Surgical Considerations for Your Patient 12/10/18
It has been well established in the endodontic literature that initial treatment can have success rates into the 90th percentile. Causes of post treatment endodontic disease can be attributed to many factors. Some of these factors include: poor debridement and obturation of the canal system, the failure to use rubber dam isolation, coronal leakage, and poor restoration placement. However, some factors are beyond our control and can impact healing as well. These include microbial factors otherwise known as extra- radicular infection. In fact, it has been documented that in approximately 20 percent of cases that involve periapical lesions, non- surgical treatment may be ineffective due to the cystic nature of such lesions (Nair et al. 1998, 2004; Simon et al. 1980).
Many factors influence my decision whether to retreat a tooth via non- surgery or surgical means. The biggest question I ask myself when making this decision is: can I improve upon what has been previously done? If I find that there has been untreated anatomy (ie, MB2), I will almost always advise for non- surgical retreatment. However, there are some incidences in which I am in favor of surgical retreatment. These typically include: obstructions or inaccessible canal anatomy, previously separated instruments, anatomical complexities, resorption defects, and persisting endodontic disease (aforementioned extra- radicular infection).
Surgical retreatment has a very favorable outcome as reported within the endodontic literature. The current standard for endodontic microsurgery includes the use of the dental microscope, micro- instruments to facilitate proper preparation of the root apices, a small osteotomy preparation within the osseous tissues to allow for proper healing, and use of MTA and/or similar root end filling materials. These new standards have proven success rates within the 90th percentile (Rubenstein and Kim 1999, Journal of Endodontics; Kim et al. 2008, Journal of Endodontics).
Below are some case examples of which I have performed and a brief summary of treatment:
1. Patient presented with initial treatment performed and was symptomatic to palpation and bite stick testing. Radiographic examination reveals a previously treated tooth (#19) with a previously short obturation of the canal system (See image 1). There was the presence of apical periodontitis at the mesial apex. A diagnosis of Previously treated with Symptomatic Apical Periodontitis was made and a decision to treat via non- surgically was determined (My rationale was that I believed I could improve upon the prior treatment). Non- surgical retreatment was completed without incident (See image 2). At one year recall (see image 3), persistence of the periapical lesion had prevailed as well as symptoms to biting and chewing. Surgical apicoectomy was performed (see image 4) and 2 year recall revealed complete healing (see image 5).
2. Patient recently presented to our office with pain localized to tooth #13. Upon examination, the preoperative diagnosis was made as Previously Treated with Symptomatic Apical Periodontitis. Radiographic examination reveals a large post within the canal space and short fill of the canal system (see image 1). I made the decision to perform surgical retreatment as opposed to crown/post disassembly. As you can see from the photo insert, 2 canals were present at the apex which joined via a connecting isthmus (many of these isthmus channels can only be treated surgically). Post- op film (image 2) reveals how the 2 canals join at the apex.
It should be emphasized that surgical retreatment is a viable option for your patient when indicated. The success rates are favorable and can be done with minimal recovery time- plus I love doing them!
If you wish to know more about this type of procedure, please give me a call anytime-
New Irrigation Technique 12/03/2018
Irrigation is one of the most important factors in the success rate of endodontic therapy. While many will focus on which type of file systems are “superior”, many lose sight of the fact that the adage “instruments shape and irrigants clean” is so true!
While it is widely accepted that sodium hypochlorite is the irrigant of choice (in fact, it truly is the gold standard of bacterial eradication), the delivery of the irrigant is extremely important to ensure proper canal cleanliness. The delivery method must be able to reach the apical third of the canal(s) to ensure the deltas, recesses, and isthmus ramifications are cleaned to allow for a good obturation and seal.
I would like to emphasize that the treatment that we perform at Cornerstone is supported by evidenced based research. This ensures that what we do is effective, proven and most importantly safe for the treatment of your patient that you refer to us.
What I would like to focus on is how I deliver the irrigant within the canal system. During cleaning and shaping, I use sodium hypochlorite and then flush with EDTA to remove the remaining inorganic debris (dentinal debris, etc). Once I am satisfied with all tissue and debris removal, I then use ultrasonic agitation of sodium hypochlorite for 1 minute prior to final obturation. This ultrasonic agitation is supported by the published works of Gutarts et al. 2005 (Journal of Endodontics) and Burleson et al. 2007 (Journal of Endodontics). These studies demonstrated how ultrasonic agitation of the irrigant within the canal system is able to debride and remove pulpal tissues in the apical third within all isthmus, deltas, and recessed areas.
See the photo inserts (courtesy of Burleson et al. 2007) of how well this method cleans the canals in the apical third:
Photo which demonstrates no use of ultrasonics. See debris between canals!
Photo which demonstrates the use of ultrasonics. Tissue removed nicely!
The benefit of this methodology is that it’s safe for your patient and predictable (how can I argue with published 90th percentile success rates in the literature which date back to the 1960s)? However, there are other methods that have recently been introduced to the market which have no substantiated research to back their claims. The technology relies on minimal cleaning and shaping of the canal system, forcing irrigation to the apical third. There is not one published article in the research data bank which shows this methodology is superior to other methods- DO NOT BE FOOLED! The only published data that I have reviewed are case reports, which incidentally are on the lowest level of evidenced based research. In addition, some of my peers that I have spoken with report incidences of apical bleeding, postoperative “tenderness” and worst of all- sodium hypochlorite accidents!
While I am sure that one day this recently introduced technology will be refined, I simply have difficulty justifying its use with unsubstantiated research. Again, I like to back my treatment modality on proven research which is beneficial and most importantly safe for your patient. If you wish to talk more about this topic, please feel free to reach out anytime!
Mandibular First Molars 11/26/18
Happy late Thanksgiving to all! Hoping all of you had a great holiday weekend with family, friends and football-
I wanted to spend some time talking about the mandibular first molar. Did you know that this is the most common tooth to need endodontic therapy? The reason begins at age 6-9: it’s typically the first permanent tooth to erupt into the oral cavity.
We were all taught in dental school that this tooth typically has 3 canals; however, my experience and current literature reviews details that this is no longer the norm. When I treat a mandibular molar, I’m always looking for five canals: the two mesial canals, two in the distal root and a possible mid- mesial canal.
Caliskan et al. 1995, within the Journal of Endodontics, reported that the incidence of a mid- mesial canal within the mesial root of the mandibular first molar is approximately 3.4%. Pomeranz et al. 1981 (Journal of Endodontics) reported an incidence of 12%; of which these were classified into the following subcategories:
a. Independent- 3 canals extend from the chamber to the apex
b. Fin- that of which the mid mesial canal is connected to either the MB or ML canal via a groove but has its own foramina at the apex
c. Confluent- that of which the mid mesial canals joins either the MB or ML canal via anastomosis or other connection as it travels to the apex
As for the distal root anatomy, Caliskan et al. 1995(same study) reported a 17% incidence of two canals in the distal root. The key to find the second canal within this root is upon access entry. Traditionally, the access of the mandibular molar has been advocated to be oval in shape. However, if you make your access more rectangular, this allows you to find that suspect second canal! (See photo insert)
I’ve attached recent radiographs and summary of a couple recent patients in our office showing both anatomical variations.
Case 1: Patient presented with a history of initiation of endodontic therapy by her restorative dentist. The tooth was asymptomatic upon presentation with a history of “aching and throbbing pain.” Radiographic interpretation and clinical testing yielded a diagnosis of Previously initiated therapy with asymptomatic apical periodontitis. Upon access revision, I located the second distal canal and completed the endodontic therapy.
Case 2: Patient presented with a history of prior endodontic therapy by another endodontist. The tooth was subsequently restored with a post/core and crown restoration. Upon presentation, the tooth was asymptomatic. Preoperative diagnosis was determined to be Previously Treated with Asymptomatic Apical Periodontitis. Upon removal of the post and core restoration, a third mesial canal was located with magnification and treatment was completed successfully. The mid- mesial canal was determined to be independent having its own apical foramen.
I hope you’re enjoying this information as much as I am blogging about it…
If you can take some time and give some feedback, that would allow me to better help you! Please send me some topics you’d like to know a little more about…I’d love to share any information I can to help you, your practice, and your patients!
Endodontic Diagnosis 11/19/2018
What’s the hardest part of endodontics? Is it access? Instrumentation and obturation? With enough experience, any clinician will tell you that these phases of endodontic therapy become routine. However, what’s not routine and can present a challenge to any practitioner is proper endodontic diagnosis! I emphasize the word proper because not everyone is familiar with the terminology adopted by the American Association of Endodontists.
It should be kept in mind that determining a diagnosis is like putting together a puzzle: there are multiple pieces that are needed for completion. Review of medical history, diagnostic quality radiographs, and clinical examination/ testing are required for interpretation of both a PULPAL and PERIRADICULAR diagnosis. Also- listen to your patient! Many times your patient will tell you what’s happening before your examination begins.
The American Association of Endodontists recognizes the following PULPAL diagnostic terms:
1. Normal Pulp- pulp is symptom free and responds normally to vitality testing
2. Reversible Pulpitis- Subjective and objective findings indicate that the inflammatory response in the pulp should resolve and the pulp return to normal after removal of the etiology. Common etiologies include: exposed dentin(recession), caries, and “high” restorations
3. Symptomatic Irreversible Pulpitis- The inflammatory response in the pulp is irreparable and root canal therapy is indicated. Common symptoms are: spontaneous pain, lingering pain to thermal stimulus
4. Asymptomatic Irreversible Pulpitis- A symptom free pulp of which the vital inflamed pulp is beyond repair and root canal therapy is indicated. These cases typically respond normally to vitality testing. An example of this type of case is visible caries to the pulp of which removal would result in pulp exposure
5. Pulp Necrosis- The tooth/pulp is beyond repair and root canal therapy is indicated. The pulp does not respond to vitality testing (ie, cold and/or EPT). However, CAREFUL of calcified teeth- these teeth typically have a limited response to cold testing and may give a false negative!
6. Previously Treated- Prior endodontic therapy with the canals obturated with a filling material
7. Previously Initiated Therapy- The tooth has been treated with partial endodontic therapy such as pulpotomy or pulpectomy
The American Association of Endodontists recognizes the following PERIAPICAL diagnostic terms:
1. Normal Apical Tissues- No symptoms to palpation and bite stick testing (I typically do not rely on percussion testing- that’s a story for another time), and radiographically the lamina dura and pdl are intact without interruption; no suggestive evidence of apical periodontitis
2. Symptomatic Apical Periodontitis- represents inflammation within the periapical tissues. Symptoms include discomfort with palpation and/or bite stick testing. This may or may not be accompanied with radiographic evidence of apical periodontitis
3. Asymptomatic Apical Periodontitis- this is deterioration of the apical periodontium that is of pulpal origin. There is evidence of apical periodontitis without clinical symptoms
4. Chronic Apical Abscess- an inflammatory reaction of pulpal necrosis with clinical evidence of a sinus tract in the gingival tissues. The area may or may not be symptomatic
5. Acute Apical Abscess- an inflammatory reaction to pulpal necrosis which is characterized by rapid onset, spontaneous pain and swelling. There may or may not be radiographic evidence of apical periodontitis. The key is swelling!
6. Condensing Osteitis- a diffuse radiopaque area at the apex of the tooth which represents a bony reaction to a low- grade inflammatory stimulus
To make an ACCURATE diagnosis, the pulpal diagnosis must be accompanied with a periapical diagnosis.
Two examples with brief scenario are below:
Case 1: Patient presented to our office this past Tuesday with spontaneous pain of 3 days’ duration localized to tooth #2. Her chief complaint was pain mainly upon biting and chewing. No thermal pain reported. Clinical and radiographic findings included: Pain upon bite stick application and palpation tenderness over the buccal root apices. Tooth #2 had no response to cold and EPT vitality testing. Radiographic interpretation yielded the presence of apical periodontitis at the root apices of tooth #2. The diagnosis of tooth #2 is: Pulp Necrosis with Symptomatic Apical Periodontitis. RCT performed without incident.
Case 2: Patient presented with “pressure” sensitivity localized to tooth #7. She had reported prior RCT therapy by her dentist. No history of thermal sensitivity; only pain “when pressing” on the gingival tissues. Clinical and radiographic findings included: Visible sinus tract over the apparent apex of tooth #7. She reported discomfort with palpation over the sinus tract and apex tooth #7. Radiographic interpretation yielded prior RCT #7 and a large, diffuse area of apical periodontitis at the apex with extension to the mesial root surface. The diagnosis of tooth #7 is: Previously Treated with Chronic Apical Abscess. Surgical apicoectomy was performed without incident.
Have a wonderful Thanksgiving and until next time,