is informed of the crack and the prognosis is good, since the new crown will be able to cover the crack. The crack should be removed at the time of the build-up.
A main key to saving teeth with cracks is to identify the location and extent of a crack.
An upcoming Inner Space Seminar, entitled "Breakdance" will help clinicians know how to identify and classify cracks in teeth, as well as treatment plan restorative options for teeth with cracks.
Monday, August 30, 2010
The periodontist realized that the bone loss around this root was not caused by periodontal disease. The patient reported no pain or swelling. He has no senstivity to percussion, normal probing depths (4mm depth on the buccal was the deepest) and when proper vitality testing was completed, the tooth was found to be necrotic. The tooth was diagnosed: Necrotic Pulp w/ Chronic Apical Periodontitis. The patient was given the option of endodontic therapy to retain the natural tooth.
Endodontic therapy completed and a 6 month recall scheduled to evaluate the periapical healing.
Please feel free to share your thoughts about these cases. The purpose of this blog is to generate discussion. What would you have done?
OK, here we are 3 years later. The tooth is asymptomatic and functional and perio probings are normal. Significant healing has occurred. There is still some lateral radiolucency - widened pdl, but at this point I think it was a good decision to retain the tooth.
Our specialty at Superstition Springs Endodontics is saving teeth.
Friday, August 20, 2010
Thursday, July 29, 2010
This root canal was originally done in 1965. A periapical lesion has developed. While the root canal filling is weak and the apical seal obviously an issue, the tooth is and has been fully functional.
It is likely that the tooth had an apicoectomy, due to the short length of the root and open apex.
The open apex is debrided and a new apical stop is created.
The canal is then obturated with MTA. MTA is chosen as the obturation material due to the open apex and the ease of future apical surgery if needed. I call this a "root canal upgrade". Preserving this tooth preserves the periapical tissues and helps to maintain the bone around the tooth. While there are lots of good replacements for missing teeth, nothing preserve the periapical architecture as well as a healthy tooth & periodontal ligament.
Friday, July 16, 2010
Tuesday, July 6, 2010
More information about Dr. Miles and cone beam and digital imaging can be found at Dr. Miles' website: www.learndigital.net
Thursday, June 24, 2010
Endodontic claims are the most frequently filed malpractice claims in dentistry. It has been reported that there are twice as many endodontic malpractice claims than other specialty areas. Endodontic claims have been reported to be 14% - 17% of the total malpractice claims in dentistry.
The study by Givol et. al. was a review of malpractice claims made in Isreal between 1992 - 2008. Some interesting data comes from this review. Of the 720 complaints that were analyzed, 72% were considered "justified" and 27% were considered "unjustified" complaints.
Errrors found and analyzed were categorized as pre-operative, intra-operative or post-operative.
Most of the errors occurred in the intraoperative phase of treatment. These included access preparation, detection of canals, instrumentation or filling.
Swelling & pain as the only complaint were reported in 100 cases and none of them were considered "justified" complaints. Swelling and pain are considered a side effect of treatment and not a complication. Patients should be informed of this possible side effect during informed consent. It has been reported by Tsesis et. al. that pain and swelling can occur following endodontic treatment in 1.5% - 20% of cases. Helping patients understand this possible side effect can help prevent misunderstanding and hopefully prevent unnecessary malpractice claims.
The lack of adherence to strict treatment protocols resulting in poor quality treatment was a common cause of malpractice claims.
Endodontic treatment requires exceptional technical skill and strict adherence to accepted treatment protocols. Proper case selection and appropriate referral to a specialist can also prevent unnecessary complications.
Givol N, Rosen E, Taicher S, Tsesis I. Risk Management in Endodontics. J Endod 2010;36:982-984.
Tsesis I, Faivishevsky V, Fuss Z, Zukerman O. Flare-ups after endodontic treatment: A meta-analysis of literature. J Endod 2008;34:1177-81.
Friday, June 4, 2010
Friday, May 7, 2010
Regenerative endodontics is currently in its infancy. However, the possibilities are exciting and the research is ongoing. Regenerative dental therapies may one day lead to more effective vital pulp therapy, more effective treatment of immature teeth, traumatized teeth, and possibly the replace of missing teeth with bioengineered teeth.
Current clinical success in regenerative endodontics is seen in the treatment of necrotic, immature teeth with apical periodontitis.
The following case, treated at Superstition Spring Endodontics, has shown ideal pulpal regeneration allowing for the continued development of an immature root.
At 6 years, the canal has closed, root has lengthened, and the tooth is now responding to electric pulp testing.
This procedure has allowed this patient to retain a tooth that otherwise may have been lost.
The future of regenerative endodontics is bright and exciting.
Monday, March 29, 2010
Traditionally, when an immature tooth became necrotic, root development was arrested and the endodontic goal was to create some kind of calcific barrier against which we could obturate. This is known as Ca(OH)2 apexification. The downside to this treatment was length of treatment time and weak, short, thin roots that remained.
Multiple case reports, including cases at Superstition Springs Endodontics, have shown the ability to remove the necrotic tissue and stimulate regeneration of pulpal-like tissue into the canal. This allows for the continued growth of the immature root. The dentinal walls thicken, the length of root increases, periapical lesions heal and the open apex closes.
This is a completely new way of approaching apexification and provides a glimpse at exciting new horizons in endodontics and tissue engineering. I was recently asked by a colleague if I had interest in placing implants. I explained to him that while implants provide a valuable service to replace missing teeth, as an endodontist, I am dedicated to preserving the natural tooth. I am grateful to work with so many great implant surgeons, but I expect there will come a day when real teeth are replaced with real, bioengineered teeth.
Tuesday, March 16, 2010
Success with this treatment is dependent upon atraumatic extraction, minimal manipulation of the periodontal ligament, rapid replacement into the socket, and minimizing occlusal forces following replantation.
While endodontic apical surgery (apicoecotomy) is the most common type of endodontic surgery performed, intentional replantation is an option when apical surgery is not indicated due to anatomical considerations. These may include: proximity to the mental foramen or mandibular canal, thickness of Md buccal bone along oblique line angle, and proximity to Mx sinuses.
I have found intention replantation useful in the following clinical situations:
Cases where endodontic surgery is not an option due to difficult anatomy...
1. Md 2nd Molars - access through buccal bone difficult
2. Md 1st & 2nd Bicuspids - closeness to the mental foramen
3. Mx 2nd Molars - access difficult & sinus complications likely
Cases where conventional retreatment has been unsuccessful or not likely to be successful
1. Cases with ledging and/or separated instruments
2. Retreatment has been attempted without success
Other factors to consider...
The root anatomy has to allow an atraumatic extraction to occur. Conical shaped roots are most ideal.
Intentional replantation provides a treatment option when tooth replacement with an implant or bridge is not feasible.
These patients have already had endodontic therapy, and crowns placed. Costs associated with this additional treatment are minimal compared to cost of tooth replacement.
The following cases demonstrate intentional replantation.
RCT was completed and patient continued to have apical pain. Extrusion of sealer was assumed to be the cause of the apical periodontitis. Close proximity to the mental foramen makes apical surgery contraindicated.
Following atraumatic extraction, the gross overextension of gutta percha is obvious. Apical resection and burnishing of gutta percha completed within minutes.
Tooth replanted and treatment completed.
Initial RCT completed.
Sinus tract persists.
Non-surgical retx completed and symptoms persist. Discussion with patient of options:
Pt understood options and selected intentional replantation.
Atraumatic extraction, immediate resection.
3 month recall. Tooth asymptomatic and completely functional.
Pathways of Pulp, 9th edition - online version. p767-768.