CSI: canine space infection.

The maxillary canine space can become directly involved as the result of infections from the maxillary canines. The infection from these long teeth can involve the canine space, the area superior to the muscles of facial expression. The resultant swelling obliterates the nasolabial fold on the affected side [obliteration of the nasolabial fold on the right side of patient’s face in the image below].

canine space infection

Superior spread of CSI, if not treated, may cause orbital/periorbital cellulitis or cavernous sinus thrombosis, both very serious infections requiring aggressive surgical interventions.  Emergency treatment for such infections include establishing drainage [detail described in previous post “Don’t Let the Sun Set on Pus!“], removing the source of infection through access, instrumentation, irrigation and placing intracanal medicament and prescribing antibiotics if indicated.  Antibiotics alone is not sufficient.


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The Little Devil Horn

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.

dens evaginatus, leong's premolar


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The Young & The Resilient

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.

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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.


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The Non-precious Stone

The only non-precious stone that I know is the pulp stone.  One of the factors contributing to root canal failure is remaining infected pulp tissue and the pulp stones, if left behind unnoticed, are the main reason for trapping tissue and retaining infection. Pulp stone removal is therefore a crucial factor in achieving a successful result in endodontic treatment.  The following case shows how a large pulp stone can result in failure of a reasonably well done root canal treatment by trapping infected tissue, hiding the MB2 canal and retaining infection.

Proper access cavity (i.e. adequately large and at the level of the CEJ) in order to visualize the outline of the pulp stone/chamber floor is the key in removing it completely.  In the above example the pulp stone is easily dislodged by troughing around it using a large diamond-coated ultrasonic tip and applying the energy directly to the calcified tissue. For demonstration and documentation purposes, no water was used in this case; however, it is highly recommended to use water for its cooling effect and in order to facilitate the debris removal.


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Watch Out for the Twisted Ones!

If you attended my lecture at the Pacific Dental Conference last month, I mentioned “The Laws” that allow us to safely and predictably locate canals without being worried about mishaps (i.e. perforations, over-enlarged access cavities, etc.).  One of the scenarios that we have to always be prepared for is accessing through a crown that is placed on a rotated tooth.  One of the key elements discussed was the use of a probe to gain a better appreciation of the root outline at the CEJ level. The “Law of Concentricity” then allows us to start our access cavity preparation in the right direction.

The case below shows a rotated tooth #1-4 under a PFM crown. Preparing a typical access cavity in the Buccal-Lingual direction would definitely result in mishaps.  Understanding the orientation of the tooth prior to the start of root canal treatment can result in achieving a safe and a conservative access prep. Note that even the rubber dam clamp wings are not good  guides for the orientation of the chamber floor and for locating canals.

 

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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.


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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


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it’s vital…with no fillings…but it hurts!

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Radiographs can be so deceiving! This radiograph of the first quadrant looks so calm, so unassuming…everything looks normal. What you didn’t see was the patient attached to this radiograph – having extreme, radiating pain. When everything looks fine on the radiograph, and we have a quadrant full of unrestored or minimally restored teeth, my spidey sense tells me to pick up a probe, and also a transilluminating device. In this particular case, there were no isolated deep probing depths (often suspicious of a root fracture), but transillumination revealed a cracked tooth. The pain can likely be ascribed to the process of “fracture necrosis” – eventual necrosis caused by a significant crack from the outside of the tooth to the pulp. A crack is just one of five types of fractures, which also include craze lines, cuspal fractures, root fractures, and a split tooth. Each are managed a little differently, depending on the presentation.

In this case, we performed a pulpectomy, and used the microscope to look into the crown. It did not appear that the mesial-distal crack extended past the CEJ. The patient had a temporary crown placed that week – and the tooth became comfortable over the ensuing weeks. This is often a nice way for us to ensure the tooth will be comfortable under a crown – an orthodontic band often serves the same purpose. The endodontic therapy was then completed. Even despite the good restorative work that was eventually completed, a tooth with a crack always has a long term guarded prognosis.

Teeth with cracks and fractures can be difficult to detect, visualize, diagnose, and treat. The prognosis of teeth with cracks and fractures also comes with uncertainty and risk. Furthermore, the symptoms of teeth presents with cracks and fractures run the gamut from mild biting sensitivity to severe and radiating pain. However, a few visual aids, like a transillumination light, magnification, and the trusty old periodontal probe can help us to diagnose and manage such cases.


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Inseparable Teeth, Unconventional Access!

Sometimes when the conventional endodontic access is not possible, the unconventional approach can save the day.

A clinician should always aim at establishing a straight line access (SLA) in order to properly instrument, irrigate and obturate the canal system.  Depending on the initial challenges, establishing a SLA could mean accessing an anterior tooth through its buccal surface [example below], accessing an anterior tooth through its incisal edge, or accessing a molar tooth through its mesial marginal ridge or its MB cusp.

 

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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


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