Endodontic Retreatment or Implant?

This patient is wondering if she would be better off having tooth #10 extracted and an implant placed.

This is her situation. She had this silver point root canal done back in the 70's. A new crown was placed about a month ago and then the crown broke off. She came to my office for an evaluation. I recommended that we retreat the root canal, and place a new post for retention of the build-up/crown.

Since the crown broke off the remaining tooth structure supporting it, the ideal situation would be to make a new crown and improve the ferrrule effect.

I explained to her that as long as the tooth is not fractured, the retention of the natural tooth will actually help maintain the bone in the esthetic zone and give her the most natural appearance.

The silver point root canal is almost 40 years old. There is no sign of failure of the endodontics. This is actually a restorative failure. Any disturbance of the silver point can jeopardize it's seal. In retrospect, it would have been best to have retreated the RCT and placed a new post and core prior to the new crown.

Research Update: Use of Articaine for Buccal Infiltration of Mandibular Molars

The inferior alveolar nerve block (IANB) is the most commonly used technique for pulpal anesthesia in the mandible, especially the mandibular molars. Due to the dense cortical bone of the mandible, buccal infiltration techniques have been known to be less successful.

However, the IANB has challenges of its own. Passing through layers of soft tissue and muscle and depositing the anesthetic in adjacent to the mandibular foramen can be very difficult. Anatomical variation among patients, including the course of the nerve, location of the mandibular foramen, accessory nerves also innervating the area can all make consistancy with this technique challenging.

If the block is unsuccessful, then the practitioner has typically repeats the block or trys another technique. The most common alternative techniques are: closed mouth block (Vazirani/Akinosi), Gow-Gates Block, intraligamentary injection, intrapulpal injection, or intraosseous injection.

Manibular buccal infiltration has traditionally not been considered as an option due to the inability for the anesthetic to diffuse through the thick cortical plate. Kanaa et al. reported that a mandibular buccal infiltration is more effective with 4% articaine with 1:100,000 epinephrine than with the traditional 2% lidocaine.

A recent study by Il-Young Jung et. al. compared the efficacy of IANB with that of buccal infiltrations in mandibular first molars.

Using 4% articaine subjects were given IANB and BI on separate appointments. Pulpal anesthesia was determined using an electric pulp tester. 54% of BI were successful and 43% of IANB were successful. (the difference was not significant p=0.34) The onset of pulpal anesthesia was significantly faster with BI (p=0.03). This study concluded that BI with 4% articaine for mandibular first molars can be a useful alternative to IANB due to it's faster onset and similar success rate.

Having difficulty with anesthetizing mandibular molars? Try using some 4% articaine in a buccal infiltration.

Sources:

Kanaa MD, Whitworth, JM, Corbett, IP, Meechan JG. Articaine and lidocaine mandibular buccal infiltration anesthesia: a prospective randomized double blind cross-over study. JOE 2006:32:919-23.

Jung, Il-Young, Kim, Jun-Hyung, Kim, Eui-Seong, Lee, Han-Young, Lee, Seung Jong. An evaluation of buccal infiltrations and inferior alveolar nerve blocks in pulpal anesthesia for mandibular first molars. JOE 2008:34:11-13.

Rotary & Warm Vertical Obturation

This video clip shows my non-surgical RCT technique on an extracted bicuspid.

Specific instruments I like to use:
1. Endo Z bur (long shank, non-end cutting bur to create direct line access)
2. Hand files #10 & #15 to open canals and create a path
3. Gates Glidden drills #2, #3, #4 to open the coronal third of the canal system (inexpensive, easy to remove if separation occurs)
4. #15 hand file for length determination (using Root ZX or radiographs)
5. .06 tapered, ISO sized NiTi Rotary files
6. .06 tapered gutta percha, gauged to ISO size at tip using a gutta gauge
7. System B heat carrier
8. Obtura for gutta percha backfill

Rhodium Coated Mirrors

Mirrors used for intraoral photography are not all the same. There are several kinds of mirrors. Standard metal mirrors reflect 55-60% of light. Chromium coated mirrors reflect 65-70% of light and rhodium coated mirrors reflect 75% of light. The manufacturer of the mirror that I use claims that this mirror reflects 99.5% visible light. This increased light reflection is also due to the flatness of the mirror. I usually use a standard mirror, but when want a good photograph, I'll pull out a rhodium coated mirror.

Here is a standard mirror.

This is the exact same photograph using a rhodium plated mirror.

When taking intraoral photographs, the quality of the mirror can make a big difference in the quality of your images.

Pulpal & Periapical Diagnosis

As previously described, endodontic diagnosis is composed of two parts.

A pulpal diagnosis, which indicates the status of the pulpal (nerve & connective tissue inside the tooth), and a periapical diagnosis, which indicates the status of the periapex (tissue around the end of the root).

Pulpal Diagnosis can be accomplished using cold, heat or electric stimulus. Cold testing is the most reliable. Endo Ice is the most convenient, and easy to use product for thermal testing.

The following flowchart will help you with your pulpal diagnosis.



As previously discussed, the new diagnostic terminology defined by the American Board of Endodontics simplifies the periapical diagnosis based upon pain and swelling. The following flowchart can be useful in helping to understand the diagnostic terminology.

New Endodontic Diagnosis Terminology

Endodontic diagnosis can be very confusing. Much of this confusion comes from differences in diagnostic terminology. The diagnostic terminology used from school to school is different. Even endodontic textbooks fail to create a systematic approach to endodontic terminology. The American Board of (ABE), the organization which oversees the board certification of endodontists, even allows for board candidates to describe the terminology they will be using during their board certification process.

Endodontic diagnostic terminology is based on clinical signs & symptoms, radiographic appearance & presence or lack of swelling or drainage. It is easily understood how confusing this can be with so many variables.

In an effort to simplify and unify the endodontic diagnostic terminology, the ABE has recently published a list of pulpal and periapical diagnostic terminology. In our practice we have adopted this terminology and will be using it in our daily practice of endodontics. We will also begin using this terminology in our cases presented in the blog. The following is the new terminology recommended by the ABE.

A complete endodontic diagnosis is made up of two parts:
1. Pulpal diagnosis
2. Periapical diagnosis


PULPAL DIAGNOSIS
Normal pulp – A clinical diagnostic category in which the pulp is symptom free and normally responsive to vitality testing.

Reversible pulpitis – A clinical diagnosis based upon subjective and objective findings indicating that the inflammation should resolve and the pulp return to normal.

Irreversible pulpitis – A clinical diagnosis based on subjective and objective findings indicating that the vital inflamed pulp is incapable of healing.

Additional descriptions:
Symptomatic – Lingering thermal pain, spontaneous pain, referred pain
Asymptomatic – No clinical symptoms but inflammation produced by caries,
caries excavation, trauma, etc.

Pulp necrosis – A clinical diagnostic category indicating death of the dental pulp. The pulp is non-responsive to vitality testing.

Previously Treated – A clinical diagnostic category indicating that the tooth has been endodontically treated and the canals are obturated with various filling materials, other that intracanal medicaments.

Previously Initiated Therapy – A clinical diagnostic category indicating that the tooth has been previously treated by partial endodontic therapy (e.g. pulpotomy, pulpectomy).




PERIAPICAL DIAGNOSIS

Normal apical tissues – Teeth with normal periradicular tissues that will not be abnormally sensitive to percussion or palpation testing. The lamina dura surrounding the root is intact and the periodontal ligament space is uniform.

Symptomatic apical periodontitis – Inflammation, usually of the apical periodontium, producing clinical symptoms including painful response to biting and percussion. It may or may not be associated with an apical radiolucent area. (This category includes what many of us call Acute Apical Periodontitis & Phoenix Abscess)

Asymptomatic apical periodontitis – Inflammation and destruction of apical periodontium that is of pulpal origin, appears as an apical radiolucent area and does not produce clinical symptoms. (This is what many of us have previously called a Chronic Apical Periodontitis)

Acute apical abscess – An inflammatory reaction to pulpal infection and necrosis characterized by rapid onset, spontaneous pain, tenderness of the tooth to pressure, pus formation and swelling of associated tissues.

Chronic apical abscess – An inflammatory reaction to pulpal infection and necrosis characterized by gradual onset, little or no discomfort and the intermittent discharge of pus through an associated sinus tract.


You can see that the pulpal diagnostic terminology has not changed. The periapical terminology is where are the confusion was and that is what they have tried to simplify. If you look closely at the definitions, you will see that the radiographic signs are not part of the periapical definition anymore. That is the reason that a Acute Apical Periodontitis & Phoenix Abscess are now both called a Symptomatic Apcial Periodontitis. Is your head spinning yet? Go back to the top and read it again. We'll have more on diagnosis to help you apply these definitions in your practice.

(Source: www.aae.org/certboard)

Upcoming Inner Space Seminar

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

These seminars are free and free from the commercialism that is creeping into all forms of dental education. Don't you get tired of reading articles only to find out the specialist writing the article is selling some dental product? We select topics and speakers that will provide valuable information for the dentists in our community.

4th Canal on Maxillary Molar

This root canal was completed 2 months ago. The patient continued to report pain with no relief. The dentist had also recently worked on #2, placing an occlusal restoration. My examination found #2 & #3 both very sensitive to percussion, normal probings and lingering pain to cold on #2. Since both teeth were very sensitive, the diagnostics become very difficult. My original recommendation was to adjust the occlusion on #3 and re-evaluate in a week. However the patient returned to the office later in the day experiencing severe pain, pointing to the vestibular area above #2 & #3.
My instincts pointed to #3. We performed diagnostic anesthesia on #3 by infiltrating a small amount (approx. 0.25ml) mesial to #3. Within several minutes the pain was gone. It was then determined that the pain was coming from #3 and endodontic retreatment was initiated.

Upon access and removal of gutta percha, no additional canals were visible. Suspecting a fourth canal, I began removing dentin from the MB groove using slow speed handpiece with #2 round bur and ultrasonic instrumentation. A fourth canal was located. The original difficulty in finding this canal was caused by the fact that it was completed covered over by secondary dentin.

The patient was informed of the fine work the general dentist had done in finding and filling 3 canals. There was no way that this fourth canal could be found without the use of the operating microscope.

Since almost all maxillary first molars have a fourth canal, make sure an look closely in the MB groove for the forth canal. This process of searching the MB groove should be done with an operating microscope, to facilitate this process as well as prevent iatrogenic damage to the tooth.

Endodontic Healing with Perforation Repair

This patient came to my office in March of 2003. She had two large "all porcelain" bridges done a year and a half earlier between #22-#27. Teeth #24 & #25 were diagnosed as necrotic with Chronic Apical Periodontitis. Endodontic therapy was initiated.

To my dismay, a suprabony perforation was created on the distal of #24.

After a little redirection, the canals were located and then instrumented and obturated.

Both teeth were obturated with gutta percha. Because the perforation was suprabony, Geristore was selected as the repair material. Since geristore is a resin, it will not wash out, making it ideal for a defect above the level of crestal bone. The patient was informed of the perforation defect and its repair.



Typically I would re-evaluate this case 6 months to a year following completion. This patient chose not to return until another tooth needed endodontic treatment.
The patient reported no symptoms and our recall film at 3 yrs 9 months shows complete healing of the apical radiolucencies.
Retaining these teeth with endodontic therapy allows for healing of the bone and maintains the crestal level of the bone as well as provides more life from the recently placed porcelain bridges.

Fractured Tooth

This patient came in today with a necrotic tooth #14. She had a draining sinus tract on the palatal and recounted a history of massive palatal swelling. Diagnostic tests found #14 Necrotic Pulp with Chronic Apical Abscess.
The tooth had a MO amalgam & O amalgam. Patient also has a history of bruxism with cuspal fractures on other teeth.

Upon access, a crack running down the distal wall and a crack running down the mesial wall both took a left turn and met across the pulpal floor. This tooth was then diagnosed as non-restorable and an extraction was recommended.
Had this tooth been crowned previously, it may have been saved. When patients exhibit severe patterns of occlusion with bruxism, I would recommend cuspal coverage at an earlier stage.
If you have difficulty making this recommendation to your patients, I would be glad to send you some pictures from my photographic collection called, "Teeth that might not have fractured if they had been crowned". You could make a nice picture book with these photos.