The Endo Blog

Value and Limitations of CBCT in Endodontics-Case Report

2012-01-19T05:50:00.000-08:00

For the longest time, I have been skeptical of the ability of the CBCT to detect vertical root fractures. Especially in previously treated teeth, where scatter radiation produces artifacts in the image. There has been research(mostly in vitro) supporting CBCT imaging for detecting fractures(Hassan 2009), and there is no doubt that the technology shows exciting promise for use in our field. This case demonstrates both the value and limitations of this exciting imaging system.

The patient first presented six months ago with new crowns on teeth #30 and #31. His symptoms were described as a spontaneous ache and a soreness to mastication that started with the new crowns and felt localized to #31. Diagnostic testing revealed percussion sensitivity and a lingering dull ache to cold on #31, as well as a mild soreness to bite forces on #30. The original root canal treatment and post on #30 were over 15 years old. A diagnosis of irreversible pulpitis was made for #31 and treatment was completed. The mild bite soreness on #30 was attributed to a heavy occlusion and/or some referred pain from #31. Here is our post op radiograph:

The patient reported an episode of severe spontaneous pain lasting one day in the area that started four days after the first visit for #31 and resolved prior to his second visit. This odd experience certainly raised some alarms for me, but when he returned, a new exam and series of diagnostic tests produced nothing of note.

At three months following treatment, the patient reported continued discomfort to mastication in the region. An exam and diagnostic testing produced some continued bite soreness on #30. A new periapical radiograph revealed a possible missed DB canal:

I also speculated on what appeared to be the early formation of a lateral radiolucency on the mesial root that could be the result of a vertical fracture:

However, there were no significant probing depths, only mild symptoms, and no obvious signs of an apical radiolucency. At this point, to aid in our diagnosis, I recommended a CBCT. I reviewed the scan at length individually, and with a periodontist and with an expert from the company. I immediately confirmed the missed DB canal, but also noticed an obvious radiolucency associated with the distal root. What we could not find, independantly or together, was any sign of a fracture in the mesial root or of any lateral bone loss along the root.

It's remarkable the accuracy with which we can pick up the missed DB canal and see the periapical radiolucency (PARL) that was not evident on the periapical radiographs above.

With the new diagnostic information, the decision was made to retreat #30. Of course, I still warned the patient about the risk of losing the tooth if a fracture is found in the root structure. Upon access, I was greeted with the familiar sight of purulent drainage pulsing up the distal with each heartbeat:

Below you can see the missed DB canal before and after post removal: Unfortunately, upon cleaning up the mesial, two fractures were found leading to the MB canal. One along the mesial wall:Another fracture was found along the MB wall: These large fractures probably form a wedge out of the MB root. Unfortunately, they severely compromise the prognosis of our treatment. I cleaned and disinfected the untreated DB canal before placing calcium hydroxide. I then closed the tooth and recommended extraction to the patient. Because of our diagnostic efforts involving a lengthy consult with clinical and radiographic images, the patient was understanding of his situation and appreciative that every effort was taken to diagnose his problem and save his tooth.

In this case, I had high hopes that the CBCT might confirm my suspicion of lateral bone loss around the mesial root. The CBCT was excellent, as it has been in the past, at confirming missed canals. However, it has still not demonstrated to early detect a vertical root fracture prior to an obvious clinical and periapical radiographic presentation.

If anyone has any questions or input, or has had different experiences with the CBCT. Please share them! Also, check out our office's facebook page at www.facebook.com/alpharettaendo where I post new cases regularly.

FAIR Health Consumer Cost Lookup

2012-01-06T15:11:00.000-08:00

FAIR Health is an independent, not-for-profit organization that was established to maintain a database to help insurers and consumers determine reimbursement rates for out-of-network charges, and provide patients with a clear, unbiased explanation of the reimbursement process. This first-of-its-kind database will allow consumer to get cost estimates for medical and dental procedures in their geographic area. The database will also help consumer estimate how much their insurer will reimburse for procedures performed "out of network". This website should help patients to clear the cloak of secrecy around the "out of network" reimbursements that the insurance companies work so hard to maintain.

If you think the insurance companies set this up to help consumers understand the insurance process, then think again. This is part of the large settlement following a 2009 investigation by New York State Attorney General Andrew Cuomo that discovered a conflict of interest between the Ingenix database, which was used by insurers nationwide to set reimbursement rates for "out of network" health services. Ingenix happened to be a subsidiary of UnitedHealth, the second largest insurer in the nation. It was determined that Ingenix had a vested interest in helping set rates low so companies could underpay patients for "out of network" services.

You can check out the website, and encourage your patients to use it too!

http://www.fairhealthconsumer.org/

This, Not That, Follow up

2011-12-21T07:16:00.000-08:00

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.

For more case reports and content, please follow Alpharetta Endodontics on Facebook. www.facebook.com/alpharettaendo

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

2011-12-08T19:18:00.000-08:00

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.

Who Cares About the Periodontal Ligament?

2011-11-28T22:00:00.000-08:00

Congratulations to the manufacturers and marketers of dental implants! We now have patients with perfectly good teeth considering removal and replacement with implants on their very own! We are actually seeing patients that are convinced that an implant is better than a natural tooth!

I was once at a seminar where a specialist was discussing implants to a group of endodontists, when I asked a question regarding the periodontal ligament, the lecturer replied, "Who cares about the periodontal ligament?". Perhaps that is a good questions to ask?

The periodontal ligament is the difference between a natural tooth and an implant.

While implants are an ideal way to replace a missing tooth, an implant will never be able to replace the periodontal ligament.

I think perhaps we overlook the benefit of having a periodontal ligament in our haste to condemn a tooth and replace it with an implant.

The periodontal ligament is the dense, fibrous connective tissue that connects the tooth to the bone. It is vital in the transmission of masticatory force from the tooth to the bone. It acts like a shock absorber, giving the tooth some movement in the socket. It provides proprioception, or feeling to the tooth. Without proprioception, we can have traumatic occlusion and have no sense of it (ie. fractured porecelain). The periodontal ligament also has an important interaction with the adjacent bone. If you loose the ligament, you will also lose bone. The periodontal ligament is the home to important cells such as osteoclasts, osteoblasts, fibroblasts, cementoblasts, cementoclasts, undifferentiated mesenchymal cells (stem cells). These cells are all important in the dynamic relationship between the tooth and the bone. These cells are important in orthodontic movement or extrusion. The periodontal ligament and its associated cells may be the only real consistant way to stimulate bone growth.

Consider the long term effects of losing a tooth (and its periodontal ligament) and replacing it with an implant...

1. The implant cannot be moved in any direction from its integrated position.

2. There WILL be crestal bone loss initially.

3. There WILL be crestal bone loss over time - up to 0.2mm/year

4. There will be loss of proprioception

5. With loss of crestal bone come loss of gingival height and esthetic issues.

As I mentioned, implants are a great way to replace MISSING teeth. But they are not alternative treatment for restorable teeth.

This patient was seen over 3 years ago. Tooth #8 was diagnosed as necrotic w/ acute apical abscess. She had swelling and pain at the time. Antibiotics were prescribed and RCT recommended.

Patient has returned again today with swelling and pain. She reports that she did not have RCT done because the swelling and pain went away. There is no mobility, despite the increased size of the lesion. The RCT has been recommended again. Unfortunately, due to previous experience with root canals, she is convinced that they are less successful than an implant.

Proper understanding of the role of the periodontal ligament with this tooth should help her decide the only acceptable way to treat this tooth is with endodontic treatment.

This, Not That.

2011-11-17T06:34:00.000-08:00

Short one today.

This is what a maxillary second molar root canal treatment should look like:

Rethink what you are doing if your cases look like this:

Consult Along: A Day at Alpharetta Endodontics

2011-11-09T12:06:00.000-08:00

Rather than try to have an overarching theme to this post, I will present each of today's patients as each case was complex and each illustrate rather important points. For the sake of brevity, I will only post significant findings (and I apologize for poor consistency and errors in grammatical tense) . Unless otherwise stated, assume medical history is non-contributory. I would love for readers to post feedback, alternate treatment plan ideas, or other approaches to these cases.

Patient 1:

This patient presented with a history of root canal treatment on #20 by an endodontist 1-2 years ago. #19 was treated by her general dentist ~8 months ago, and #18 was fractured and replaced with an implant within the last two years. The crown came loose and was replaced with a post 1 month ago. Following this treatment, she described severe pain upon chewing and swelling on her tongue side of the tooth. There is no extraoral sign of swelling or lymphadenapathy. No intraoral swelling or sinus tract. Around #19, the gingiva is edematous and inflamed with bleeding on probing. The crown margins are open and overextended. The probing depths on #19 are 3 mm interproximally and 8-9mm mid buccal and mid lingual. The radiograph reveals a laterally widened PDL with a hint of an apical radiolucency. The restoration on the mesial is into the furcation and associated with horizontal bone loss. #20 displays an apical radiolucency as well. The implant on #18 is bulbous and overcontoured to the mesial with some signs of horizontal bone loss.

Unfortunately, I recommended extraction of #19 due to the likelihood of a vertical root fracture and a poor restorative prognosis. I recommended she return to her previous endodontist for reevaluation/recall of #20. I also provided her some proxibrushes to maintain oral hygiene around #18. Would you rather have that root canal/crown or that implant...or neither?

Patient 2:

This patient is referred by her general dentist for evaluation of #3 and initially presented two weeks ago. She reports having root canal therapy a year and a half ago by another local endodontist, no microscope. Since the time of treatment, she has had spontaneous "shooting" pain that is localized to tooth #3. It is worse in the morning and with mastication. A history of symptoms indicates that the tooth was likely vital preoperatively and so persistent bacteria is not a feasible etiology. No extraoral swelling or lymphadenopathy. No intraoral swelling or sinus tract. Probing depths 2-3mm, crown margins are in tact. Occlusion is light in MI with no interferences. No palpation tenderness, no swelling, no sinus tract, no percussion tenderness, no mobility. Slight bite pressure tenderness on the MB cusp and P cusp only.

Preop, no radiolucency, slight ligament widening in the palatal, short palatal obturation, overenlarged mesial obturation in the cervical third, undermined/weakened mesial tooth structure. Diagnosis: previous treatment/acute apical periodontitis. Possible etiology: restorative recontamination, root fracture, strip perforation of MB/MB2. I recommended retreatment but cautioned that a finding of a root fracture would indicate a need for extraction.

Upon access, blood was found on the palatal canal, and, in spite of anesthesia, the GP was tender to pressure with fluid built up around it. No fractures were found. Additionally, a strip perforation was found in the cervical third of MB2. It was repaired with MTA and the palatal canal was retreated. The patients symptoms resolved immediately, and the case was finished this morning.

Patient 3:

This patient went to her new dentist for a broken restoration on #30. Decay was found encroaching on the pulp chamber and she was referred for root canal therapy. She is asymptomatic. #31 was treated 2 years ago by another endodontist, no microscope. The anatomy appears to be very challenging. A history of symptoms of cold sensitivity and throbbing pain prior to the previous treatment indicate that #31 was likely diagnosed as irreversible pulpitis preoperatively.

Treatment on #30 was completed at today's visit and treatment options for #31 were discussed. Restoratively, the case is compromised with a crown on a buildup with voids. Additionally, retreatment of the mesial root is going to be challenging if not impossible. If, as it appears, the distal root is the primary source, retreatment may be successful. One alternative, if retreatment is not successful, is to place spacers to loosen the tooth and then try an intentional reimplantation. Apical surgery is difficult to impossible in this location with such long roots (25mm working length on #30).

Patient 4:

Asymptomatic, original treatment over 15 years ago. Her crown and posts came off and extensive recurrent caries was found beneath. Her dentist cleaned the area and placed a temporary crown before referring her for evaluation. While radiographically, the ligament is in tact, her history indicates bacterial contamination and retreatment was recommended.

Case #5:

This patient is asymptomatic. She recently moved here and her new dentist noted a parulis buccal to #30. She is ~85 years old. Probing depths were 2-3mm with bleeding on probing and a class 1 furcation involvement. The margins on the composite were open. Due to the compromised restorative prognosis and the furcation radiolucency, I recommended extraction. She does not wish to replace this tooth at this time, but an FPD is likely her best option. She is fortunate to have full molar occlusion on her left side.

I hope that our readers learned something from these cases. You will probably realize that I started no new root canal treatment today, and that all our cases were complex diagnostically and involved molars. This is typical for our practice.

If you have any input or questions, please voice them in the comments, but please remain constructive. As always, I invite readers to see more cases posted regularly on our facebook page at www.facebook.com/alpharettaendo.

If you have any suggestions or requests for future posts, please leave them in the comments!

Saving Teeth: Repairing a Resorptive Defect with MTA

2011-10-27T09:50:00.000-07:00

In 2006, #19 was diagnosed as necrotic pulp w/ acute apical periodontitis. An irregular radiolucency was noted on the mesial aspect of distal root. This was diagnosed a resorptive defect. While some may have elected to remove the tooth and place an implant or bridge, this patient wanted to preserve her tooth, so a root canal and root repair was performed.

During our RCT procedure, the resorptive defect was cleaned out without perforation of the root. The appearance of the post-op radiograph appears to show some kind of communication.

At 20 months, the patient returned for recall and a large furcal lesion was present. Once again, more may have elected to extract the tooth and replace it with an implant or bridge. We discussed options/prognosis and decided to retreat and try to repair the resorptive area with MTA.

#19 was retreated and resorptive defect repaired with MTA. You can see the resorptive defect was opened more aggressively and there was extrusion of MTA into the periodontal ligament.

3 year recall (since the retx and repair with MTA) shows complete healing of the furcal lesion. The tooth is fully functional and asymptomatic. This is a tooth was was saved by endodontic therapy using the right material. This tooth was saved by endodontic therapy and the use of MTA to repair and seal the resorptive defect.

Avoiding Root Canal Therapy with MTA

2011-09-26T12:10:00.001-07:00

Dr. Hale's excellent post on pulp canal obliteration inspired me to share these few cases where a coronal barrier was also used to avoid root canal therapy. The most recognized reason to avoid complete pulpal debridement is biological, to maintain pulpal vitality, and thus continue root formation, subsequently improving fracture resistance, but there also exist technical limitations on the debridement procedure, imposed by anatomy or resorptive defects, that might prevent success of conventional root canal therapy.

This first example is a straightforward partial pulpotomy (or Cvek pulpotomy) with an MTA direct pulp cap. This patient had cerebral palsy and toppled out of his wheel chair causing a complicated (pulpal involvement) crown fracture of #10. You will note #9 was treated at this time as well, and if I recall correctly, was discolored and non-vital from a previous similar trauma. Multiple dental injuries (and traumatic injuries of all kinds) are very common in CP patients due to negative effects on balance. Fortunately, working with a pediatric dentist who scheduled OR time, the patient was seen within two days of the incident and the pulp vitality of #10 was maintained. Remember, inflammation in traumatic exposures very slowly spreads apically, and immature pulps with large vascular supplies are largely resistant to necrosis in the short term.

PreOp

Post-op

1-Year Recall

Please note the complete root formation.

At a 1 year recall, #10 responded normally to vitality testing. Radiographs revealed a complete formed root and a dentin barrier beneath the MTA. Astute viewers will note this success is amazingly in the absence of a coronal restoration (unfortunately, not the only time I've seen bare, unrestored MTA pulp caps succeed at 1 year recalls).

This next case is similar, although a little less conventional. As you can see in the preoperative radiograph, the root is severely dilacerated. While certainly it is possible to perform root canal therapy on this type of root (see my previous post for an arguably more challenging S curve), the difficulty level is unquestionably high. This treatment plan not only reduces the risk of instrument separation, but also saves the patient time and money, and the operator from fatigue.

PreOp

Post-Op

The key here is that this was an asymptomatic carious pulp exposure. In the case of symptoms of irreversible pulpitis, it is generally thought that an MTA pulpotomy is a more risky procedure. It is certainly contraindicated in cases with symptomatic apical periodontitis (although I have had success direct pulp capping an immature tooth with apical periodontitis).

This last case is open to the most controversy. This patient had multiple large composite restorations across the anterior maxillary dentition. He admitted to being far more motivated by financials than esthetics. His previous composite restoration and crown had sheered off unconventionally at an oblique angle to the buccal leaving a substantial cingulum. The fractured portion had been rebonded by his general dentist. This tooth had a history of trauma over 40 years ago and some extensive external resorption is visible overlapping an obliterated pulp chamber and canal. The PDL is definitely in tact and there is no history of symptoms. The option of extraction and implant placement was discussed and encouraged. The alternative treatment plan chosen by the patient is less than ideal and the patient was more than okay with a compromised long-term prognosis. I intentionally described a grim outlook to the patient, as I do with most unconventional treatments, although here I can admit that I am confident in the predictability of the patient's choice. As you can see from the preop radiographs, conventional root canal therapy is impossible due to the irregular resorptive defect sandwiched between obliterated canal space.

PreOp

PostOp

I am still waiting on the general dentist to forward over a restored recall radiograph. Hopefully I will have the image to edit in by the end of the week. You can see the post space that I prepared using a 2 round bur and a gates-glidden with the tip flattened. The post space communicated with the resorptive more coronal than I anticipated, necessitating the use of MTA as a sort of resorptive cap. I feel as long as the area remains aseptic, it is reasonable to assume a successful result.

Here is a bonus case posted on our facebook page, http://www.facebook.com/pages/Alpharetta-Endodontics/137382942943581 . I'd encourage everyone to follow there (and check the backlog of case photos) for more interesting cases.

The patient's symptoms were intermittent, spontaneous, a 6 or 7 out of 10 on the pain scale, occasionally throbbing, and worse with mastication and pressure. The key history here is the patient's remark, "it feels like my gums are coming loose from my tooth."

Make the diagnosis. I have obviously helped by circling the key components.

Calcific Metamorphosis (Pulpal Obliteration) and Internal Bleaching

2011-09-16T23:09:00.000-07:00

It has been reported that 11.6% - 33% of boys and 3.6% - 19% of girls suffer some kind of dental trauma before age 12. Internal staining is common following a traumatic injury to a tooth. Calcific metamorphosis is the partial or complete obliteration of the pulp following dental trauma. An interesting study of 168 traumatized, discolored, anterior teeth found that 47.6% were partially obliterated, 31.6% were totally obliterated, and 20.8% were found necrotic. Necrosis was more associated with fractured teeth, while pulpal obliteration was associated with subluxation and concussion injury. It was also noted that injuries suffered in the 1st and 2nd decades of life resulted in more pulpal obliteration, while those suffered in the 3rd decade resulted in necrosis more often.
To remove this discoloration, typically endodontic therapy is performed and internal, non-vital bleaching is performed. The following case is a variation of this procedure.

This 13 year old boy previously suffered a traumatic injury. Tooth #8 has discolored. The tooth is asymptomatic. Non-responsive to thermal testing, normal to percussion and probing.
It was decided to perform endodontic therapy, prior to internal bleaching to improve the esthetics of this tooth.

Partial pulpal obliteration is noted. A 1mm thick calcific barrier is found just below the level of the CEJ.

RCT is initiated and a complete calcific barrier is noted. It was decided to perform the internal bleaching without endodontic therapy.

A standard internal coronal barrier (glass ionomer) is placed over the calcific barrier to prevent internal bleach from exiting through cervical dentinal tubules and causing an inflammatory reaction in the pdl. A walking bleach technique is used. (Opalesence Endo)

After 1 week, pt returns and the internal bleach is removed. This tooth will be recalled to monitor vitality over time.

If pulpal obliteration occurs without necrosis, there may not be a need for endodontic therapy prior to internal bleaching. If a coronal barrier can be placed, without exposure (and possible contamination) of the pulpal tissue, then it would seem that internal bleaching could be performed without the need for complete endodontic therapy. Long term recall to monitor vitality will be done with this type of approach.

SOURCE:
Adeleke O Oginni and Comfort A Adekoya-Sofowora "Pulpal sequelae after trauma to anterior teeth among adult Nigerian dental patients", BMC Oral Health 2007, 7:11doi:10.1186/1472-6831-7-11.

Cone Beam (CBCT): To Use or Not to Use?

2011-09-01T21:22:00.000-07:00

There has been some discussion about the indications for use of CBCT in endodontics. The AAE and AAOMR released a joint position statement regarding the use of CBCT in endodontics.

The section on patient selection criteria states, "CBCT must not be used routinely for endodontic diagnosis or for screening purposes in the absence of clinical signs and symptoms. The patient’s history and clinical examination must justify the use of CBCT by demonstrating that the benefits to the patient outweigh the potential risks. Clinicians should use CBCT only when the need for imaging cannot be answered adequately by lower dose conventional dental radiography or alternate imaging modalities."

I would suggest that there are times when a clinician has no way of knowing what additional information a CBCT would provide prior to starting treatment. This information may often prevent complications, such as perforation, which potentially could affect long term prognosis.

The following case is a perfect example.

This patient came to SSE for emergency treatment. #18 DX: Necrotic pulp w/ Symptomatic Apical Periodontitis. RCT initiated. 3 canals located, however a 4th distal canal is not found. 2 distal roots are apparent the pre-op film. The ML, MB and a distal canal are located. The distal is opened looking for the 4th canal. After 20-30 minutes of searching for 4th canal, the patient is re-appointed for 2 step treatment.

Upon return for second visit, the symptoms of SAP have not completely resolved. Slight vestibular swelling noted. We decided at that point to take a CBCT to help us located the 4th canal.

The CBCT clearly shows us that a perforation has been created (red arrow), and the additional canal/root is lingual to the DB canal. A sagittal view, provided only by CBCT, can provide information that is not available by conventional radiography.

With these images, the 4th canal is easily located within minutes of opening the tooth.

In this case, a CBCT provided valuable information that identified location of the 4th canal. If taken prior to starting, the 4th canal would have been located more quickly and without the small perforation in the distal.

I am not suggesting that CBCT should be used on every patient, but I am suggesting that with multiple rooted teeth, the sagittal & axial view provided by CBCT can save time and prevent endodontic complications, both of which provide justification for a more routine use of CBCT in endodontics. In our practice at SSE, the CBCT is not a profit center. We have priced these images to make them affordable to all patients. Our implementation of CBCT is to provide the highest quality of endodontic care available.

Persistent Post-Treatment (Apical) Periodontitis.

2011-08-17T08:36:00.000-07:00

When endodontically treating a tooth experiencing symptoms to percussion, that is symptomatic apical periodontitis or acute apical abscess, it is reasonable and normal to expect those symptoms to persist a few days following treatment. I make it a point to explain to patients that this sensitivity is emanating from the periodontal ligament surrounding the tooth, and, just like a sports injury, ligaments require time to heal following removal of the insult (bacteria in teeth). However, occasionally we evaluate a tooth that has had symptoms to percussion for an extended period of time. In this post, I will discuss the sources of these symptoms and how to diagnose and treat them. I will also show a few cases of persistent apical periodontitis and how they were managed.

Before we get into diagnosis and cases, it is essential to understand the sources of apical periodontitis. With few exceptions, the source of symptoms is either trauma, occlusal or otherwise, or bacteria, apical or otherwise. It really is that simple. It is up to the clinician, through history and exam, to determine the source of symptoms.

Briefly, a common scenario would be a tooth with an apical radiolucency, sensitivity to percussion, and a lack of cold response. Our diagnosis is necrotic/symptomatic apical periodontitis and the source of both is bacteria. By removing the insulting bacteria with root canal therapy, we can resolve the apical periodontitis and the radiolucency will heal with time. The below images are from a patient with that exact scenario and illustrate an important point.

This #18 clearly has a challenging s-curvature in the apical third of the mesial root. If we are unable to instrument and clean around that curve, we run the risk of bacteria persisting, and consequently, symptoms persisting.

Fortunately, with a little luck, I was able to clean around the curve and the patient's symptoms resolved within a day of initiation of treatment and calcium hydroxide placement. Also, note the mid-mesial canal. There is an important point here:

With a necrotic tooth, if symptoms persist following treatment, especially if the treatment is deficient in cleaning or rife with errors such as a perforation, then we must suspect bacteria as the source and look to treat the tooth endodontically (possible retreat and/or surgery).

Here is another scenario, this patient was referred for evaluation and treatment of symptoms in the lower left. Symptoms were described as a short, sharp sensitivity to chewing over the past year and a half, and a moderate sensitivity to hot and cold that lingers for a few minutes over the past few months. The patient points to #19 for the chewing sensitivity and farther back for #18. Clearly, we have two issues at hand as an endodontically treated tooth will never cause the type of sensitivity described by the patient.

The previous root canal treatment was done by an endodontist a year and a half ago. This endodontist evaluated the patient and placed him on penicillin and methylprednisone. I must stop here and say that I do not support treating this situation with these medications. I have never felt compelled to prescribe steriods and rarely prescribe antibiotics. It is easy to understand why when we realize that neither of these medications will address the possible sources of the patient's symptoms. Permanently resolving the inflammation will not happen without removal of the trauma source and systemic antibiotics will not have any effect on bacteria within a root end. Symptoms can be masked, but even a placebo can help a patient's symptoms. In this case, following medication, there was some improvement in symptoms but they soon returned.

Let us ignore the cold sensitivity for a minute, which was traced to #18, found to linger and be associated with a cracked tooth, and was treated appropriately. What questions are important to ask the patient at this point? Maybe we can deduce the diagnosis of #19 prior to treatment. As it turns out, with more specific questions, I learned that the tooth was cold sensitive prior to root canal therapy, and that these symptoms resolved. I also learned the tooth was actually asymptomatic until the crown was placed a few weeks following treatment. Now, I can proceed to the clinical and radiographic exam knowing that the most likely cause of apical periodontitis is a traumatic occlusion, since even a poor root canal on a vital tooth will likely be asymptomatic for many years before bacteria can negotiate to the apex.

Exam revealed #19 to be sensitive to percussion and bite forces (in MI and with a bite stick), and #18 to be hypersensitive with a prolonged cold response and a fracture. I also located a 5mm ML probing depth with associated erythematous and edematous gingiva. The crown on #19 was bulbous, overhanging the lingual, and flat on the occlusal with wide contacts.

In the below radiographs, we see a short obturation on the mesial and distal roots of #19 with some slight and debatable ligament widening. Not a perfect root canal but unlikely to be the source of symptoms.

Another radiograph revealed overhanging cement on the mesial.

Local scaling removed the excess cement and crown recontouring with a diamond bur combined with an occlusal adjustment was performed. The patient returned for treatment of #18 a few days later and all his symptoms from 19 had resolved. A reevaluation in a few months will determine if our treatment worked permanently. Incidentally, here is the completed treatment on #18 (and check out the distal root of 17 curving at the x-ray plane).

The point to be learned from this case is that an accurate and complete history will illuminate possible sources of the problem, exam can confirm that source, and conservative local treatment will often be enough to resolve symptoms. Occlusal trauma is the most common cause of post-treatment apical periodontitis.

Here is a case I treated that exhibited persistent symptoms and is similar in many respects to the one above. The original symptoms and exam were indicative of irreversible pulpitis and extensive recurrent caries was located underneath the buccal margin. I painted a grim picture and recommended extraction. The restorative prognosis was compromised, decay reached into the furcation and alveolar crest. Nevertheless, the referring dentist was confident and capable, and the patient was well informed knowing the risks and that periodontal therapy was in her future. She was anxious to avoid implant treatment due to a prior bad experience with one in another site.

At the second visit of treatment, the patient reported her symptoms to cold had quickly resolved. However, her tooth that was not previously symptomatic to percussion was now hypersensitive to occlusal forces. I had not cleaned long at the first visit, and I had not yet placed the obturation material (not that these usually cause any problems). Likewise, I had merely placed CaOH within the top of the orifices as a barrier to reinfection and not deep into the canals (again, not that this usually causes a problem). The tooth was out of occlusion as well so the only possible source of ligamental inflammation was the buccal area where decay had been removed to the level of the alveolar crest and into the furcation. This area was not well restored yet, merely patched with IRM, and was a definite irritant to the ligament. I cautioned patience, completed treatment, and recommended returning to her general dentist for evaluation and restoration.

When the patient returned for reevaluation a month later, complaining of chewing sensitivity in the temporary crown, I was impressed with the quality of the buccal composite restoration and the buccal gingiva was minimally inflamed. The distal gingiva was inflamed with bleeding on probing. The patient had plans for an evaluation with a periodontist and I again counseled patience with symptoms until all periodontal treatment was complete. The occlusion was found to be heavy in non-working lateral excursion and adjustment relieved the patient's symptoms in the chair.

The important point here is since I had done the initial root canal treatment, I knew that the tooth was vital preoperatively. There is no way I would consider touching this tooth with any endodontic therapy since I know that I cannot improve upon my root canal treatment. The dental history leads me to look for sources of trauma to the ligament, occlusion and biologic width infringement in this case.

One other common cause that I see of persistent apical periodontitis is when a patient wears an occlusal splint or night guard, dentist fabricated or store bought, that is not well adjusted following a new crown on the tooth. Consider how a kids teeth feel after an orthodontic visit and you will understand the source of these symptoms.

This last case was treated by a general dentist 2-3 years ago and has exhibited persistent symptoms that have only seemed to worsen through multiple occlusal adjustments. The dentist reports an instrument separation in the distal root. Her symptoms had only recently become spontaneous and were described as a minor dull ache or pressure. In discussing the situation with the patient, she remembered the tooth being asymptomatic and the crown having been placed years prior to the root canal treatment. She claimed the referring dentist saw signs of a problem on the radiograph and recommended treatment through the crown. Clinical exam revealed no relevant findings and occlusion appeared well adjusted. A distal shift radiograph, the most important radiograph to take on a maxillary molar, displayed an all too common radiographic finding in maxillary molars treated without a microscope, a radiolucency on the mesial root.

The most common cause of this problem and one that we see every week is a missed MB2 (also called MP or ML) canal. This tooth was unusual in that I speculated a missed MB canal outlined below.

Upon retreatment, the untreated MB canal was found and is seen on the below photograph and radiograph.

The patients symptoms resolved quickly following the first visit. Here is the post operative radiograph.

Not all cases of persistent apical periodontitis require endodontic retreatment or surgery. In fact, most don't. By a taking a careful dental history, it is often possible to discern the preoperative diagnosis, which informs how and where bacteria could be causing a problem. It is also possible to create a timeline as to when symptoms first occurred and what events could have initiated them. If symptoms started with restorative work, then carefully examine the occlusion, margins, and gingival health. Only when we have a radiolucency or a smoking gun, like a missed canal, a short obturation in a previously necrotic case, or a case recontaminated with recurrent caries, should we be looking into endodontic therapy as our first choice to solve the problem. Often times, diagnosis is not clear, and I start with the conservative options, occlusal adjustments and periodontal therapy, before proceeding to endodontic therapy. I cannot think of a single instance where I have recommended medication as a primary therapy.

I hope these cases will help those of you out there to think like an endodontist. Some may point out that I have not talked about tooth fractures. I plan to discuss my philosophy on those in future posts. I look forward to any feedback and invite everyone to check out more cases on our facebook page: http://www.facebook.com/pages/Alpharetta-Endodontics/137382942943581

The Blame Game - Root Canal Failure?

2011-07-29T09:06:00.000-07:00

CASE #1
I recently completed a diagnostic excavation on this tooth and determined that it was non-restorable due to decay under mesial crown margin and into the pulpal floor of the tooth. The findings of the implant surgeon indicated a "failed root canal" as the cause for extraction.

It is well known that a common reason for endodontic failure is root canal recontamination caused by coronal leakage. If coronal leakage allows bacteria to re-enter the root canal system, then did the root canal fail or did the restoration fail? In this particular case, when rampant caries is found under the crown margin and extending into the pulpal floor, it is more accurate to say that extensive recurrent decay is the reason the tooth is non-restorable requiring extraction.

A review of the root canal history also confirms that endodontic therapy was successful.

This pt presented in 2006 with an prior rct & acute apical abscess. Retx was recommended. A periapical lesion is noted on the distal root.

Retreatment completed in 2006.

In 2010, the patient returns with symptoms. The distal lesion has healed, and the mesial margin of the crown shows leakage. It is recommended to remove crown and excavate decay.

The radiographic history would indicate that the endodontic retreatment performed in 2006 was was successful with healing of distal lesion.

When a tooth is to be extracted, a proper diagnosis should be given.

CASE #2

This patient came to our office today for consultation. Pt reports that RCT was done many years ago without any issues. Last year he traveled to Mexico for some dental work. The crowns were placed on #30 & #31. A periapical lesion has now developed on the mesial root of #30. My diagnosis is: prior RCT w/ symptomatic apical periodontitis. Coronal leakage is identified radiographically on mesial and distal margin. In this case, you could easily say the root canal failed. However, the inadaquate coronal seal on #30, in my opinion, is just as likely the cause for the periapical lesion on the MB root.

In our practice at Superstition Spring Endodontics, we would diagnose #30 as: Prior RCT with SAP (symptomatic apical periodontitis - percussion pain) with coronal leakage. Retreatment would be recommended. We would explain to the patient that for long term success, we need to prevent any leakage from above. (We would also recommend evaluation of mesial margin #31 by general dentist)

A proper diagnosis does not cast blame. It objectively reports current findings and indicates the reasons for recommended treatment.

Success with endodontic surgery (apicoectomy)

2011-07-21T22:33:00.000-07:00

This patient was kicked in the face by a horse in 1998. Teeth were displaced (luxated). She repositioned them herself. RCT's on #24 and #25 were done in 2008 by her general dentist. In
Jan 2011 she is having pain, percussion sensitivity, normal probings, adjacent teeth WNL. These teeth are diagnosed as: Prior RCT's w/ Symptomatic Apical Periodontitis.

Axial and sagittal views in CBCT verify that these are single canals incisors. It also shows us the extent of the bone loss prior to our surgical access.

Due to the large size of the canals and over extension of the previous RCT, it was recommended to treat these teeth surgically with an apicoectomy.

Apicoectomy completed with MTA retrofill.

At 6 month recall the teeth are fully functional and asymptomatic. Radiographs show impressive healing of the apical bone. Endodontic surgery can preserve the natural tooth, which then helps to preserve the periodontium.

UPDATE: 1 year recall. Pt asymptomatic, fully functional.

CASE #2

The following case is a similar, double apicoectomy. The CBCT confirmed that there were no missed canals. The large posts and good crown margins were the reasons we chose surgery over non-surgical retreatment.

Endodontic surgery saves natural teeth.

Evaluation of #2 for Retreatment, CBCT Revisited.

2011-07-07T10:34:00.000-07:00

I want to thank Dr. Hales for the introduction and for inviting me to contribute here on the Endoblog. I've been following and learning from the Endoblog for some time. It's my hope that I can not only share some of my knowledge, but also receive some valuable feedback from others who read this blog with other experiences and points of view.

Many interesting cases, treated by myself and Dr. Stephen Parente, can be found on the Facebook page for our practice: http://www.facebook.com/pages/Alpharetta-Endodontics/137382942943581 I would urge those interested in endodontics to check us out there as well.

This past week, I evaluated a patient who's tooth reminded me of the case previously presented here on June 7th by Dr. Hales. Since it was so similar, I thought it would be a perfect follow up and first post. This patient had #2 treated with root canal therapy 1 year ago by another endodontist. I am familiar with this endodontist's work from other patients requiring retreatment and know that he does not use a microscope. He also tends to limit most treatments to one visit.

The patient described symptoms as an occasional spontaneous dull ache of varying intensity that has persisted since initial root canal treatment. At worst, the symptoms are moderate with some pulsing or throbbing. At the time of evaluation, the patient was experiencing a mild awareness of the tooth, a common description of symptoms from a failing root canal. Prior to root canal therapy, symptoms were similar, but more intense, and the patient has no recollection of any hot or cold sensitivity at that time period. From this information, we learn the tooth was likely necrotic prior to treatment, which is relevant when understanding possible challenges to disinfection. The symptoms are well localized, and the patient points directly at tooth #2. The tooth has been reevaluated by the previous endodontist and by the referring dentist. They adjusted the the occlusion and prescribed antibiotics.

The relevant medical history consists of prior dual knee replacement surgeries in 2009 and 2010 necessitating antibiotic prophylaxis. The patient is currently taking clarithromycin (Biaxin) for a sinus infection, but the tooth symptoms predate the sinus problems by many months.

Extraoral exam revealed no relevant findings. Intraoral exam revealed normal tissue contour and consistency with no swelling or sinus tracts. All probing depths were 2-3mm and percussion and bite tests produced only a mild discomfort on #2.

In addition to the above two radiographs, I also examined a bitewing and two traditional film radiographs which I chose not to include here. One thing that stands out is that the crown margin is placed on the buildup, not an ideal situation. You can see only two canals treated and an in tact PDL. The orifices of the canals are clearly overenlargedand the obturation does not appear to follow the root anatomy.

Drawn below is what I drew for the patient, predicting the true root and canal anatomy of the tooth and showing where I speculated there to be an untreated distal buccal canal.

It appeared as if the previous operator perforated during instrumentation, not only between the mesial and distal roots, but also at the apex. In addition to these root perforations, the coronal tooth structure is clearly compromised. The patient was anxious to save the tooth since she invested in root canal treatment and a crown within the last year. I did not feel retreatment would have a good prognosis and recommended extraction. The patient was understandably reluctant about this option, and so I opted to image the tooth with CBCT for more information and better patient education.

In the below left image, I circled the missed DB canal. The below right images (one is reversed, please forgive me) display the missed DB root in the sagittal plane as well as the apical perforation and over enlargement (strip perforation) of the MB root.

The below horizontal slice displays the previous instrumentation into the furcation between the MB and DB roots. I question if the radiolucent line mesial to the radiopacity is a fracture.

The left and below images show a palatal radiolucency forming as well as the off center and possibly apically perforated palatal obturation.

This last image to the left is a horizontal slice in the apical third of the root again displaying the palatal radiolucency forming.

The CBCT shows this tooth has many problems that are not reliably correctable with endodontic retreatment. Finding the missed DB canal and even repairing the MB perforation in the furcation will not help recapture the correct path of the MB or P canals.

The CBCT confirmed with certainty what was highlighted in the periapical radiograph above. With these images, the patient was better able to visualize the root anatomy and obstacles to repairing this tooth. Consequently, the patient was much more accepting of the treatment plan of extraction.

We are increasingly using the CBCT as a diagnostic tool in our practice, specifically in complex retreatment cases or in vague diagnostic situations. In this specific case, the CBCT images confirmed suspicions about root perforations and missed anatomy. They also displayed a palatal radiolucency that was not evident on the periapical radiographs. Lastly, and not to be overlooked, the images were invaluable for patient education and treatment plan acceptance.

All CBCT images provided by Dr. Colin Richman and his Kodak 9000.

The Endo Blog Welcomes a New Contributing Author - Dr. Justin M. Parente

2011-06-23T08:04:00.000-07:00

We would like introduce and welcome a new contributing author to The Endo Blog, Dr. Justin M. Parente of Alpharetta Endodontics (Alpharetta, GA).

Dr. Justin M. Parente is from Alpharetta, GA. After undergraduate studies the University of Georgia, he attended dental school at the Medical College of Georgia. While at dental school, he earned awards for clinical excellence in both periodontics and endodontics, as well as awards for academic achievement and the highest score on the national boards. Dr. Parente was recognized as distinguished Hinman scholar and was inducted into OKU dental honors society upon graduation. He then completed the two year endodontic specialty program at the Medical College of Georgia. At the annual meeting of the American Association of Endodontists, Dr. Parente presented and won an award for his research on endodontic irrigation. Dr. Parente lectures and mentors students in endodontics at the Medical College of Georgia. He lives in Alpharetta, GA and enjoys playing guitar, reading books, and drawing art.

Dr. Parente has presented at the American Association of Endodontists annual meeting and at his local chapter of the Seattle Study Club. He serves as a scientific advisor for the Journal of Endodontics, peer reviewing research submissions.

He is a member of the American Association of Endodontists, the Georgia Association of Endodontists, the American Dental Association, the Georgia Dental Association, the Hinman Dental Association, the Northern District Dental Society, Southern Endodontic Study Group, the Alpha Omega Dental Society and the Seattle Study Club.

Welcome Dr. Parente!

To Scan or Not to Scan?

2011-06-07T10:34:00.000-07:00

This patient had RCT #2 done about 8 yrs ago in the military. She is reporting pain of several days duration. Today it is percussion sensitive, normal perio probings, no swelling or palpation tenderness. Adjacent teeth are WNL.

Radiographs reveal peripical radiolucency and conical shaped root. Two canals have been filled. My assumption is that this is likely a c-shaped canal that was incompletely treated. We decided to take a CBCT to evaluate the root form to determine if there is a missed canal or c-shaped canal. If a canal is missed, then retreatment will be recommended. If all the canals were found, then we might consider a surgical approach.

I was surprised to see a large resorptive defect on the DB root surface. This defect has destroyed most of what was once a DB root. Non-surgical retreatment of this tooth would result in perforation and extrusion of RCT material, and likely failure. It was determined that surgical treatment of this tooth would also have a poor prognosis as well. Extraction has been recommended.

Also noted was a perforation in the floor of the Mx sinus, with adjacent sinus inflammation. This tooth is also causing a sinusitis of dental origin. Removal of this tooth should help clear up some of the chronic sinus issues the patient has been experiencing.

Another example of CBCT showing what you cannot see in a traditional radiographic image. Neither of these problems were identifiable with regular imaging and were not the purpose were were taking the scan. However, identifying the root resorption and the sinus perforation had a significant impact on the diagnosis and treatment plan for this patient. The CBCT is a valuable tool for case selection which improves the rate of successful of endodontic treatment at Superstition Springs Endodontics.

3D Evaluation of Root Canal Morphology (Cone Beam Computed Tomography)

2011-05-28T12:12:00.000-07:00

At Superstition Springs Endodontics, the use of cone beam computed tomography (CBCT) is a valuable tool in endodontic diagnosis and treatment. This technology is used on a case by case basis, following the guidelines specified in the joint position statement by the AAE and AAOMR.

The joint position statement by the AAE and AAOMR regarding the use of CBCT in endodontics states that "The patient’s history and clinical examination must justify the use of CBCT by demonstrating that the benefits to the patient outweigh the potential risks. Clinicians should use CBCT only when the need for imaging cannot be answered adequately by lower dose conventional dental radiography or alternate imaging modalities."

A significant concern noted in this position statement is the added radiation dosage to the patient. In our practice, using the J. Morita Veraviewepocs 3De, the patient is exposed to the lowest radiation dose on the market. A single 40 x 40mm 3D scan exposes the patient to 0.029mSv. This is approximately the same amount of radiation a patient would receive with 9 digital periapical films (0.003mSv).

The volume of data acquired in a single scan allows us to look at that tooth from any coronal, sagittal or axial view, and the ability to re-slice the volume at any slice thickness. This volume of data can be manipulated over and over to gather unlimited amount of information about the tooth and it's periapical tissues.

A CBCT scan, provides visualization of root number & anatomy, canal number & morphology, much more accurate evaluation of peripical tissues. Understanding the advantages of CBCT, the limited radiation and limited liability associated with a focus field CBCT, I would suggest that the benefits routinely outweigh the potential risks. Unfortunately, there are often benefits of a CBCT scan that are not apparent unless the scan is taken. The following case is an example.

This patient presented with complaint of pain in lower left quadrant. Recent crown prep on #19. Regular diagnostics were inconclusive as to the source of this pain (#19 was testing normally to vitality, probing and percussion testing) A short obturation of #18 was noted, but this tooth was asymptomatic. After short period of time waiting to see if symptoms localized, and failure to do so, a CBCT scan was acquired to evaluate if there was apical bone loss associated with one of these teeth that would help in the diagnosis.

CBCT did not show any radiographic lesions on #18 or #19. The temporary crown #19 was removed for additional pulpal testing. Tooth #19 gave no response to cold on the buccal side and a vital response on the lingual side. It was decided that endodontic treatment should be initiated on #19 with a probable "partially necrotic" pulp.

The CBCT gives us valuable information about tooth #19. For example, following CBCT, prior to starting RCT #19, we know that the mesial root is a single root with 3 canals that merge. We also know that distal root has a single canal.

3 canals found in a single, mesial root. This was identified prior to treatment with CBCT. In this particular case, the 3rd (middle) canal would likely not have been found due to its location.

In this case, the CBCT identified a variation in the mesial canal morphology. Knowing that the mesial root was a single root and that it had 3 canals, gave me the ability & confidence to explore the ML-MB groove to a greater depth than would have normally been done for fear of perforation. This is a perfect example of radiographic information that is not available through traditional 2D imaging. This information allowed us to provide better cleaning, shaping and obturation, which will lead to a better RCT.

Endodontic Retreatment - Another Tooth Saved!

2011-05-06T21:28:00.001-07:00

DX: Prior RCT w/ Chronic Apical Abscess
Huge periapical lesion noted. A thin, short (mesial) and long (distal) obturation.
Retreatment recommended.

Retreatment completed.

4 month initial healing seen.

2 yr recall shows fantastic healing. This tooth could easily have been condemned and extracted initially. Proper diagnosis, and ability to improve the cleaning, shaping and obturation allowed this tooth to be saved. Endodontists are specialists in saving teeth.

CBCT to Evaluate Apical Lesions

2011-03-24T10:23:00.000-07:00

We have been discussing the use of CBCT in the practice of endodontics. There have been questions about whether CBCT is really necessary, or just another cool image. That particular question was one of the biggest we had in our decision to move to CBCT. We also ask that question to ourselves when we recommend a CBCT scan to our patients. However, much like a microscope, until you look through the scope, you often don't know what you are missing. I have found that quite regularly, I will find things that I could not have seen otherwise and it has changed the treatment that I have recommended.

Here's an example of a routine CBCT scan that I did prior to endodontic surgery. This scan gave me added information, that then changed the treatment plan and give us better prognosis.

This patient presented for evaluation. The teeth are asymptomatic, but a lesion seen by his general dentist. The lesion is obviously on the MB root of #3, with ledged MB canal. The crown margins looked good and since the MB canal is ledged, we were planning to treat this tooth with an apicoectomy. I recommended a routine, pre-surgical CBCT to evaluate the root anatomy, sinus proximity and buccal bone contours.

This slice through the MB root shows that there is a missed MB#2 canal.

A slice through the palatal root shows a periapical lesion on the palate not visible in the original, pre-op radiograph. This now changes our treatment recommendation. An apicoectomy will resolve the MB issues, but fail to resolve the palatal lesion. This could cause continued problems and lead to the assumption of a failed endodontic surgery, when the palatal root could be the problem.

An additional slice through the palatal roots shows that #2 also has a significant periapical lesion requiring treatment.

A sagittal view of #2 again shows the extent of the lesion.

While the lesion on the palate of #2 is visible in the original radiograph, there is no doubt about it's presence with the sagittal view above.

In this case the additional information about the palatal lesion on #3 changed the treatment recommendation and will thereby improve the prognosis. Lack of CBCT scan in this case would have led to wrong treatment recommendation.

That being said, I know there are those who will say..."alway retreat first" and you don't need a CBCT scan to make that decision.

CBCT provides improved imaging of the the teeth and periapex. I welcome the added information into the diagnostic and treatment part of my practice. For more information about the application of CBCT into endodontics, the upcoming Inner Space Seminar is right around the corner.

Implant Training by Mentorship!!!!????

2011-03-08T09:03:00.000-08:00

I think we all agree that continuing education is one of the foundations of every profession.

It guarantees that practitioners remain up to date and abreast of new techniques, materials and research studies that are continuously changing and improving.
With that in mind, I have noticed a trend in the past two years that in my opinion is alarming, if not outright dangerous for the dental profession.

Recently many, for profit, seminar groups, institutes and other continuing education providers are marketing so called “Implant Mentorship courses”. Most of these courses are 2-4 days. Most faculties are general dentists and they claim they provide training for implant placement and restoration in that time period, through “mentoring”.
As an educator and a practitioner; I believe these kinds of so called “training”, will only give a false sense of knowledge and competence to people attending them.
The advances in implant dentistry have been wonderful for patients who are missing one or more teeth. In my opinion, any general dentist, who is interested in implant dentistry, should seriously think about attending these courses.

The best continuing education training programs in implant dentistry are offered by dental schools through out the United States. These programs are spread over a few months (usually about 300 CE hours or more) and all aspects of implant dentistry from A – Z are covered.
Faculties are periodontists, oral surgeons, prosthodontists and general dentists. And, they will tell you at the end of these programs, that you should not take on certain implant cases due to level of difficulty or possibility of complication. Keep in mind that a poorly done endodontic case, can easily be corrected by retreatment or apical micro-surgery. A poorly done implant case, is very very difficult and sometimes impossible to correct.

From a legal point of view,when a general dentist begins to perform procedures that are primarily performed by specialists, the law holds them to the standard of care, expected of specialists providing similar procedures on a regular basis.
Before you sign up for one of these implant training or mentorship courses, stop and think. Would you have an implant done on yourself or a loved one by a dentist that had training for 2-3 days?

I welcome your comments.

Robert Salehrabi, DDS

2011-03-03T15:54:00.000-08:00

Did you know that 70% of Americans are afraid of root canals?

Root canal treatment allows patients to save their natural teeth. The endodontists at Superstition Springs Endodontics are partners with general dentists in helping to save natural teeth. Modern, microscopic endodontic treatment can be a relaxing and pain-free experience.

In a recent AAE survey, 76 percent of participants said they would prefer a root canal to tooth extraction.

Nearly a third would not sell a healthy front tooth for any amount of money.

Most people are not aware that root canal treatment is a viable alternative to tooth extraction

Despite great progress in modern endodontic therapy, there are still misunderstandings about root canal treatment.

Myth #1: Root canal treatment is painful.
Myth #2: Root canal treatment causes illness. (focal infection theory still persists today!)
Myth #3: A good alternative to root canal treatment is extraction.

Cone Beam Computed Tomography (CBCT): A Proper Introduction

2011-02-18T16:00:00.000-08:00

At Superstition Springs Endodontics (SSE), we have recently integrated Cone Beam Computed Tomography (CBCT) into our practice of endodontics . In my opinion, CBCT is the future of endodontics and the applications in endodontics seem almost limitless. For this reason, we have chosen to implement this technology into our practice.

However, here are a few basic principles about CBCT that might be helpful.

Traditional Computed Tomography (CT or CAT Scan), uses a linear detector and a fan shaped X-ray beam (diagram on left). The detector spins around the patient multiple times over the area to be scan. The computer then takes all of these slices and puts them back together into a 3D image. CT scans are very effective at differentiating between soft and hard tissues.

With Cone Beam Computed Tomography (CBCT), a large detector is used, a cone shaped X ray beam is used, and all data is gathered in a single pass (diagram on right).

This makes the CBCT a smaller unit with the ability to focus the radiographic exam, a single pass around the patient, less radiation exposure and less costly procedure.
CBCT is most effective at evaluation of hard tissues. An important fact to point out is that radiation exposure with CBCT in general is significantly less than traditional CT. Some CBCT units have reduced the radiation exposed to a fraction of the amount of traditional CT.

The field of view (FOV) is an important factor in selecting a CBCT. CBCT has the ability to take a large FOV (full skull), medium FOV (Mx & Md) or focused field (quadrant).

A voxel is a 3 dimensional pixel. The resolution of a CBCT image is determined by the voxel size, as well as the unit's ability to gather & interpret the data with minimal interference/noise.

CBCT units with smaller voxel size are more effective for applications in endodontics, allowing us to see the detail needed.

There have been concerns about the additional radiation exposure associated with CBCT. For the reasons described above, the focus field CBCT has a fraction of the radiation exposure associated with traditional CT. Here are the numbers on radiation...

Since radiation affects different body tissues differently, an effective dose compares the radiation dosage on different body parts on an equivilant basis. The unit for effective dose is the sievert (Sv) joules/kilogram.

In medical procedures, the millisievert (mSv) is used to measure the effective dose.

We are all exposed to about 3.0 mSv/year of natural radiation. Natural radiation comes from the earth as well as from the atmosphere/space.

The following table shows the radiation exposure from several dental radiographic sources as well as medical CT and environmental exposure.

An average American receives 0.0082mSv per day in normal background radiation.

As you can see, one periapical film with d-speed film exposes a patient to 0.0095mSv (which is the equal to about 1.1 days of natural radiation).

A digital periapical film exposes a patient to 1/3 the amount of radiation, 0.0032mSv (which is the equal to about 0.36 days of natural radiation).

The radiation exposure of several CBCT units is listed below.

The amount of radiation exposure is minimal. As with any diagnostic radiographic image, we must balance the need for the information vs. the potential harmful effects of radiation.

The radiation level associated with a CBCT at SSE is the lowest radiation level of any dental CBCT currently available on the market.

Some have inquired into which CBCT that we are using at Superstition Springs Endodontics. We selected the Veraviewepocs 3De by J. Morita. The features we like about it are its high resolution, fast speed, panorex feature, low radiation level and ease of use.

Since many of you will not be able to visit our office to see this in action, the following video clip shows the ease of use and speed of our CBCT.

The following video clip also shows some of the additional benefits of CBCT.

If you are in the Phoenix east valley, we would invite you to contact Annette at our office to schedule a "lunch & learn" and CBCT demonstration (annette@superendo or 480 807-8022). This would include a live demonstration and introduction on how to read a CBCT scan.

If you are in the Phoenix area and would like more information regarding J. Morita or any other CBCT systems (Sirona, Instrumentarium, Soradex, Planmeca or NewTom), contact Jordan at (jordanlhales@gmail.com or 480 227-0435). He will get you any product information for your review.

Pulpal Regeneration - More Evidence

2011-02-01T12:31:00.000-08:00

In previous posts regarding pulpal regeneration, we have shown not only apical closure, but some dentinal bridging coronal to the apex. While difficult to believe, we have also seen teeth become responsive once again to electric pulp testing. The tissue that forms during pulpal regeneration has been described as "pulp-like", which includes some kind of innervation.

The following case was re-evaluated at 1 year using CBCT. The ability to evaluate apical closure in 3 dimensions is a new way of evaluating success of apexification/apexigenesis/regenerative procedures.

The following case was previously reported and includes the CBCT follow up.

Apical closure at 6 months is noted in regular films.

1 yr recall using CBCT not only shows the apical closure, but coronal bridging under the MTA barrier. In this case a collagen plug was placed prior to MTA. This accounts for the space between the MTA and the new dentinal bridging.

A sagittal view of the tooth also shows complete apical closure as well as coronal dentinal bridging. In this particular case, the MTA plug was not placed deep enough below the enamel and staining occurred, despite using white MTA.

The teeth responded to electric pulp testing with the following readings
#7 - 31 & 36
#8 - 42 &38
#9 - 29
#10 - 28

We recently completed internal bleaching. We removed the MTA down to the layer of collagen plug. Staining noted at the WMTA-dentin barrier. We mechanically removed as much of stain as possible, placed a new coronal barrier and then bleached with the Ultradent endodontic bleaching product. The tooth now looks great. (Sorry no photos on this part)

CBCT as a Tool in Endodontic Diagnosis

2011-01-19T15:48:00.000-08:00

Cone Beam Computed Tomography (CBCT) is a valuable tool in endodontic diagnosis. The following case illustrates how CBCT provides added diagnostic information not available through traditional 2D imaging.

This patient was referred to our office today after a long week of infection and diagnostic dilemmas. Here's the story...

10 days ago with an ear ache.
9 days ago pt reports pain to chewing & closing teeth together.
8 days ago swelling began. Pt went to ER and was given zithromax, ibuprofen & tylenol #3.
7 days ago swelling increased under tongue and into face.
5 days ago, pt returned to ER where they did a CT scan and found nothing. Pt reports numbness in lip. Pt admitted to hospital and given IV clindamycin. MRI done and "something was found in lower left jaw". Pt started 300mg clindamycin.
Today, patient referred from oral surgery for endodontic consult/vitality testing. Here's how he looked.

Radiographs fairly inconclusive. #18, #19, #20, #21 all normal to percussion, probing and thermal testing.

A small crack noted on the distal marginal ridge of #18. Thermal testing once again indicates a vital pulp. Typically, we would expect a necrotic tooth to be the source of the submandibular swelling that this patient has experienced.

Since tooth #18 is responding normally to thermal testing, we decided to take a CBCT to look for more evidence of the source of infection.

This coronal slice (.25mm) shows radiolucency around the distal root #18. This image is more conclusive than the standard 2D image.

A sagittal slice through the distal root of #18 shows the lesion and its perforation of the lingual plate.

An axial view of the distal root of #18 also shows perforation to the lingual.

These CBCT slices are conclusive enough to revise the pulpal diagnosis to "partially necrotic" and recommend endodontic treatment. It appears that the distal root is necrotic and the infection is spreading through the lingual plate.

RCT initiated. Upon access, we find vital pulp tissue in the mesial canals, and necrotic pulp tissue in the distal canal.

Further removal of the distal crack finds the crack extending down the distal root, below the CEJ. Extraction is recommended.

In endodontic diagnostics, we typically classify pulpal status as:

1. Normal
2. Reversibly Inflammed
3. Irreversibly Inflammed
4. Necrotic

However, things are not always a cut an dry as that. This case illustrates that "partially necrotic" pulp is a possible classification of pulpal status.

Following removal of the tooth, the infection quickly resolved.

CBCT is an important tool for diagnostic imaging in endodontics.

CBCT to Evaluate Internal Root Resorption

2010-12-27T22:02:00.000-08:00

CBCT can be used to evaluate the extent of root resorption. Before this technology, we would have to excavate a resorptive defect to evaluated the extent and restorability. The CBCT allows us to see in all dimensions the extent of a resorptive defect. In this case, the non-restorability was determined with CBCT alone. This saves the patient and clinician time and money.

This video is made of individuals slices 1.0mm thick with 0.25mm interval between each slice.

CBCT to Diagnose Sinusitis of Dental Origin

2010-12-16T21:04:00.000-08:00

The CBCT can be used to make a diagnosis of sinusitis of dental origin.

Successful Perforation Repair using MTA

2010-11-29T22:14:00.000-08:00

This patient presented for treatment of #30 in March 2009. Prior RCT had been done and a large furcal lesion as well as periapical lesion were noted. Retreatment was recommended. Upon access, we found 2 additional canals as well as a furcal perforation. The tooth was obturated and perforation was repaired using MTA.

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.

Superstition Springs Endodontics goes 3D

2010-11-17T21:14:00.000-08:00

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.

An inexpensive solution for transillumination

2010-11-10T21:56:00.000-08:00

At the most recent Inner Space Seminar, we discussed all different kinds of cracks in teeth. We reviewed how to detect them, classify them, treat them, & prevent them. An effective way to identify cracks in the crown of a tooth is by using transillumination.

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.

Managing a Cracked Tooth

2010-11-01T13:55:00.001-07:00

Dealing with cracked teeth can be very challenging. In the first place, there is a lot of confusion about what we are calling a cracked tooth. Craze lines, fractured cusps, split teeth and vertical root fractures are all often called "cracked" teeth. However, treatment and prognosis are different for all of these different situations.

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.

Would you implant or do RCT? - UPDATED

2010-08-30T12:43:00.000-07:00

I work with some great oral surgeons & periodontists. I was recently asked to evaluate tooth #31 by my periodontist colleague. This patient had been referred to him for extraction and placement of an implant.

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.

Pulpal access revealed a necrotic pulp chamber.

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.

Clinical Clues for Identifying Cracked/Fracture Roots

2010-08-20T21:48:00.000-07:00

Accurate diagnosis of a cracked/fractured root is a difficult task. It is important to get it right, because the treatment for a cracked root is usually extraction. I explain to patients that there are some clinical signs that would indicate a cracked root, but they are not 100% conclusive all the time. These same clinical signs can occur in other situations as well.

The typical signs associated with a cracked/fracture root that we have previously reported:

1. J-shaped lesion or large lateral lesion

2. Deep, narrow periodontal pocket

A couple new clinical signs that I have not previously reported include:

3. Swelling in the in the marginal gingival, adjacent to the fracture

4. Failure of a swelling to resolve despite a course of antibiotics

The more of these clinical signs I see in one patient, the more confident I am that the root is cracked/fractured.

I explain to patients that the only way to know with certainty is to visualize the crack. This is most effectively done with magnification. This can either be done through an endodontic access, or through a small periodontal flap to examine the root surface. I expect that with time, CBCT will be better able to help us in the diagnosis of cracked/fractured roots. At this time, the CBCT does not appear pick up on a cracked/fractured root until the pieces of the root begin to separate.

Here is an example of a case in which several of the described clinical signs were present indicating a cracked/fractured root. Access and visualization confirmed the diagnosis of cracked root.

Pt presents with a swelling in the marginal gingiva adjacent to distal root of #19. The radiograph shows a large, lateral lesion on mesial of distal root. Patient had been taking Penicillin for several days, without resolution of the swelling. Antibiotic was changed to clindamycin to see if swelling would resolve.

Swelling did not resolve after taking clindamycin.

At this point, I am quite certain I will find a cracked root. If this were simply a perio issue or an endo issue, I would have expected it to clear up with the antibiotics.

Access into pulp chamber exposes a vertical crack/fracture on the MB root as well as the DB root.

The tooth is deemed non-restorable and extraction recommended.

If you are unsure if a tooth has a cracked/fractured root, contact your endodontist. Not all teeth can be saved, but endodontists are the specialists for saving teeth and can help you determine which ones to save.

Upgrading your Root Canal

2010-07-29T16:00:00.000-07:00

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.

Removal of previous gutta percha show obvious corrosion and leakage.

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.

Pulpal Regeneration - More Case Reports

2010-07-16T11:32:00.001-07:00

For more information on pulpal regeneration, click here.

Uses of Cone Beam in Endodontics

2010-07-06T09:44:00.000-07:00

At a recent Inner Space Seminar, Dr. Dale A. Miles reviewed the principles of cone beam imaging and introduced a wide variety of applications for CBCT in dentistry. The following video clip describes how CBCT may be useful in the practice of endodontics.

More information about Dr. Miles and cone beam and digital imaging can be found at Dr. Miles' website: www.learndigital.net

Malpractice Claims in Endodontics

2010-06-24T21:31:00.000-07:00

A recent study by Givol, Rosen, Taicher & Tsesis, published in the Journal of Endodontics, points out some interesting facts about malpractice claims in endodontics.

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.

SOURCES
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.

Why All the "Buzz"? Cone Beam Imaging

2010-06-04T10:00:00.000-07:00

Dr. Dale A. Miles DDS, MS, a diplomate of the American Board of Oral and Maxillofacial Radiology will be presenting the upcoming Inner Space Seminar entitled, "Why All the "Buzz"? Cone Beam Imaging. At Superstition Springs Endodontics, we feel it is the role of specialists, not manufacturers, to educate the dental community. With all the new information regarding 3D imaging, and the barrage of marketing to go with it, we have invited a specialist in radiology to come and share his expertise and experience with cone beam imaging.

Regenerative Endodontics - Another Case Report

2010-05-07T09:20:00.000-07:00

Regenerative endodontics is the application of tissue engineering concepts into the treatment of the pulp-dentin complex. We all know that the pulp has regenerative/healing properties. We routinely tell our patients that the restorative treatments that we do will cause inflammation/irritation to the pulp. Occasionally, we even encroach upon the pulpal space and then medicate the pulp in an effort promote pulpal healing and repair. The formation of reparative dentin is evidence of the pulp's ability to regenerate/repair dentinal tissues.

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.

A necrotic tooth #29, with a large periapical lesion, and wide open apex is selected for regenerative endodontic therapy. The canal accessed and the pulp completely removed to the apex with minimal filing and copious NaOCl irrigation.

A coronal MTA plug is placed to prevent coronal leakage, while the apical portion of the tooth is left wide open for regeneration.

At 3 months, the large apical lesion has healed.

At 6 months, the apex is thickening and lengthening.

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.

Regenerative Endodontics - New Frontiers in Endodontics

2010-03-29T08:00:00.000-07:00

Regenerative endodontics is an exciting new concept that seeks to apply the advances in tissue engineering to the regeneration of the pulp-dentin complex. Multiple case reports have shown the ability for previously necrotic, immature teeth to "regenerate" pulp-like tissue allowing for continued development of the tooth.

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.

More recently, MTA apexification has become more common. This consists of debridement of the immature root and immediate obturation with MTA. This shortened the treatment time, but the problem of short, thin roots still 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.

Here is an example of pulpal regeneration performed at Superstition Springs Endodontics.

This young patient had tooth #8 avulsed. The tooth was stored in milk <1hr>

Tooth #8 was accessed, pulpal tissue removed with minimal filing and copious NaOCl irrigation.

Coronal MTA plug placed w/ cotton & resin access filling.

At 2 months, the periapical lesion is gone and tooth is asymptomatic.

At 4 year recall, the apex has closed, the dentinal walls of the root have thickened and the tooth is asymptomatic and functional.

The protocol for this procedure is still being developed. The American Association of Endodontists is building a database regenerative cases to aid in the development of this protocol.

The upcoming Inner Space Seminar entitled, "It's Alive! Pulpal Regeneration" will review concepts in stem cell therapy, current accepted treatment protocol for pulpal regeneration and additional case reports of pulpal regeneration.

Indications for Intentional Replantation

2010-03-16T16:00:00.000-07:00

Intentional replantation is the intentional removal of a tooth and replantion into the socket following endodontic manipulation.

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.

CASE #1

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.

CASE #2

Initial RCT completed.

Sinus tract persists.

Non-surgical retx completed and symptoms persist. Discussion with patient of options:
1. Extraction
2. Replantation
Pt understood options and selected intentional replantation.

Atraumatic extraction, immediate resection.

Replantation completed.

3 month recall. Tooth asymptomatic and completely functional.

Sources:
Pathways of Pulp, 9th edition - online version. p767-768.

Is That a Root Fracture?

2010-02-11T16:36:00.000-08:00

Large J-shaped lesions are often associated with vertical root fractures. This tooth was asymptomatic to percussion, non responsive to thermal testing and surprisingly normal to probing. Diagnosis: necrotic pulp and asymptomatic apical periodontitis. It was was determined to be an endodontic problem.

The large radiolucency extends up the distal root into the furcation. Microscopic examination during endodontic therapy revealed no root fracture. In this case, the assumption of a root fracture, based on radiographs alone, would have been incorrect.

Without proper diagnosis, this tooth might easily be labeled a fractured root and extracted. A new crown is indicated to prevent coronal leakage.

Root Canal Treatment Saves a Perforated Tooth

2010-01-12T20:21:00.000-08:00

This root canal was started in July '09. After having difficulty finding the canals, the tooth was referred to our office.

Upon opening the tooth, we found a supraboney perforation on the ML surface.

Canals were located using a operating microscope and the root canal completed.

The ML perforation was repaired using Geristore. (Since this perforation was above the crestal bone, a restorative material that would not wash out must be used. MTA is not the best material in this type of perforation)

A six month recall finds the lesions almost completely healed and the tooth pain free and functional.

Calcium Hydroxide as Intercanal Medicament

2009-12-09T14:31:00.000-08:00

Ca(OH)2 pastes are used in endodontics as a temporary canal filling material for multiple purposes including:
1. Stimulate continue root development
2. Control exudate/disinfect the canal system
3. Prevention of external root resorption following traumatic injuries
4. Create an apical barrier following over instrumentation

Occasionally, I will use calcium hydroxide as a intracanal medicament to look for signs of initial healing prior to obturation. On this particular retreatment case, the distal canal was long and wide. I was concerned there may have been some resorption or possible an apical crack that I could not visualize.

Pre-Operative Radiograph

Calcium Hydroxide paste was placed (and extruded) in the canals.

3 month recall shows remarkable resorption of the extruded Ca(OH)2 and healing of the apical lesion.

Tooth was re-obturated and another tooth has been saved!

Source:
Cohen & Burns. Pathways of Pulp 6th ed. p.406-407.

Herodontics? - Revisited

2009-12-03T14:00:00.000-08:00

In Aug 2009, an American Academy of Implant Dentistry press release stated, "...times have changed and patients should forego prolonged dental heroics to save failing teeth and replace them with long-lasting dental implants". While it universally accepted that implants are a great way to replace missing teeth, a more controversial topic is when to replace a diseased tooth with an implant. In my opinion, those promoting dental implants have become increasingly more aggressive about replacing natural teeth.

As a specialist, I am occasionally called upon to perform "heroic" procedures. This may be following some iatrogenic damage or by a patient who wishes to retain a natural tooth at any cost. While I would much rather treat a normal, straightforward endodontic case, the use of microscopes, ultrasonics and MTA have allowed us to preserve teeth that many would consider "hopeless". I am often amazed at the success that we have with some of these "heroic" cases.

The following case was previously posted, but the patient returned for a 4 year recall last month. Unfortunately, the patient was returning for another root repair perforation following endodontic access on a different tooth. This case would be considered a "heroic" case by anyone's standard! In this particular case, this patient has been pleased with his decision to retain the tooth.

Original Post
This root canal was done just over four years ago. The patient presented with pain to percussion, and an 8 mm buccal probing was present. The RCT had been completed 2 years previously and recently became symptomatic.
DX: Prior RCT w/ Symptomatic Apical Periodontitis.
Treatment recommended: Non-surgical retreatment, perforation repair with possible need for endodontic surgery. Prognosis: guarded.

As you can see, the MB canal is very calcified. Calcification of this kind would make this case a very high level of difficulty. The MB canal was missed and the furcation was found, instrumented & obturated. Proper case selection can help prevent this type of complication. However, if this does occur, one would expect to find bleeding and the tactile sensation of the pdl/cortical bone is very different from the canal. Length determination films, working films or final films should also identify the perforation. I would recommend immediate referral to an endodontist for treatment of an iatrogenic event such as this.

Retreatment completed. MB canal located and treated. Furcal perforation repaired with MTA. Patient placed on recall to watch the area and see if endodontic surgery will be required.

Recall at 2 years & 3 months. Patient reports complete function and no symptoms. The 8mm periodontal probing has dissappeared. This tooth is considered "healing", and scheduled for a 1 year recall.

You can call it "herodontics", but that tooth is functional, apical bone looks good, periodontal pocket has disappeared. This will be a fun case to watch over time.

4 Year Recall

Asymptomatic & fully functional.

NOTE: I have never said this is pretty. Actually, its pretty ugly. However, retaining the natural tooth has preserved the crestal bone, provided normal function, and cost much less in time and money than any replacement option available.

Retreatment & MTA Save a Perforated Tooth

2009-11-12T07:30:00.000-08:00

The following case was submitted by Dr. Rico D. Short of Smyrna, GA.

Original endodontic treatment was done 15 years ago. The crowns on 8 & 9 were replaced 2 years earlier at which time the dentist placed post for retention. During post preparation, the root was perforated. A large lesion has developed.

DX: Prior RCT w/ Chronic Apical Abscess w/ root perforation. Pt was informed the prognosis was questionable due to the perforation. Pt understood and consented for treatment including perforation repair.

Retreatment on #8 completed with MTA root repair.

8 month recall

22 month recall finds patient asymptomatic and functioning with no mobility and normal probing depths.

While many clinicians would have deemed this tooth "hopeless" and recommended extraction, MTA, microscopes and a expert clinician can save teeth that otherwise would be extracted.

Endodontic Retreatment & MTA Preserve the Tooth

2009-10-30T00:11:00.000-07:00

Here's a tooth that had endodontic treatment over 10 years ago. While the clinician had difficulty finding all the canals, the tooth has been functional for quite some time. A large furcal defect raises suspicion of a root fracture or perforation.

DX: Prior RCT w/ Symptomatic Apical Periodontitis.

There are many who would consider this hopeless and recommend extraction.

Let us consider the cause of this treatment failure:

1. Missed Canals

2. Furcal Perforation or Root Fracture?

Can these issues be addressed to preserve the natural tooth?

In my consultation with the patient, I explain these issues and that endodontic re-treatment may be able to save the tooth (as long as the root is not fractured). I also explain the alternative option of extraction.

Finding missing canals is a simple solution.

A perforated root can be repaired with guarded prognosis.

A fractured root will require extraction.

I tell the patient the only way to know for sure is to open the tooth and investigate. Considering the nice crown on the tooth, the cost of attempting to save the tooth is minimal, compared to the cost of removing and replacing. In this case the patient elected re-treatment.

Pre-operative radiograph.

Upon access, 2 additional canals are located and instrumented. A furcal perforation is also identified. No root fractures are found.

Re-treatment is complete. Canals obturated with gutta percha and furcal perforation repaired with MTA. Glass ionomer base is placed over MTA.

7 month recall shows a tooth that is fully functional with remarkable healing of the furcal defect. Endodontic re-treatment has preserved the natural tooth.

Dens in Dente

2009-10-13T17:48:00.000-07:00

Dens in Dente literally means "a tooth within a tooth". It is a developmental anomaly caused by an epithelial invagination during the development of the tooth. Enamel is laid down on the internal surface of the tooth. This is most frequently seen in maxillary lateral incisors.

A thin layer of enamel can be seen internally. An amalgam restoration was previously placed at some point to try and seal off the development groove into the dens in dente.

Access for endodontic treatment reveals the internal layer of enamel.

Endodontic treatment is completed.

This peg lateral incisor also shows the internal and external layers of enamel of a dens in dente. The large dens in dente has also affected the overall development of the tooth.
Submitted by: Dr. Rico D. Short of Smyrna, GA.

Apexification with Calcium Hydroxide & MTA Fill

2009-09-08T10:11:00.000-07:00

This 15 year old patient has a history of trauma to #8. Trauma occurred at an age before apical closure occurred. Tooth was diagnosed with necrotic pulp and symptomatic apical periodontitis. Note the large periapical lesion.

Traditional apexification using Ca(OH)2 was used.

Tooth debrided to the apex, NaOCl irrigation.

Ca(OH)2 placed.

3 month check shows resorption of Ca(OH)2, but apex still open. Apical lesion almost completely healed.

Ca(OH)2 placed again.

10 month re-evaluation. Apical barrier present, so it was time to obturate. This is a great view of the apical barrier that has formed.

Tooth was obturated with MTA. If this tooth ever needs apical treatment, a simple resection will be done without retropreparation or retrofilling.

Removing a Broken Endodontic File

2009-07-31T23:59:00.001-07:00

Anyone performing endodontics occasionally has a separated instrument. This case was referred for removal of a separated instrument.

The file is in the MB#2 canal. Since it is in the upper third of the canal, good visualization with a microscope and proper ultrasonic technique will make this file removal possible.

After finding the file, careful ultrasonic instrumention is used to remove dentin around the file - opening up the MB groove. This is done carefully without touching the file itself. We want to expose 2-3 mm of the file before we begin vibrating the file itself.

Too much contact with the file in this early stage can cause a coronal piece of the file to break off, making it more difficult.

Once the coronal coronal 2-3mm of the file has been accessed, the ultrasonic is placed on the most apical part of the file to begin vibrating it. This should loosen the file and vibrate it out. If the file breaks again, then repeat step one.

The file was removed and the MB#2 canal instrumented.

Removal of the separated instrument complete.

Use of an operating microscope is essential in effective removal of a separated instrument.

Lichen Planus - A Review

2009-06-26T16:40:00.000-07:00

Lichen planus is a fairly common condition that affects the oral mucosa. This idiopathic condition is believed to be an immunologically mediated.

The name likely comes from the appearance of the lesion which resembles that of a lichen. A lichen is a symbiotic organism composed of an algae and fungi.

There are medications that may induce a reaction in the oral mucosa that appears like the idiopathic form of lichen planus. The medication induced form of the this condition is referred to as "lichenoid mucositis" or "lichenoid dermatitis".

Lichen planus can cause skin lesions as well as oral lesions. Skin lesions are usually purple, pruritic, polygonal papules. Skin papules may exhibit Wickham's straie (lacelike network of white lines).

Oral lesions may be reticular or erosive.

Reticular lichen planus is most common. It usually causes no symptoms. Wickham's straie are seen throughout. The lesions may "wax and wane" over time. It is commonly seen in the buccal mucosa, but also seen in the tongue, gingiva, palate and vermillion border.

Appearance of reticular lichen planus in oral mucosa.

Erosive lichen planus is more symptomatic. It appears as atrophic, erythematous areas with ulceration. White straie are also seen in the periphery of the lesions.

Diagnosis can usually be made on clinical findings alone.

No treatment is usually recommended for reticular lichen planus. Antifungal therapy can be helpful if a candidiasis infection occurs.

Erosive lichen planus is usually treated symptomatically with topical corticosteroids and frequent follow up care.

The malignant potential of lichen planus has not been resolved. If the possibility for malignant transformation exists, it appears to be small and associated with erosive lichen planus.

Interlacing white lines, known as Wickham's straie are the characteristic feature of lichen planus.

(Source: Neville, Damm, Allen, Bouquot. Oral & Maxillofacial Pathology, 680-685, 2002.)

Saving the Natural Tooth with Intentional Replantation

2009-05-29T16:14:00.000-07:00

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.

Strengthening the future of endodontics

2009-05-12T11:57:00.000-07:00

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

Loss of Tooth Structure - by Mark Montana DDS

2009-05-01T08:11:00.001-07:00

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:

Attrition

Corrosion/Erosion

Mark S. Montana DDS

2147 E. Southern Ave.

Tempe, AZ 85282

480 820-2901

Resorption of Calcium Hydroxide Paste

2009-04-03T15:45:00.000-07:00

Calcium Hydroxide is widely used in endodontics for a number of purposes. Its antimicrobial properties are attributed to its high pH (basic), destructive effects on bacterial cell walls and ability to dissolve organic tissue. It is used routinely as an intracanal medicament. It is also used for apexification, apexigenesis, treatment of root resorption.

Ca(OH)2 used in endodontics is made with Ca(OH)2 powder, a vehicle and a radiopacifier. Most common radiopacifiers are barium sulfate, bismuth or compounds containing iodine or bromine. While radiopacifiers make the calcium hydroxide more visible radiographically, some radiopacifiers are known to resorb at a slower pace, sometimes making it difficult to see the subtle changes.

While the control of a paste material at the apex of a canal can be very difficult, the resorptive properties of calcium hydroxide make it a very forgiving material. Extrusion of calcium hydroxide past the apex of a tooth is not uncommon. In fact, there are some who would recommend deliberate extrusion in the case of a large, chronic periapical lesion to help in the healing of such a lesion.

Calcium hydroxide (Ultracal - Ultradent - 35% Ca(OH)2 with barium sulfate) was used during treatment of this tooth to control exudate prior to obturation. A significant amount was extruded past the apex in close approximation to the maxillary sinuses during the endodontic treatment.

14 months later, the patient returned for treatment of #14. Our recall radiograph of #15 shows complete resorption of Ca(OH)2. The patient had no complaints and is in full function.

Sources:

Hasan Orucoglu, Funda Kont Cobankara, "Effect of Unintentionally Extruded Calcium Hydroxide Paste Including Barium Sulfate as a Radiopaquing Agent in Treatment of Teeth with Periapical Lesions: Report of a Case", Journal of Endodontics, July 2008 (Vol. 34, Issue 7, Pages 888-891)

The Evolution of Implant Success

2009-03-16T08:00:00.000-07:00

The 7th Annual Spring into Dentistry seminar was held on March 6th, 2009 in Mesa, AZ. The guest lecturer was Dr. Robert London of Seattle, Washington. Dr. London is currently a clinical professor and director of graduate periodontics at the University of Washington. Prior to his work at UW, Dr. London was director of graduate periodontics at NOVA Southeastern and at University of Southern California.
Dr. London's presentation was entitled, "Enhancing Dental Outcomes".

While a good portion of his presentation had to do with implant treatment planning and preparation of implant sites, he made some comments that I found fascinating.

He used an analogy of a pendulum to describe the acceptance of dental implants into mainstream dentistry. Early on, there was some resistance to accepting them into everyday practice. Like the swinging of a pendulum, treatment with dental implants then became the solution to every situation. Now that the pendulum has swung to both extremes, we are now hopefully settling somewhere in the middle.

He also discussed the changing definition of success with implants. Early on, successful implant therapy meant osseointegration. If the implant was not loose, it was considered a success. In endodontics, success has always been defined very strictly as the complete resolution of signs and symptoms and complete healing of bone. With two such different definitions of success, it is no wonder that there has been misinterpretation regarding the treatment outcomes of the two different treatments.

Dr. London pointed out that what was once considered a successful implant (osseointegration alone) may no longer be an acceptable treatment outcome. Successful implant therapy now requires getting the implant to integrate in the right position, where it can support a prosthesis and look like a natural tooth. This is a major difference from simple osseointegration.

Dr. London stressed how important it was to have an interdisciplinary approach to dental treatment so all specialties are included in the best treatment approach for each patient.

We were pleased to have Dr. London come and share some of his expertise regarding periodontal bone grafting and implant treatment. We hope that the balanced approach to endodontics and implants which he described continues to gain momentum.

Longevity of dental implants vs. natural teeth

2009-02-16T11:43:00.000-08:00

Longevity of natural teeth surpass the dental implants.
February 16, 2009

A lot of marketing has been done in the past few years to present dental implants as a better choice than a tooth that can be retained with endodontic therapy.

This has resulted in many un-necessary extractions, increase in implant failures, associated lawsuits and complaints to the states board.

Recently the academic community in the fields of periodontics and prosthodontics have come out with some evidence-based recommendations regarding natural teeth vs. dental implants.
For those of you who may be interested, here are some quotes from these articles:

Periodontology 2000
Lundgren D, Rylander H, Laurell L
Vol 47, 2008: 27-50
“It is well documented that properly treated natural teeth with healthy but markedly reduced periodontal support, are capable of carrying extensive fixed prosthesis for a very long time, with survival rates of about 90%,provided the periodontal disease is eradicated and prevented from re-occuring.”
“Based on assumptions that implants perform better than periodontally compromised teeth, teeth that could be saved and used as support, are extracted and replaced with implants, sometimes on doubtful indications.”
Peri-impantitis (loss of at least 2 mm of marginal bone) at one or more implants have been found to occur in 16-28% of implant patients after 5-10 years and with higher prevalence among patients with multiple implants.
“The natural tooth should not be considered an obstacle but a possibility, whether or not the treatment is to include implant placement.”
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Journal of Clinical Oral Implant Research
Holm-Pedersen P, Lang N, Muller F
University of Copenhagen
2007, 18(suppl) 15-19
“Oral Implants when evaluated after 10 years of service do not surpass the longevity of natural teeth even of those that are compromised, for either periodontal or endodontic reason. “
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Journal of Oral Rehabilitation;
2008,35 (suppl.1) 2-8
Consensus statements and recommendations of the European Conference on Evidence-based Reconstructive Dentistry: Implants and/or teeth

(Gathering of major European researchers and clinicians who were periodontists and prosthodntists )

Some of the recommendations were:
Implants do not have a better prognosis than teeth with reduced marginal bone support.
Dentist should not recommend extraction of these teeth.
There is no evidence available to support an aggressive approach in early extraction of teeth, to preserve bone for later implant placement.
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Journal of Prosthodontics ; 2008, Volume 17: 345-347
Editorial : Inconvenient truths by George Zarb,DDS ( Dr Zarb is one of the pioneers of the field of implantology)

“The integrity of purpose and scientific rigor that characterized the original osseo-integration clinical research has been largely discarded as passe’.”

“Partnership with commercial enterprise now dominate continuing education.”

“New lecture circuit celebrities keep being recruited to promote osseo-integration's newer and expanded promises, albeit it falls significantly outside the technique’s initial oral ecological context.”

“We risk overlooking safety, simplicity and prudence in our clinical judgment.”

“The risk of yet another anarchic phase in treatment decision making has resurfaced."
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I think these statements speak for themselves.
I welcome your comments.
Robert Salehrabi,DDS

Your Endodontist as a member of your Restorative Team

2009-02-13T15:50:00.000-08:00

Your endodontist can be a valuable member of your restorative team. You can rely on your endodontist to support and reinforce your appropriate treatment plan.

As an endodontist, I want to see two things happen for my patients:
1. Endodontic therapy be successful
2. Patients value and retain their natural teeth

1. Endodontic therapy be successful:
Everyone knows that successful endodontic therapy requires proper coronal restoration. Without adequate restoration, even the best endodontic therapy will fail. As endodontists, we are invested in the successful treatment of the tooth, therefore, we will always encourage the patients to have their endodontically treated teeth properly restored. That means uncrowned posterior teeth and teeth with large restorations getting coronal coverage to protect them from cracks and fractures and current crowns/bridges with leaking margins/decay replaced to prevent coronal leakage. When a patient leaves my office, I make sure to let them know that they need to protect the root canal against bacterial leakage and occlusal forces. If our patients have been educated correctly, they will return to your office and ask for their new crown or bridge.

This patient came into my office today hoping for a root canal and a filling to preserve this bridge. I encouraged the patient to place a new bridge to prevent coronal leakage following endodontic treatment.

2. Patients value and retain their natural teeth:
I frequently see uncrowned posterior teeth with large restorations, craze lines & cracks. These teeth, especially in patients who are bruxers or have severe patterns of occlusal wear, are at risk of splitting the tooth. I encourage them to talk to their dentist about crowns to protect those teeth before they are damaged and become non-restorable. I hate to tell patients that they need an extraction because the tooth has split in half.

The general dentist has the primary responsibility for treatment planning. Your endodontist can play an important part of your restorative team by helping to educate your patients on the importance of proper restoration following endodontic treatment and the importance of proper restoration to prevent cracks/fractures.

The Endo Blog Welcomes a New Contributing Author - Dr. Robert Salehrabi

2009-01-26T08:23:00.000-08:00

I would like introduce and welcome a new contributing author to The Endo Blog, Dr. Robert Salehrabi of Advanced Microscopic Endodontics (Aurora, CO). For quite some time I have considered the idea of adding additional authors to help provide more frequent postings, give additional clinical expertise and perspective and share the workload associated with the blog.

Dr. Salehrabi started his education at University of Massachusetts. He earned his DDS with a minor in Oral Medicine from State University of New York (Buffalo). His endodontic specialty training was completed at University of Southern California.

While a full time member of the USC endodontic faculty, Dr. Salehrabi became well known for his research. His work entitled "Endodontic Treatment Outcomes in a Large Patient Population in the USA: an epidemiological study." (JOE 2004 Dec:30(12):846-50) has been recognized as one of the most important endodontic research articles published in 2004. In a groundbreaking study to evaluate the long term treatment outcomes of non-surgical endodontic treatment, over 1.4 million root canal treatments done by specialists and generalists alike were evaluated. This study provides the clinician with useful tools for clinical decision making and assessment of tooth prognosis.

Dr. Salehrabi has presented endodontic lectures internationally as well as seminars throughout the United States.

While currently in private practice in Aurora, Colorado, Dr. Salehrabi maintains his teaching position as an associate clinical professor in the Department of Advanced Endodontics at USC.

Welcome Dr. Salehrabi!

Root Canals Save Your Natural Teeth

2009-01-12T22:44:00.000-08:00

Occasionally I will use the images posted on the endo blog to aid in communication with patients. Whether trying to explain the healing of an abscess or show the patient how their tooth is cracked or fractured, a picture is worth a thousand words. Access to the internet in the operatory allows the endo blog to serve as a useful educational tool with patients. These images designed for patient education are written in lay terms will be labeled "patient education". Feel free to use them in your discussions with your patients. (click on the image for a larger, high resolution image)

Research Update: Use of MTA for Direct Pulp Capping

2008-12-18T13:12:00.000-08:00

In a recent post, we have discussed the use of MTA as a pulp capping agent.

A recent article by Yasuda, Ogawa, Arakawa, Kadowaki and Saito entitled "The Effect of Mineral Trioxide Aggregate on the Mineralization Ability of Rat Dental Pulp Cells: An In Vitro Study" may shed some light on the reasons MTA may be more effective than calcium hydroxide for direct pulp capping.

Direct pulp capping is an effort to maintain the vitality of a dental pulp following exposure during excavation and thereby avoid endodontic therapy. The formation of a dentinal bridge over the exposed pulp surface is the goal while maintaining pulpal vitality.

Conventional pulp capping treatment included medicating the exposed pulp with calcium hydroxide (ie. Dycal) prior to restoration. Calcium hydroxide is known to cause an inflammatory reaction of the dental pulp. Appication of adhesive resins has also been attempted. Incomplete dentinal bridges has been found with a lack of published long term clinical results.

It has been reported that MTA induces the formation of dentinal bridging with little or no inflammation. MTA is known for it's biocompatibility and lack of cytotoxicity. Tani-Ishii et. al. reported that MTA upregulated the expression of type I collagen and osteocalcin in osteoblasts.

Bone morphogenic proteins (BMP's) are crucial to bone and collagen formation. BMP-2 and it's receptor are expressed in the dental pulp. BMP-2 has been shown to accelerate the differentiation of human pulp cells into odontoblasts. This study hypothesized that BMP-2 is involved in the MTA induced mineralization.

This study found that MTA significantly stimulated mineralization (in rat dental pulp cells) by 60% compared to the controls. MTA and Dycal both significantly upregulated by 2-fold the level of BMP-2 mRNA compared with the controls. MTA increased the BMP-2 protein production by 40% while Dycal significantly reduced it. The authors suggest that BMP-2 may play an important role in mineralization stimulated by MTA.

MTA has shown promise as a direct pulp capping agent which may improve the success of direct pulp capping over convention calcium hydroxide techniques.

Sources:
Yasuda, Ogawa, Arakawa, Kadowaki, Saito. "The Effect of Mineral Trioxide Aggregate on the Mineralization Ability of Rat Dental Pulp Cells: An In Vitro Study". JOE 2008; 34:1057-1060.

Tani-Ishii, Hamad, Watanabe, Tujimoto, Teranaka, Umemoto. "Expression of Bone Extracellular Matrix Proteins on Osteoblast Cells in the Presence of Mineral Trioxide". JOE 2007; 33:836-839.

Preventing Coronal Leakage in A Pediatric Patient After Endodontic Treatment

2008-12-05T11:17:00.000-08:00

This 10 year old patient had a carious pulp exposure on tooth #19. The tooth was diagnosed with a reversible pulpitis and normal periapex. Upon excavation, a carious pulpal exposure occurred. With root developement completed and a cooperative patient, endodontic treatment was completed.
In a case like this, knowing that she will not have a permanent crown for about 8 more years, I become concerned about preventing coronal leakage. In an effort to create another barrier to prevent coronal leakage, I use MTA to seal the canal orifaces.

MTA (Mineral Trioxide Aggregate) is placed into the canal oriface. The MTA will provide a better coronal seal than a bonded restoration alone. The gray color of the MTA makes it easy to remove if the GP ever needs to place a post. Patient's parents are informed of the risk of coronal leakage during the adolescent years and proper preventive care is encouraged to protect the investment made in the tooth.

Patient is referred back to general dentist for comprehensive care. This may include a provisional type crown which will be monitored closely over time.

Endodontic Surgery in the Esthetic Zone

2008-11-24T14:31:00.000-08:00

One of the big challenges with dental implants is working in the esthetic zone (anterior maxilla). Crestal bone loss, which often occurs with dental implants, can lead to loss of gingival papilla. Loss of the papilla will lead to dark triangles and long clinical crowns. In an areas as esthetically sensitive as the maxillary anterior, loss of crestal bone can become a big challenge.

Endodontic microsurgery may allow you to save a natural tooth and preserve the crestal bone. Since endodontic surgery is an advanced technique taught in specialty residencies, many dentists are not as familiar with the possibilities of endodontic surgery. In addition, the advancement of surgical techniques and instruments have completely changed the endodontic surgical technique and it's outcomes.

The following case is an example of endodontic microsurgery.

Pt presents with a draining sinus tract on #10. A periapical radiolucency is noted. While pt reports the RCT was completed "eons ago", the post and crown are only a year old. The silver cone obturation, while past the apex, has served this patient well for many years. Options were discussed and the patient elected to have endodontic surgery.

An Ochsenbein-Luebke flap was used to help preserve the marginal gingiva. The silver point was removed and the canal was retrofilled with MTA (Mineral Trioxide Aggregate).

Post-op radiograph

3 month recall finds complete function, significant radiographic healing & preservation of the crestal bone.

Getting the Stain Out!

2008-11-11T21:06:00.000-08:00

Following trauma, tooth discoloration is very common. The discoloration comes from the bleeding inside the pulpal chamber. The dentin becomes stained as the blood gets into the dentinal tubules and trapped in the pulp horns. The first step in restoring the natural color to the tooth is good endodontic therapy with adequate removal of the stained facial dentin and complete removal of the pulp horns. If the natural tooth color is not restored with this procedure, then the additional treatment of non-vital internal bleaching is indicated.

A common error is incomplete removal of the pulpal horns due to a small apically placed access. Care must be taken to remove stained dentin and pulpal horns while trying to preserve maximum tooth structure.

The following case shows how to "get the stain out".

Tooth #9 & #10 sustained traumatic injury.

Note the discoloration on #9.

After opening the access, staining can be seen in #9. #10 looks normal.

A round bur is used to remove the stain from the facial surface of the pulp chamber. Careful examination with magnification reveals remaining stain in pulp horns. The access is carefully refined to remove stain from pulp horns while keeping access as conservative as possible.

Following removal of rubber dam, the change in coloration is noted. Patient is informed that the tooth is dehydrated and will continue to change color until rehydration is complete. At that time, evaluation can be made if additional internal bleaching procedures will be needed.

Obturation completed.

Adequate endodontic therapy alone will often resolve the patient's esthetic concerns. Non-vital bleaching is a good adjunct for teeth requiring additional whitening.

Another Abscess Healed - At Least for Now!

2008-10-28T17:00:00.000-07:00

This patient presented for treatment on #19. Tooth was diagnosed as necrotic with symptomatic apical periodontitis. Endodontic therapy recommended.

RCT completed. 6 month recall shows complete healing of the apical lesion. My concern is the distal leakage under the bridge. If this bridge is not replaced, the abscess will return. Some would then consider that endodontic failure, when in reality it would be a restorative failure.

The Split Tooth - A Cracked Tooth Gone Bad

2008-10-16T10:38:00.000-07:00

Talking about cracked teeth is sometimes confusing. There are several types of cracked teeth. The treatment and prognosis of a cracked tooth depends on the type, location & severity of the crack.

Types of cracked teeth include: craze lines, fractured cusps, cracked tooth (restorable type and non-restorable type), split tooth & vertical root fracture.

A split tooth is caused by a cracked tooth that has gone untreated over a period of time. The tooth is literally split into two pieces by a crack that runs through the tooth. A tooth can be split mesio-distally or linguo-buccally. The crack of a split tooth includes damage to the root itself. The crack of a split tooth can be seen crossing the floor of the pulpal chamber. This is a sure sign of a non-restorable tooth.

The following case is an example of a split tooth.

This patient presented for endodontic therapy. #15 had a small occlusal amalgam. The tooth is diagnosed as necrotic with symptomatic apical periodontitis.

Close examination of the occlusal surface shows a stained crack on the mesial & distal marginal ridges. You can see that the lingual and buccal surfaces of the tooth have been flexing for an extended period of time. The clinical appearance of this tooth strongly suggests a split tooth.
In this case, the patient was informed of the probable non-restorability of this tooth.

Removal of the amalgam shows the connection between the MMR & DMR cracks. The argument for a split tooth becomes even stronger.

After access into the pulpal chamber, the cracks can be traced down the mesial and distal walls and then connecting across the pulpal floor. The diagnosis of split tooth is now confirmed.

Just for fun, transillumination is used to show the cracks.

Tooth was referred for extraction.

Source: AAE publication

Root Perforation causing Tooth Loss

2008-09-29T10:38:00.000-07:00

This patient came to our office for evaluation of tooth #3. He reported having a recent root canal and crown done by a general dentist. Since the time the work was completed, he was experiencing "burning & itching in the gums around that tooth". The patient was concerned that he was having an allergic reaction to the cement or materials of the crown.

Our examination found #3 sensitive to palpation, moderately sensitive to percussion. (Adjacent teeth WNL) The radiopacent material in the furcation area of the tooth was noted.

Retreatment was initiated to evaluate the area.

The crown was first removed. Upon first look, there appears to be mesial decay still present and an obvious void between the tooth and the post/core material.

Additional removal of the buildup material shows a surprise underneath.

It become obvious that the distal wall of the MB canal has been perforated.

At this point, we can understand where the symptoms have been coming from. An attempt could be made to try and repair this defect (with MTA), however, the long term prognosis would be guarded to poor. Considering the the cost of initial treatment, the cost of retreatment which would then require post & build-up and new crown, this patient elected to extract the tooth.

This then becomes an appropriate time to replace this missing tooth with an implant or bridge. I recommended an implant consultation.

Endodontic treatment did not fail on this patient. The treating doctor failed to put his patient's best interest first and failed to inform the patient of the treatment complication (perforation) that occurred during treatment.

In a case like this, the patient referred himself to our office for evaluation. Had his dentist properly evaluated the case difficulty and referred him to an endodontist for treatment, this tooth would likely not have been lost.

This is not endodontic failure. This is failure to do good endodontics. This failure to do quality endodontics may be part of the reason that some clinicians are questioning the success of endodontic treatment.

Root Canal or Implant?

2008-09-16T14:31:00.000-07:00

The latest version of Inside Dentistry (July/August 2008, volume 4, number 7) has a very interesting cover story by Allison M. DiMatteo BA, MPS. As an endodontist, I have been watching this debate develop for quite some time. I think it is important to determine what is behind this effort to pit one dental specialty against another.

This particular article seeks the opinion of endodontists and periodontists alike. All sides agree that implants are a great way to replace missing teeth. There is consensus that there is value to retaining natural teeth. The disagreement seems to come from the debate about when to remove a tooth in order to place an implant.

There are some who argue that implants are more successful than endodontically treated teeth. This is despite the evidence that shows that implants and endodontically treated teeth have similar, almost identical success rates.

Richard Mounce DDS, an endodontist, points out that the only controversy between endodontics and implants is "primarily economic and more artificially manufactured than exists in reality...There are clear indications for endodontic therapy and clear indications for implant therapy. Rarely are these treatment options so evenly weighted that when considered side by side (as to their advantages and disadvantages) that there should be a 'competition' or 'controversy', most especially when the patient's interest is put first".

According to Gregori M. Kurtzman DDS, "as a general rule, it is better to save a tooth...if you can". Restorability is the key factor in determining when a tooth needs to be removed. Ability to get a good margin, not violate biological width, cracks, strength of furcation, crown:root ratio etc. are all important factors in determining the restorability of the tooth. An endodontically treated tooth with a poor restoration, will generally not have long term success.

However in the same article, Dr. Kurtzman goes on to questions the success rates of endodontic surgery, and even the value of endodontic retreatment. Dr. Kurtzman points out that the financial investment into retreatment, like all treatment options which does not have 100% success rate, may be better made in a more predictable treatment of an implant.
That argument shows lack of understanding and appreciation for modern microscopic endodontic therapy.

I routinely recommend implant therapy for patients. What concerns me as a specialist is to see the marketing techniques and lack of proper endodontic evaluation during the treatment planning of implant cases. All of our mailboxes are full of marketing journals filled with clinical cases of implant placement.

Here is an example of two cases in the same issue of Inside Dentistry p.104-108.

This case is described as a "peri-apically involved maxillary incisor resulting from a failed root canal." Treatment options were reviewed and informed consent was obtained. Based on the patient's desire to reduce trauma and treatment time, it was decided to perform immediate implant placement. First of all, failed root canal is not an accurate diagnosis. The radiograph does not show the peri-apex. As best as we can tell the periodontal ligament looks fairly normal at the periapex. Was retreatment an option discussed? If it was, would it not be considered "less truamatic" than extraction and immediate implant placement? Not to mention the ability of a natural tooth to retain the crestal bone levels. Unless this tooth has a vertical fracture, of which there is no evidence, endodontic retreatment is a better option.

Another case from the same article shows a 27 year old female with a "symptomatic maxillary left lateral incisor with a history of endotherapy with a core build-up and crown". Active infection was noted with perilous fistula and exudate at the gingival margin. The prognosis of this tooth was deemed "hopeless".

Again, the endodontic evaluation of this tooth is incomplete. The anterior "bite-wing" type film certainly shows a normal crestal bone level, however, it is impossible to evaluate the endodontic therapy and is not a sufficient pretreatment radiograph. The conclusion that this tooth has a "hopeless" is premature.

Inadequate endodontic evaluation seems to be commonplace in many of the published clinical cases and those marketing dental implants. As mentioned above, there should be little controversy regarding endodontics and implants. Our specialties should not be pitted against one another, but should work together to meet the needs of our patients.

Sources:

DiMatteo, A. "Making the Right Move: Planning Your Clinical Strategy", Inside Dentistry, July/August 2008. p122-133.

Malek, M. "Done in a Day: Immediate Tooth Replacement with Definitive Prosthesis", Inside Dentistry, July/August 2008. p104-108.

Diagnosing Root Fractures - continued

2008-08-19T16:50:00.000-07:00

As mentioned in the last post, in most cases, I prefer to verify a fracture before extraction. This is time consuming and not very profitable, but I believe it is in the patient's best interest.

However, there are some cases where it is reasonable to call a root fractured without seeing the fracture. Here is an example.

This 80 year old patient had this root canal done many years ago. She presented today with redness and swelling/sinus tract on the buccal surface. Examination finds #4 with normal pocket depths, lateral and apical radiolucency & class II mobility.

All of these clinical findings (normal probings, lateral lucency, mobility, sinus tract at the midroot) point to the probability of a root fracture at the level of the post rather than an endodontic abscess or periodontal abscess.

I recommended extraction due to fractured root.

Diagnosing Root Fractures

2008-08-08T17:00:00.000-07:00

Diagnosis of a vertical root fracture is very difficult. It sometimes frustrates me to see how quickly some people diagnose a root fracture. I tell my patients that I like to rule everything else out before I make that assumption. I say assumption, because unless you can visualize the root fracture, you are making an assumption.

There are some clinical signs that can be associated with a vertical root fracture, however, they are not 100% diagnostic of a vertical root fracture.

For example, a long narrow periodontal pocket is often associated with a vertical root fracture. The periodontal attachment breaks down along the fracture line, creating this defect. However this same type of narrow periodontal defect can also be caused by an abscess draining through the periodontal ligament.

A j-shaped lesion is often associated with vertical root fractures. However, not all j-shaped lesions are fractured roots.

In this case there were no fractures found. Complete resolution of these lesions is expected.

If visualization of a vertical root fracture is the most accurate way to diagnose a root fracture, how is that to be done?

Visualization of a fracture is best done using a microscope. A microscope with a light source will allow you to see fractures during endodontic treatment.

A microscope will allow you to determine if a crack goes down past the CEJ and into the root
or if it crosses the pulpal floor.

Visualizing a crack running across the pulpal floor of the tooth is (on left) is a 100% accurate diagnosis. This tooth must be extracted.

This is another example of a crack running along the floor of the pulp chamber from the MB root to the Palatal root of a Mx first molar.

In most cases, I prefer to verify a fracture before extraction. This is time consuming and not very profitable, but I believe it is in the patient's best interest. This is also the course I would take if it were my tooth.

A Good Day

2008-07-28T16:53:00.000-07:00

These are my cases from Monday. This is how I like my cases to look. Nice open canals, obturation to 0.5mm of radiographic apex & small puff of extruded sealer confirming patency. I do have a couple of little backfill voids. All cases done using gates glidden, .06 ISO sized profiles, .06 tapered gutta percha using a warm vertical condensation technique.

AAE's Updated Antibiotic Prophylaxis Guidelines

2008-07-17T09:47:00.000-07:00

As many of you know, on April 19th, 2007, the American Heart Association announced a major change in the guidelines for antibiotic prophylaxis to prevent infective endocarditis in certain dental patients. (Click here to see the official publication)

The AAE has also released it's updated guidelines relating to dental/endodontic procedures. These published guidelines were prepared by the AAE Clinical Practice Committee and are based on the ADA guidelines. (click here to see the ADA's official statement)

The new guidelines note that the practice of premedicating patients before a dental procedure is not longer recommended EXCEPT for patients with the highest risk of adverse outcomes resulting from bacterial endocarditis.

Premedication for patients with mitral valve prolapse, rheumatic heart disease, bicuspid valve disease, calcified aortic stenosis or congenital heart conditions such as ventricular septal defect, atrial septal defect and hypertrophic cardiomyopathy.

The American Academy of Orthopaedic Surgeons have made no changes to their recommendations for patients with joint replacement. This means that those patients should continue to take antibiotics prior to dental procedures. (click here to see the official statement from AAOS)

Idiopathic Osteoslerosis

2008-07-01T09:09:00.000-07:00

This patient presents as a 30 year old, white female. Asymptomatic tooth #19 was identified in a routine radiographic exam. Clinical findings: normal to thermal testing, normal to percussion, normal to probing, slight pain to biting on lingual cusps. DX: Normal pulp & periapex

The radiopacent area on the mesial root is noted and diagnosed as an idiopathic osteosclerosis. As a quick review, this is a designation for a uniformly radiopacent lesion that cannot be attributed to any inflammatory, dysplastic or neoplastic source. They may also be found in other locations. Most commonly found in patients between 20 & 40 years old and may have a female predilection. Also appears more commonly in black population. 90% of cases are seen in the mandible, usually in the 2nd premolar/molar area.

No treatment is indicated. Little change is usually seen in these lesions.

Another term that is often used interchangably is condensing osteitis or focal chronic sclerosing osteomyelitis. While looking identical, these lesions are associated with necrotic pulps and are believed to be a result of chronic, low grade inflammation. The interchangable use of these terms can be somewhat confusing. However, accurate pulpal diagnosis will help determine whether the radiolucent lesion is the result of inflammation caused by a necrotic pulp (condensing osteitis) or truly idiopathic (unknown) origin (idiopathic osteosclerosis).

(Source: Neville, Damm, Allen & Bouquot. Oral & Maxillofacial Pathology, 445-446, 1995)

Endodontic Success

2008-06-18T18:04:00.001-07:00

This patient presented today with a dull, radiating ache in the lower right quadrant. Clinical examination finds #29 sensitive to percussion, normal probings with prior RCT (30 years). A short obturation is evident. Adjacent teeth #30 & #28 have normal pulps . #29 is diagnosed with Prior RCT & Symptomatic Apical Periodontitis. Retreatment is recommended & completed.

I think that it is great that a root canal, done sometime in the late 70's, can be retreated, using modern techniques and equipment and be functional for another 30-40 years. Unless that root is fractured, there is nothing better than a natural tooth.

Surgical Repair of Post Perforation

2008-05-28T09:12:00.000-07:00

This patient presented without pain but presence of draining sinus tract in the buccal attached tissue over #7. The position of the draining sinus tract directly at the level of the post, normal periodontal probings and evaluation of the radiograph made me suspicious of a post perforation. (note the widened ligament to the level of the post, and completely normal appearance at the periapex)
Options discussed included retreatment or apical surgery. Since the crown is all porcelain, we decided to treat surgically.

Ochsenbein-Luebke surgical flap was selected to prevent recession of marginal gingival, and minimal loss of crestal bone. The periodontal attachment was still in tact following flap reflection despite the loss of buccal bone adjacent to the perforation.

Metal tip of the post was visible without any removal of any buccal bone.

The post was counter-sunk using a high speed handpiece.

Preparation of the root. Note that this was not the apex of the root. This repair was being done on the mid-root surface.

Geristore was selected as the restorative material. Since Geristore is a bonded material, moisture control is important. Astringedent was used for hemostasis and the root was acid etched, primed and bonded.

Geristore placed in the preparation and cured.

Geristore was contoured to the root surface.

Final film. This will be an interesting case to follow. Expect a good result and repair of boney defect. We'll continue to monitor this tooth over time. Endodontic surgery has provided a valuable service to this patient prolonging the life of this tooth, the crown and hopefully regenerating the boney defect. Stay tuned for updates!

Vertical Root Fracture

2008-05-19T10:25:00.001-07:00

This 92 year old patient came into our office for evaluation of #7. She reported no pain, but had a sinus tract between #6 & #7. Probing around #7 appeared normal.

The radiograph appeared to show some lateral radiolucency at the level of the post. The post also appeared slightly off angle with the root canal obturation. Despite the lack of narrow probing depths, I suspected a root fracture.

At this point, we decided to verify that fracture by disassembling the restoration. The patient was informed that if the root was fractured, then she we would not be able to save the tooth.

After simultaneous removal of the post and crown, multiple vertical root fractures were identified. A lingual, and distal fracture are seen in this image.

A mesial root fracture is seen in this angle.

Visualizing a fracture is the only certain way to diagnose a root fracture. This procedure is not well reimbursed, if at all. It will certainly require time that could be used for more productive treatment. However, if it was my tooth, I would want to know it is fractured before extracting it.

I suspect that a possible application of the new cone beam dental CT's will help with diagnosis of vertical root fracture.

Placement of MTA

2008-05-07T16:03:00.000-07:00

Mineral Trioxide Aggregate (MTA) is a great material for retrofills, root perforation repair, direct pulp capping, apexification & apexogenesis. This material is mostly used by specialists, under a microscope. However, new applications, such as direct pulp capping, will make this material more commonplace.
Unlike most dental materials, MTA requires moisture to set up. Since moisture control is one of the largest challenges in working with most dental materials, this actually is a positive characteristic of this material.

Using this material is like playing with wet sand. You can add or remove water to the consistency that you like. If you put too much water in it, it runs. If you put too little water in it or it dries out, it crumbles. If you put just the right amount of water in it, it becomes packable, just like wet sand. It takes a little practice, but once you learn how to manage the moisture, it's great to work with. The material does dry out while you use it, so additional water can be added to return it to your desired consistancy.

There are few specialized instrument that aid in the placement of MTA. Carriers are made in all shapes and sizes. These work just like an amalgam carrier on a much smaller scale.

Another useful carrier is made from a plastic block and a simple hand instrument.

Handling MTA will take a little practice, but once you learn how to mix and handle it, you will find it is a great material to work with.

The following video clip shows the placement of MTA as a retrofill during an apicoectomy surgery.

Upcoming Inner Space Seminar

2008-04-22T16:51:00.001-07:00

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 endodontics and help all dentists perform the highest quality endodontic procedures, we have developed a seminar series entitled, "Inner Space Seminars".

Our upcoming seminar will be held on Thursday, May 8th, 2008. Please call or email to register.

Intentional Replantation

2008-04-14T17:00:00.000-07:00

Replantation of an avulsed tooth is a well known and accepted treatment following a traumatic dental injury. Preservation of vital cells in the periodontal ligament allow reattachment of the tooth in the alveolar socket. Rates of success at 5 years reported in the literature ranges between 70% - 91% (1).

The main factors limiting the success of this treatment are the amount of time the tooth is out of the mouth, disruption of the periodontal ligament and bacterial contamination.

Although not common or well known, intentional removal and replantation of a tooth is an effective mode of treatment 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.

Intentional replantation allows the clinician to control the variables that would limit the success of a replantation following traumatic avulsion. Atraumatic extraction, minimal time out of the mouth and aseptic technique, allow a clinician to perform apical procedures that otherwise could not be performed.

Again, while not commonplace, intentional replantation is a treatment option that can be considered in special cases. It may offer your patient a final opportunity to retain a natural tooth, when endodontic surgery is not an option.

This case was actually an UNintentional, intentional replantation. Let me explain. This patient presented to our office with a bridge from #27 to #29. Significant buccal decay was present. The general dentist and the patient wanted to try and maintain this bridge.

Her dentist placed an amalgam root surface filling under the buccal margin of the bridge. A distal periapical radiolucency developed. I was then asked to complete the RCT on the tooth. Since the anterior abutment was loose, we decided that to remove the bridge, complete the endodontic treatment, and retrofit a post and core back to the bridge. Hardly an ideal restorative solution, but a solution that worked for the patient in her particular circumstance.

While attempting to remove the bridge, the entire tooth came out. At this point, this became an intentional replantation case.

Within a matter of minutes, we did a retroprep and MTA retrofill.

The anterior abutment of the bridge was then permanently cemented on and the posterior abutment replanted into the socket.

This patient returned last week for a 3 month re-evaluation. The tooth was sensitive for a while, but she now reports no sensitivity or swelling and she can now chew nuts on that side!
If you look closely you can see that the distal lesion has healed. While this is a very short term result, the healing of the apical lesion, lack of symptoms would indicate initial success. We will continue to monitor this tooth over time. Look forward to updates!

Sources:

1. Nuzzolese E, Ciruli N, Lepore MM, et. al. Intentional Dental Reimplantation: A Case Report. J Contemp Dent Pract 2004. August;(5)3:121-130.

Gates Glidden Drills

2008-04-01T08:56:00.000-07:00

I know that all the manufacturers are encouraging you to shape the canal oriface with their special oriface shaping files, but I still like to use the gates glidden drills to open the upper third of the root canal system.

Quick research this morning indicates a gates glidden drill costs me $3.12 and a NiTi rotary instrument costs me $7.15 (taking into account the endodontist's bulk discount).

Call me "old fashioned" but why anyone would want to pay twice as much for an instrument that takes twice as long to do the same job is beyond me. The gates is non-end cutting and also improves the direct line access into the canal, which will help prevent separation of your rotary files. The shaft of the gates is somewhat flexible and usually, if there is a separation, it will separate high on the shaft and is easily removed with a pair of cotton pliers.

If I had to guess, I would guess that nineteen out of twenty times a gates glidden drill breaks, it breaks high on the shaft. That being said, here is a case where the gates separated in the mid-shank area. When this occurs, it just the same as if a rotary file separates. It can be just as difficult and time consuming.

Pre-Op #19

Gates Glidden #3 separated in MB canal.

Technique for removal is the same as with a rotary instrument. Visualize it, ultrasonic instrumentation around the instrument until it loosens, and retrieve.

All said, I would much rather use a gates glidden to open the upper third of the canal for all the reasons described above. Can anyone give me a better reason to use a rotary file to do the same thing?