Tuesday, June 16, 2015

5 Year Recall on a Cracked Tooth

Now you are probably wondering what that title means?  As we all know, posterior teeth often get craze lines (surface cracks) in the enamel due to truama, large restorations, heavy occlusion or parafunctional habits.  When these craze lines go past the enamel and into the dentin, we refer to them as cracks.  Coronal cracks are very common in adult teeth.  Seeing a coronal crack in a tooth should prompt you to question the occlusal forces, parafunctional habits, size the existing restoration, the vitality of the tooth and then the need for coronal coverage.

This patient came to our office in early 2010.  She was reporting throbbing pain to temperature that had been bothering her for a couple of weeks.  She also reporting biting pain.  Diagnostics found #3 was normal to cold test, normal to probing, mild pain to percussion, pain to biting pressure.  DX; #3 reversible pulpitis with symptomatic apical periodontitis and cracked tooth syndrome.  We decided to treat endodontically before a crown would be placed.

Upon accessing the pulp, we found a stained crack on the mesial and smaller crack on the distal.  Pt was informed that these cracks would not be completely removed, and would affect the long term prognosis for the tooth.  The patient, understanding that the prognosis is guarded, elected to preserve the tooth as long as possible by completing the RCT and placing a crown.

RCT was completed and returned to GP for coronal coverage.

5 year recall of the tooth finds it fully functional and asymptomatic. Note the fine margins of the crown which play a key role in the success of this treatment. Some patients will elect to retain a natural tooth with a crack, understanding the guarded long term prognosis, rather than extract and replace it immediately.

Monday, June 8, 2015

Are Dental Implants Forever?

In previous posts, we have discussed the differences between implants and root canal therapy.  We have made the argument, which is still seen playing out in many of our dental journals, that implants and root canals are not really alternative treatments.  If a tooth is restorable (no root fracture, stable periodontium) then maintaining the the natural tooth is the ideal treatment.

At Superstition Springs Endodontics, we work with the best dentists in the east valley, who understand and help their patients understand the value of the natural tooth. However, many patients get information from other sources that give them the impression that implants are just like teeth, but never get cavities, periodontal disease or any of the other challenges we have in maintaining our natural teeth. This view is not the whole story and doesn't help patients understand the unique challenges that implants have.

Those who propagate the idea that implants are a better and hassle-free version of natural teeth will use implant research to argue that an implant is more successful than traditional restorative dentistry.  Many patients and some dentists are convinced that dental implants are without complication and have unlimited lifespan.  It is not until recently that we have begun to see articles addressing the "Failure of Dental Implants" (JADA Aug 2014, p.835-842.)  Terms such as "ailing" implants and "reimplantation" are new on the scene.

However, an article in the Journal of Clinical Periodontology by Cairo et. al. reviewed the quality of reporting of randomized clinical trials in implant dentistry from 1989 - 2011.  Their systematic review found that the implant trials were mainly parallel trials, single center trials.

Methodological flaws noted were:
Random sequence generation only 37% of the time
No information given regarding allocation concealment 75% of the time
Correct sample size calculation only 12% of the time
Blinded examiner only 42% of the time

While these methodological flaws affected the reporting of these studies, they also noted that the quality of these studies only partially improved over time.  They found that allocation concealment was at a high risk of bias, there was a lack of reporting characteristics of drop-outs, and lack of CONSORT adherence.

The authors concluded that with these methodological flaws, and failure to adhere to CONSORT, the statistically significant results reported in this body of implant studies, caution is suggested in data interpretation and generalization of outcomes.

It is also noted that many of the methodological flaws seen in implant research are also found in endodontic research, dental research in general, and all throughout medicine as well. However, we should expect and demand that the quality of the research published and used to make treatment recommendations should be improving over time.


Greenstein, G. Cavallaro, John. "Failed Dental Implants: Diagnosis, Removal and Survival of Reimplantations" JADA 2014. 145(8), 835-842.

Cairo, F., Sanz, I., Matesanz, P., Nieri, M., Pagliaro, U. "Quality of Reporting of Randomized Clinical Trials In Implant Dentistry. A Systematic Review on Critical Aspects in Design, Outcome Assessment and Clinical Relevance"  J. Clin Periodontol 2012. 39(Suppl. 12), 81-107.

Friday, June 5, 2015

Medicare Opt-In or Opt-Out Delayed Again

CMS has delayed the enforcement of the new Medicare rule until June 1, 2016.  The deadline for enrollment has been moved back to Jan 1, 2016.

For more information from ADA, click here.