If you are interested in an endodontic refresher lecture, come and join me next Thursday at the Pacific Dental Conference (PDC 2019). Two and a half hours lecture filled with pictures and videos demonstrating the initial endodontic treatment.
The following is an excerpt from #vanendo lecture series at this year’s Pacific Dental Conference.
The apical 3mm of an infected root canal system is considered to be the “Critical Zone” when it comes to the chemomechanical preparation. Mechanical instrumentation and chemical disinfection of the root canal system to its full length significantly affect the outcome of treatment. All endodontists agree that the irrigation phase of the root canal treatment must be accompanied by an agitation technique. These techniques include: sonic agitation (EndoActivator), ultrasonic agitation, multi-sonic agitation (promising area of research currently), and the cheapest and simplest of all, Manual Dynamic Agitation (MDA).
The following video demonstrates how the MDA technique (repeated insertion of a well-fitting gutta-percha cone to the WL at a frequency of 100 strokes/min) significantly facilitates debris removal from the apical portion of a root canal system that appears to be fully shaped and cleaned.
Are you ready for the Pacific Dental Conference 2018 next week?
Come and join me for an overview of the “shaping” and “cleaning” stages of root canal treatment.
Patient presents with apparent sinus tract in quadrant 4. According to the patient, the sinus tract had been identified by a hygienist during a hygiene appointment. Subsequently, the endodontic treatment had been initiated in order to resolve the infection. Here is a clinical photo of the sinus tract-like tissue.
The above image shows what appears to be a non-draining sinus tract. If this is indeed the case, it means that there should be a necrotic tooth with a lesion in close proximity to the drainage site and one should be able to express exudate from the site by poking it with a sharp explorer tip. Upon palpation, the tissue felt like a fibrous nodule that can be easily displaced under the non-keratinized tissue and it could not be drained with an explorer. Evaluation of available radiographs confirms lack of apical lesion in this area. Furthermore, the radiographs show significant pulp recession and heavy coronal calcification in all teeth. This could have resulted in false negative pulp vitality test results.
In the absence of periapical radiolucency and pain symptoms, one should not feel pressured to rush into treatment. The diagnosis for the above tooth might have been healthy pulp with normal apical tissues which would have required no treatment. Instead, the overall treatment has resulted in some structural compromise.
In my previous post “The Little Devil Horn,” I showed a case of fractured Dens Evaginatus (DE) that had resulted in pulpal necrosis in an 11 years old girl. In almost all cases the tubercles fracture off as soon as the teeth come into occlusion. The resultant pulp exposure goes unnoticed until patient develops pain and symptoms and a combined endodontic-restorative procedures would then be necessary. Therefore, just observing what does not belong to a proper occlusion is not a good choice.
The endodontic treatment for necrotic teeth with immature roots is either regenerative endodontics or MTA apexogenesis depending on many factors. The latter was used to treat the case of fractured DE with pulpal necrosis.
So, what should we do if we face a vital tooth with an intact tubercle?
Some evidence suggest a gradual shaving off the tubercle over a period of few months in order to allow tertiary dentin formation is the treatment of choice. However, tertiary dentinogenesis may not provide a complete seal of the pulp chamber as this process lays down an irregularly formed dentinal structure.
Another approach would be to remove the tubercle mechanically under RD isolation and to seal off the resultant mechanical exposure, if any, with bonding material. This approach was performed for the same young patient for tooth #3-5.
Dens evaginatus (a.k.a. Leong’s premolar) is an odontogenic developmental anomaly. This anomaly, an enamel-covered tubercle with an extension of pulp horn in most cases, occurs primarily in premolars. Loss of this tuberculated cusp during natural root maturation and development will result in early pulp exposure, pulpal necrosis, periapical disease, and arrested root development. Early diagnosis and management of dens evaginatus is therefore the key factor in preventing premature loss of tooth vitality.
When deciding on an endodontic-restorative plan for a tooth, one should always keep in mind the age of the dental pulp (i.e. patient’s age). Younger dental pulp = more cellular, vascular, defensive and therefore resilient. This fact can help us decide on a more appropriate and conservative treatment for a tooth when facing pulp exposure as a result of trauma or caries excavation.
Vital Pulp Therapy (VPT) techniques is attempted in order to remove the reversible pulpal injury, to preserve the vitality of the pulp and to ultimately allow continued root/tooth growth. The technique comprises: a) good isolation, b) complete caries removal, c) disinfection of the access cavity with NaOCl, d) stopping the bleeding with a moist cotton pellet, e) applying pulp capping material such as ProRoot® MTA or Biodentine™, and f) restoring the access cavity with permanent restoration after confirming the setting of the capping material.
In the above case Direct Pulp Capping with MTA, irrespective of the size of carious exposure, was performed because this 13 year-old patient presented with non-lingering, non-spontaneous and reversible pulpitis symptoms. In addition, carious exposure resulted in fresh bleeding from pulp horns that could be stopped with applying moist cotton pellet. If a patient presents with irreversible pulpitis symptoms, other VPT techniques should be considered.