Is This Tooth Bothering My Sinuses?

"Is this tooth bothering my sinuses?" For years patients with chronic sinus issues have asked this question at the dental office.  Unfortunately, there has been a communications gap between diagnostic medicine and dentistry in this overlapping area of practice.  Endodontists are experts diagnosing pulpal disease, but not trained in diagnosis of sinusitis. Most otolarygologists (ENT) physicians, and especially rhinologists, are experts in sinus diagnosis, but not trained in evaluating dental and pulpal infection, which may be a source of infection for the sinuses. Most sinus CTs are not including the teeth and rarely are medical radiologists evaluating the teeth in their reads.

In cooperation with Dr. Tim Haegen of the Arizona Sinus Center, a division of Valley ENT, we have been able to help patients with chronic sinus issues. Many of these patients have bounced from ENT to ENT looking for answers, some have had continuous courses of antibiotics and some have had sinus surgery, only to continue to have chronic sinus issues. With some interdisciplinary education between endodontics and otolaryngology, familiarization with each other's diagnostics and terminology and the use of medical and dental CT imaging, we are working together to diagnose and treat the often time overlooked odontogenic sources of sinusitis.  The use of 3D imaging between disciplines has helped to bridge the gap of communication between medical and dental specialists trying to help patients with sinusitis and dental infections.

The following case demonstrates how proper understanding of endodontic and ENT imaging, diagnostics and terminology facilitate proper diagnosis and treatment.

This patient presented to Arizona Sinus Center for evaluation of chronic sinus issues.  She presented with chronic, unilateral nasal and facial symptoms, along with foul smelling nasal discharge.  Nasal endoscopy was performed and findings include:



FINDINGS:

• Nasal septum - superior deviation to right, mucosa intact, no perforation or crust
• Right inferior turbinate - normal
• Right middle turbinate - edematous
• Right middle meatus - closed; edematous medialized uncinate. Tissue is pulsatile. No purulence or polyps.
• Right posterior choanae - normal
• Left inferior turbinate - normal
• Left middle turbinate - normal
• Left middle meatus - open, no mucopus or polyps
• Left posterior choanae - normal
• Nasopharynx - no masses

RADIOGRAPHIC FINDINGS:

 Complete opacification of the right frontal sinus.

Partial opacification of the R ethmoid sinuses.

Complete opacification of R maxilliary sinus, superior septal deviation to the right, bilateral opacified concha bullosas.

Molar #2 and #3 have periapical radiolucency (PARL), one of which is dehiscent into the maxillary sinus and buccal gingival sulcus.  This may be the most important diagnostic information in the CT scan.  Too often, radiologists and otolaryngologists are not looking at this part of the scan - if it is even included in the field of view.

Following evaluation, the following impressions were recorded.

Impression:

• Nasal Obstruction
• Deviated nasal septum
• Frontal sinusitis, chronic
• Maxillary sinusitis, chronic
• Ethmoidal sinusitis, chronic
• Dental caries, unspecified
• Disturbances of sensation of smell and taste

 With these radiographic findings and clinical impressions, the patient was then referred to Superstition Springs Endodontics for evaluation and definitive treatment of the maxillary molars #2 and #3.  Due to the complete opacification of multiple sinuses along with bony erosion of the medial orbital wall, the possibility of endoscopic sinus surgery was discussed.  Discussion included risks of failure to treat the infection within the sinuses as well as failure to remove the source of the infection, which in this case has to include the dental source of infection.

Pt presents for endodontic evaluation of #2 and #3 following ENT identification of possible dental abscess adjacent to Mx sinus.

Endodontic diagnosis, including CBCT, determines that tooth #2 has a prior root canal with a root fracture and extraction is recommended.  Tooth #3 has a prior RCT with apical abscess - caused by a missed MB#2 canal during the initial root canal treatment.  Retreatment of the root canal #3 is recommended.

Endodontic retreatment with microscope locates the previously missed MB#2 canal.

MB#2 canal is debrided and irrigated with NaOCl.

PostOp radiograph shows all 4 canals have been properly treated.

PeriApical RadioLucency (PARL) seen at apex of MB root - which had a missed canal on initial treatment.

6 month recall following endodontic retreatment shows healing of the PARL.

After 6 months, extraction of tooth #2 and retreatment of tooth #3 has shown periapical healing.  The potential odontogenic source of the sinus infection has been eliminated.  Since the Mx sinus continues to show opacification, the patient is referred back to Dr. Haegen for continued sinus evaluation and treatment.

Why See An Endodontist?

Dental Operating Microscope used by endodontists

The endodontists at Superstition Springs Endodontics are experts in endodontic diagnosis and have extensive experience with CBCT.  In addition, endodontists are specially trained to perform the most difficult endodontic cases.  Maxillary molars, most closely associated with the maxillary sinus, almost always have 4 canals.
A common reason for root canal failure on Mx molars is inadequte cleaning, and often completely missing the MB#2 canal.  Endodontists using an operating microscope are able to find and treat the MB#2 (4th canal) more effectively and efficiently.  Endodontist are also trained to perform endodontic microsurgery when traditional endodontic therapy is unsuccessful.

When endodontists and otolaryngologists work together, they can provide the best care for patients with odontogenic sinusitis. 

Preventing Root Canal Perforation by Case Selection

This patient came to Superstition Springs Endodontics in June 2009.  Her general dentist had started RCT on #3 but was unable to locate the MB canal(s).  A perforation was made during the efforts to find the MB canals.  We have taught the generalists in our community that the most successful and fulfilling way to practice endodontics depends upon careful case selection.  Proper case evaluation can:

1.  prevent lost chair time without reimbursement
2.  prevent loss in patient confidence
3.  prevent clinician frustration

The Endodontic Case Assessment Form from the AAE, can help clinicians determine the difficulty level of treatment - before therapy is started. This is how this case should have been classified - prior to starting treatment. 

 

 

 The treatment for this tooth was RCT completion and repair of the iatrogenic damage using Mineral Trioxide Aggregate (MTA).

Fortunately, with good repair materials, the prognosis for a tooth like this is still good.  A 7 year recall finds the tooth in full function and asymptomatic.

However, proper case selection will make your practice of endodontics more fulfilling, less stressful and ultimately, more successful.

Congressman Paul Gosar to Speak at 2016 Spring Into Dentistry Seminar on Feb. 19th

This year's Spring Into Dentistry Seminar will feature Congressman (and Dentist) Paul Gosar from Arizona's 4th Congressional District.  We are excited to have him as our guest speaker and hear about his unique perspective as a dentist and a congressman.  We hope you can join us!

Apicoectomy on Mx Molar - All Three Roots Through A Buccal Approach

Endodontic surgery on maxillary molars is usually limited to the MB and DB roots - through a buccal approach.  Surgical treatment of the palatal root often requires a palatal surgical approach, and is therefore rarely done.  In this particular surgical case, due to the root anatomy and size of the periapical lesion and osteotomy, all three roots were accessed through a buccal surgical approach.

Surgical PreOp

Root resection of all three roots using a buccal approach

Retrofills with MTA

Post-Op radiograph

1 year recall. Patient fully functional and asymptomatic.  Radiographic healing evident.

Pulpal Tissue

Dental pulpal tissue removed using a barbed broach.

Success with Vital Pulp Therapy

With the advancement of pulpal regenerative therapies, we have come to appreciate and respect the healing capacity of the pulp.  While MTA and new bioceramic materials are allowing us to create better coronal seals, we now have new treatment options to replace the traditional apexification and apexigenesis procedures. While pulpal regenerative procedures were first applied to necrotic immature teeth, usually affected by trauma, this has led to the development of new vital pulp therapies on carious, immature teeth.

The following case demonstrates a MTA pulpotomy on a vital, healthy pulp with carious exposure.

This 8 yr old presented in 2012 with deep caries on an immature #19.  The pulp tested vital, but his dentist expected pulpal exposure.  He was also reporting night time pain, which typically is associated with irreversible pulpitis.

Caries removed, pulp chamber cleaned out, MTA placed against the amputated pulp tissue, with resin restoration.

9 month re-eval finds the tooth a symptomatic and functional. Apices continue to develop normally.

2 year recall reveals a symptomatic tooth with full function. Roots have continued to develop to normal length and thickness. Coronal protection recommended.

3 year recall finds tooth a symptomatic and functional. Root development is complete and appears normal.

While previous apexigenesis procedure have been used to keep the pulp alive in order to complete root development, these new materials seem to give a better prognosis and are an exciting advance in the development of vital pulp therapies.

5 Year Recall on a Cracked Tooth

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

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

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

RCT was completed and returned to GP for coronal coverage.

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

Are Dental Implants Forever?

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

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

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

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

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

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

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

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

SOURCES:

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


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

Medicare Opt-In or Opt-Out Delayed Again

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

For more information from ADA, click here.

UPDATE! Medicare Enrollment: Opt In or Opt Out?

Recent changes in some of the rules regarding Medicare will now affect dentists more than they previously have.   Thanks to a recent visit with Aaron Fisher of HealthChoice, we learned a few things about these changes effective June 1, 2015.

The number of participating doctors in Medicare is remarkably low.  That is understandable, since "Medicare doesn't cover most dental care, dental procedures, or supplies, like cleanings, fillings, tooth extractions, dentures, dental plates, or other dental devices."  source

However, Medicare will begin offering supplemental dental insurance to Medicare participants through 3rd party insurance companies. These are known as Medicare Advantage Plans.  In other words, Medicare is offering private dental insurance through private dental insurance companies.  Here's the catch... The federal government gets to set the fee schedule.   So if you want to participate in the the medicare advantage plans, through any given provider, you have to be willing to take the federal fee schedule.

So before you sign up for the Medicare Advantage Plans, you need to review the fee schedule, as you would any other dental PPO fee schedule, and decide if it makes business sense to work at the discounted fee schedule.  If you are in Arizona, the easiest way to describe these plans would be "AHCCCS for Medicare Patients".  The fee schedule would be the same as the AHCCCS fee schedule.

A quick example of some commonly billed codes on the AHCCCS fee schedule.

• D0150 Comprehensive Exam - $38.33
• D0210 Full Mouth Series - $66.02
• D1110 Adult Prophy - $46.71
• D2392 2-Surface Posterior Resin - $82.10
• D2792 Noble Crown - $514.70
• D3330 Molar RCT - $507.48

For a full fee schedule, click here.

The ADA Benefit Plan Analyzer may be a useful tool in helping you decide what impact Medicare participation, as well as any other PPO, will have on your practice. click here.

So if you decide to participate in the Medicare Advantage Plans, you will be agreeing to this fee schedule like any other PPO that you would sign up for.  There may be some benefits with some of these plans.  Since these plans are administered by a 3rd party, they may have less paperwork than you would expect from a government program, less pre-authorization needed and may have higher benefit levels than the typical $1000-$1500 benefit level of most dental benefit plans.

However, EVEN if you decide NOT to participate in Medicare Advantage plans, you can still be affected by the new laws.  Here's how...

If you order or refer covered clinical laboratory services (biopsies), imaging services, or DMEPOS (apnea devices) for Medicare patients you will need to either enroll in Medicare or formally "opt out" of Medicare.  For more information, click here.

As of Dec. 1, 2015, Medicare will require all physicians, including dentists, who prescribe Part D covered drugs to their patients to either be enrolled in Medicare OR must "opt out" of Medicare, in order for their patient's prescriptions to be covered by Part D.

Doctors who "opt out" of Medicare are required to have written contracts with the Medicare beneficiary stating that the doctor and the patient have forfeited the right to bill Medicare, and the patient is essentially paying a "fee for service" out of their own pocket.  The doctor must also submit an affidavit to Medicare expressing their desire to "opt out" of the Medicare program.  This "opt out" affidavit is for a period of 2 years.  So while all dentists are free to participate in Medicare, there are new compliance issues if you choose not to participate.
source

So to summarize:

• Dentists who want to be a part of Medicare Supplemental Dental Plans should enroll in Medicare using form CMS-855I
• Dentists who want to be able to order lab services (biopsy), imaging services or DMEPOS (apnea appliances) covered by Medicare need to enroll with shortened form CMS-855O. Dentists who want to are not Medicare providers, but want their patient's prescriptions to be covered by Medicare Part D, can also use for CMS-855O.
• Dentists who want to be able to order lab services (biopsy), imaging services or DMEPOS (apnea appliances) but DO NOT want to use Medicare benefits must "Opt Out" by:
• Sending Medicare an affidavit stating they are not participating in the Medicare program - you have 90 days to change your mind - otherwise there is a 2 yr waiting period before you can sign up.  This "opt-out" option will expire after 2 yrs and will need to be done again.
• Signing contracts with Medicare patients stating that both parties forfeit the right to bill Medicare - essentially agreeing to pay a "fee for service"
• Dentists who "opt out" of Medicare DO NOT need a contract with the patient for them to recieve their Medicare Part D prescriptions.  Contracts with patients are only needed when you are providing other services that would normally be covered by Medicare.
•  Dentists who do not want to participate in any Medicare services, but still wish for their patient's prescriptions to be filled by their Medicare Part D need to formally "opt out" by sending Medicare the affidavit.
• Dentists who do not provide any Medicare services, who do not order or refer Medicare services (lab, imaging, DMEPOS) and who do not need Medicare Part D to cover the prescriptions they write for their patients do not need to enroll or "opt out"

 The deadline for dentists to "opt in" or "opt out" of Medicare is June 1, 2015.

Those dentists who don't take any action will not likely see many changes this year, but eventually will begin to get calls from the pharmacy or patients complaining that the medications they have prescribed to their patients are not covered by Medicare Part D.  According to the ADA, complying with this law will save you time and aggravation.

The following infographic, published by ADA, will help you decide whether to "opt in" or "opt out" of Medicare.

 

The clearest explanation that I have seen is with a video tutorial on the ADA website for ADA members.  click here

For more information from the ADA News, click here.

The Arizona Dental Association has recently published another summary that is very helpful.  Click Here

Sources/More Info
Medicare Enrollment FAQ
Information about "Opting Out"
Enrolling with Medicare for ordering and referring only

A special thanks to the endoblog guest editor, Dr. Morris Oswald of Red Canyon Dentistry