Wednesday, December 21, 2011

This, Not That, Follow up

I realize that my last post was a little short. It was meant for the reader to contrast two root canal treatments on maxillary second molars and draw conclusions about differences. The obvious, and most important difference, is the treatment of 4 canals in the first case.

Here is the preoperative radiograph again:

History: This patient has had symptoms on and off in the upper left for six years. She cannot chew comfortably on this side and feels a constant pressure in the area. She cannot walk up stairs without feeling dull pain in the area. The original treatment on #14 was performed in 2006 or 2007. Tooth #14 was then retreated by an endodontist in 2009, followed by persistent symptoms, and then treatment of tooth #15 soon after. With retreatment of #14 and treatment of #15, her symptoms improved for a short time, but soon returned.

Med History: Non-contributory.
Extraoral Exam: Alert/responsive, no extraoral swelling, significant asymmetry, or lymphadenopathy.
Intraoral Exam: All tissues normal in color and consistency, no swelling, no sinus tract, crown margins in tact. Large porcelain fracture on the occlusal of #15. All probing depths were 2-3mm with minimal signs of gingival inflammation.
Diagnostic tests: Tooth #15 was responded with a mild tenderness to percussion, both tooth #14 and tooth #15 were sore upon selective bite forces.
Radiographic Exam: Large radiolucency centered on #15 but overlapping the distal of #14. Widened PDL mesial #14. 3 canals obturated #15. Large, possibly strip perforated, canal preparation in the middle and cervical third of both #14 and #15, possibly compromising root strength.

The patient understandably harbored a very negative opinion of the success rate of root canal therapy. When patients harbor this attitude, treatment planning long, challenging retreatments with less than perfect success rates is usually out of the question. I recommended extraction of tooth #15, especially since saving the tooth would also require the investment of a new crown. I offered the alternative of a CBCT evaluation to aid in treatment planning any approach to saving the tooth. The patient understood my concerns, and opted for the CBCT. Here are some selected images from the CBCT.

Circled is the MB root in cross section. From this view, it becomes apparent there is untreated canal anatomy in the form of a MB2 canal.

Even still, having looked through the CBCT images, I recommended extraction as the most predictable course due to the size of the lesion and the compromised tooth structure. The painted a pretty grim picture, but the patient asked me to take a chance on tooth #15 and consented to a guarded prognosis.

Upon access of #15, I was greeted with this view:
Circled is the site of the untreated MB2 canal.

Following 2 hours of uninterrupted work at the first visit, where I had to fight to unledge all 3 previously treated canals, and was ultimately unsuccessful with the distal, calcium hydroxide was placed. The MB2 canal, while easy to see with the microscope, still consumed a majority of the time to navigate. The patient reported all symptoms resolved immediately following return of sensation, an unexpected result. She was able to run up stairs without pain that same night.

Here is the final obturation:

As you can see, still short on the distal where it was ledged. Some of the previous obturation in the palatal was unfortunately extruded. MTA was placed as a coronal seal in the cervical third and across the pulpal floor. Unknown to me at the time, she contacted her previous endodontist (in another city), who she still has a good relationship with to inform him of the outcome. She said he didn't believe there was another canal in #15 and will likely be requesting CBCT and clinical images...I haven't heard from him yet though.

It is unfortunate that so many patients I see have had unsuccessful experiences with dentistry and root canal therapy leading to negative opinions of the treatment options and profession. These patients are in our office literally every day, asking why? why? why? Here is another case of failure that required a consult lasting an hour and half to help the patient understand her condition, the etiology, and the treatment options (not many in this situation unfortunately). Having invested significant time and money in her teeth without success, it was challenging (understatement) to earn her trust in my diagnosis and plan.

#18 has a sinus tract tracing to the furcation radiolucency and a clinical class 2 furcation.
#19 has a narrow isolated 8+mm probing depth along the MB with an obvious apical-lateral lesion extending up the root.

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Thursday, December 8, 2011

Are Implants the Future of Dentistry or Just a Step Along the Way?

The real future in medicine and dentistry is in regenerative therapy. While restorative materials including cements, resins, rubbers, metals, titanium etc. are the best materials we currrently have to replace damaged, diseased or missing teeth, the big picture is to replace damaged tissue with regenerated tissues. The dental pulp stem cell has been identified as a source undifferentiated mesenchymal stem cells which may have ability to differentiated into cardio-myocytes, neurocytes, myocytes, osteocytes, chondrocytes and adipocytes. So while our current restorative materials/techniques are the best available in the world, the future of dental care is tissue based rather than titanium based.

While regenerative treatments in dentistry are still years, perhaps decades away, endodontists are beginning to explore this area with what is called pulpal revascularization. This concept of taking a necrotic pulp in an immature root and stimulating revascularization of the pulp canal to allow for continued root development. Yes, I said continued root development. That is a completely new concept.

Here's another case report.

This 9 year old was at home and jumping on the bean bag and someone pulled it away, caught his tooth and completely avulsed tooth #8. It was out of the mouth for 20 minutes and properly replanted by the pediatric dentist.

A couple weeks later, symptoms presented. The tooth was opened, debrided and pasted with Ca(OH)2 paste.

Shortly after (<2 weeks) the tooth was reopened, instrumented lightly to apex, irrigated with 5.25% NaOCl, rinsed with saline and dried with paper point. A file was then used to pierce the periapical tissues to induce bleeding into the canal. An MTA coronal barrier was placed with wet cotton and IRM temporary. PLEASE NOTE THE PA LESION

At 3 month recall the tooth is asymptomatic and pa lesion has resolved.

At 9 month recall the tooth is asymptomatic and fully functional. No percussion pain, normal probings and NORMAL RESPONSE TO EPT. While there is no reaction to thermal testing, there is definitely a normal response to ept.
Looking closely at the radiograph you can see that the dentin walls in the apical portion of the root have thickened and there appears to be dentinal bridging forming in the mid-root area.

While this procedure has also been called pulpal regeneration, some argue that it should be called pulpal revascularization. It is not completely known what type of tissue that is growing into the canal or the source of that tissue (cells from within the canal or migrating in from the periapex). The continued development of the root and healing of the lesion however, is not debatable.

This type of novel treatment may give us a glimpse of the future of dental treatment using tissue regenerative techniques rather than artificial tooth replacement with traditional restorative materials.

For more information regarding the considerations of this procedure, click here.

To see more cases of pulpal revascularization, click here.