Category Archives: Prognosis

How Does Your Endodontist Do it?

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.

Dr. Ektefaie PDC 2019


A Compromised Tooth is Still a Tooth.

In my previous post “What to do with a compromised tooth?” I asked everyone about the options for a tooth which appeared to be compromised on X-rays.  Four options were presented: a) endodontic retreatment, b) apical surgery, c) extraction/implant and d) other.  Apical surgery won the race and all responders chose one of the first three options given.  In this case, the fourth option was chosen: Intentional Replantation.

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Intentional replantation procedure allows us to control all the contributing factors to endodontic failure in this case: ruling out the presence of root fracture, removing the subgingival calculus as a result of loss of enamel, removing the resorbing granulation tissue, eliminating possible established extra-radicular infection or biofilm, sealing the root-ends without the need for retreatment and possible further extrusion of obturation material into the lesion, preserving the intact buccal and palatal cortical bone through eliminating the need for apical surgery (Risks: proximity to Greater Palatine nerve and artery, inadequate palatal root length, possible loss of palatal cortical bone post-surgery).

The final radiograph shows the periapical healing after 1 year. Patient is asymptomatic, the tooth is functional with great periodontal health post-restoration, awaiting a crown. Extraction/implant option can wait for now.


Office website: vanendo ,  FaceBook page: @endospecialists


What to Do with a Compromised Tooth?

Endodontic diagnosis for tooth #27: previously treated, symptomatic apical periodontitis.  I/O examination reveals a wide, 6-8mm clinical attachment loss (i.e. probing defect) distal to tooth #27 and loss of distal contact due to enamel fracture.  A CBCT scan shows intact buccal and palatal bone and a significantly shortened palatal root due to external inflammatory root resorption.

intentional replantation

intentional replantation


Office website: vanendo ,  FaceBook page: @endospecialists


Misdiagnosis: A Nail in This One’s Coffin.

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.

sinus tract

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.

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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.


Office website: vanendo ,  FaceBook page: @endospecialists


Cover It Up!

Heavy bite, specially with less than ideal occlusion or cusp-fossa relationship, can result in cracks and fractures in teeth.  Here is an example of a case with heavy occlusal pressure concentrated on the lingual inclinations of the buccal and lingual cusps of tooth #2-4.  Two mesial enamel cracks are evident in this case.

cracked tooth

 

Lets imagine the following scenario if we do nothing for this asymptomatic tooth:

With time, the cracks propagate and involve the pulp chamber. Based on the position of the existing restoration, a tooth split may result no matter how innocent (don’t blame the amalgam fillings). Clinical symptoms (pulpitis) appear.  Root canal is done and the initial sensitivity symptoms do resolve. A crown is then fabricated for a possibly deeply cracked tooth. The biting tenderness however persists post-endodontic treatment.  If the patient is lucky not to go through further unnecessary treatments (i.e. retreatment, apical surgery, etc.), the tooth will eventually be replaced with an implant. And, this is one of the reasons why root canals get their poor reputation. “Root canals don’t work”, “every root canaled tooth fractures”, or the most insulting to my profession that I have ever heard: “root canaled tooth is an eventual space maintainer for an implant.”

So, lets contemplate the above scenario and think about prevention and saving teeth instead.


Office website: vanendo ,  FaceBook page: @endospecialists


What Lies Beneath!

Excessive root dentin removal during endodontic treatment and use of posts are the predominant risk factors for root fractures. Common clinical findings associate with root fractured teeth have been discussed in a previous post (It is ‘Game Over’!)

Vertical root fractures are usually detected through careful probing around a tooth but sometimes all you need is air-water syringe.

 

vertical root fracture  vertical root fracture


Office website: vanendo ,  FaceBook page: @endospecialists


Beware of the Cracks!

Imagine the following scenario:

A busy day in practice! A patient comes in with tooth #2-6 (upper left first maxillary molar) being extremely sensitive to cold (a.k.a. a “hot tooth”).  You notice a very old, large amalgam filling on the tooth which had been done over 2o years ago.  No recent restorative changes in the area  is reported by the patient.  Breathing in air, blowing air on this tooth with an air-water syringe or applying ice to the tooth sends the patient through the roof.  All other teeth in this quadrant are responding normally to cold test. Quickly and confidently, a pulpal diagnosis is reached (irreversible pulpitis), endodontic treatment is recommended, and the need for a full coverage crown is also emphasized after root canal treatment. Simple, right?

cracked tooth, split tooth

pre-op radiograph

 

Well, not so fast!

  • unless you stopped and thought about the reasons why the tooth became sensitive to begin with (i.e. thinking about the etiology for pulpitis and the possible pathways to the pulp),
  • unless you thoroughly examined the tooth clinically and looked for signs of cracks, leakage, caries, periodontal disease, parafunctional habits, etc.,
  • unless you grabbed a perio probe and actually noticed a 6-7mm probing defect on the distal aspect of the tooth,
  • unless you noticed on the pre-op radiograph a questionable area with respect to the quality of the crestal bone between teeth #2-6 and #2-7,
  • unless you removed the obscuring filling and gave yourself an adequate view of what lies beneath during the treatment (as opposed to those who still love to brag about their super conservative access and their beautiful final result through a tiny 2x2mm hole),

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You may miss a more serious issue with this innocent-looking tooth in need of JUST a root canal and a crown,  you may lose the opportunity to properly inform your patient of possible outcomes of your treatment and you may end up performing unnecessary treatments for a tooth with no hope.

Just imagine the final conversation with the patient after a quick exploratory/pulpectomy procedure:

Me –  “Ms. Black, unfortunately your tooth cannot be saved as I had suspected and warned you before we started the root canal procedure today.”

Ms. Black – “I am amazed Dr. E! [with a smile]  You knew exactly what was wrong with my tooth. You called it.”


Office website: vanendo ,  FaceBook page: @endospecialists


Not Every Hole is a Canal!

Sometimes when we try locating canals during access preparation stage, we may accidentally exit the pulp chamber in the wrong spot and create perforations.  Perforations or accidental communications need to be repaired as soon as possible in order to achieve the best possible prognosis.  The choice of repair material depends on the location and the size of perforation. MTA is still one of the best materials that can be used to seal the pulp floor perforations as long as it is not communicating with the sulcus.

To Prevent Perforations:
1. The pulp chamber floor is always at or slightly below the level of CEJ and the canals are located at the periphery of the pulp chamber floor.  Any attempt to locate canals farther apically may result in perforation.
2. The chamber floor colour is always greyish. If the colour during locating canals is turning dentin-colour, that would be the best time to stop and reorient ourselves.
3. Always probe around the CEJ to gain a better appreciation the outline of the root trunk, as the chamber floor is at the center and concentric to the CEJ outline.
4. When in doubt, stop and take an X-ray to confirm that treatment is progressing in the right direction.

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To Treat Perforations:
1. If facing significant difficulty with locating canals, the procedure should be stopped, the tooth should be medicated with CaOH, and patient should be referred out for proper care.  More digging may result in multiple perforation sites, further weakening of the tooth structure and enlargement of the existing perforation site, which ultimately results in an unfavorable outcome.
2. If canals are already located, ignore the perforation site, complete the root canal treatment and repair the perforation site with MTA.  Attempting to repair the site before obturating the canals may result in the repair material occluding the shaped and cleaned canals.
3. When dealing with established infection in the canal system which benefits from the utilization of short term CaOH medicament, the perforation site can be repaired and sealed before final obturation. In this case, the other canals need to be protected by paper points while the site is being repaired (the above case).


How can an apicoectomy help?

Let’s not give up on even the smallest of teeth!

There are times when conventional root canal treatment or retreatment cannot heal every periapical lesion out there. Luckily, we have the option of an apicoectomy – which in today’s terms, means microsurgery. During an apicoectomy, the most apical part of the root tip (usually about 3 mm) is removed. A retropreparation – which is similar to a class one preparation – is made using an ultrasonic tip specially designed and angled for apicoectomy under the microscope. The retropreparation is filled with an MTA material, of which there are many choices now, like the traditional powder that is mixed with sterile water, or even a pre-mixed putty.

In this case, we see a tiny little lateral incisor, which has a ceramic crown that is a few years old, and underneath it, a great big post. The current root canal treatment is somewhat underprepared, and was done more than 15 years ago. The tooth had recently become symptomatic. Is it extraction time for this little tooth? Should we dismantle the crown, remove the post, and retreat it? Should we place an implant now?

This case was ideal for an apicoectomy. This means the patient is able to keep the crown intact and we wouldn’t be compromising restorability by removing the post. With such a short and fine root, we have to be aware of the crown to root ratio, occlusion, and be conservative in our surgical technique.

After a full thickness flap was created, the retropreparation and the MTA retrofilling are seen:

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Here are the radiographs from start to finish: initial presentation, immediately after the procedure, and 6 months after with good healing.


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How do you “seal” the deal?

After we’ve spent so much time doing great endodontic treatment – with rubber dam isolation, perhaps gingerly applying OraSeal or Kool-Dam to make sure everything is water tight, carefully instrumenting, copiously irrigating, and then obturating with great style – how can we protect our painstaking work?

Here is a case where the root canal has been completed, but unfortunately, the final restoration – a ceramic restoration – has been made without replacing the cotton pellet and temporary base material. Even though the periapical lesion has healed nicely, the risk of coronal leakage, and thus the need for retreatment in the future again, is great.

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One nice way to prevent coronal microleakage is to definitively restore the teeth after root canal treatment. If you want to go one step further, you might consider an intra-orifice barrier. This is simply a (bonded) restoration that involves removing approximately 2 mm of gutta percha from the orifice of the root canal. Then, a material, such as glass ionomer, or composite, or MTA can be placed into the orifice. I also prefer to cover the furcation floor. I have been placing an intra-orifice barrier of glass ionomer (and often a 1 mm intra-canal barrier when I prepare post spaces), and then restoring the rest of the access with a bonded core material when indicated. The glass ionomer can be placed with a small plugger, or a Centrix Accudose needle tube.

I have also been trying a neat product as an intra-orifice barrier, PermaFlo Purple, which is simply a flowable composite that is colored purple. You can place a tooth-colored material on top, in the bulk of the access. I suppose the rationale of a purple-tinted flowable composite is to make any future treatment easier, since you’ll be looking for purple composite, instead of B2 composite! The case below shows a 2 mm intraorifice barrier of glass ionomer, extending below the floor of the root canal chamber.

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