Digital Technology in Endodontic Practice

When I created the initial version of this website approximately 25 years ago, digital imaging techniques were relatively new and digital radiography was just beginning to receive wide acceptance. Focused field CBCT’s were not yet available and most full head digital imaging involved extremely expensive machines and relatively high exposures to patients. Contemporary imaging techniques have revolutionized dental imaging and if you are practicing Dentistry, you need to modernize your office.

Today there appears to be no reason why anyone should be using antiquated conventional film developing techniques when digital radiography offers much better images. Unlike conventional film, digital radiographs allow us to manipulate brightness contrast and use filters to further enhance the image.

In endodontics, there is a distinct advantage in having immediate images to check for working length and cone placement by shifting of the angle of beam without having to remove the sensor from the patient’s mouth. Digital radiographs also offer far greater efficiency of use and better options for the environment. Digital imaging also offers the ability to share data and images effortlessly with no cost. We know that better treatment is rendered when all parties involved in the treatment can communicate efficiently and minimize both exposure of the patient and cost of procedures. However, they have one drawback: they require the practice using them to be completely computerized, to have a local network and the appropriate backups and safeguards to preserve the data.

One byproduct of the recent Covid pandemic is the greater emphasis on interoffice communication using video conferencing to discuss shared cases. in my own practice I have begun to send short video messages to my referring dentists showing them all the images involved and explaining my rationale for treatment. When images are digitized, case presentation and interdisciplinary treatment can be optimized through collaborative treatment planning, with all parties involved being able to share images and formulate a treatment plan that best suits the patient’s needs.

Virtually all dental practices today are using some sort of software to manage their practices. The most efficient practices are ones in which there are two computers in each operatory, one for the assistant and a second for the dentist. The assistant computer is used for making chart notations and other specific information relayed to the assistant by  the dentist. The dentist’s computer can be used to activate radiography programs, access online website information, tooth atlases and illustrations, photos and x ray images that are used to educate patients and explain the prospective treatment.  Unlike conventional radiographs which are extremely small, digital radiographs and clinical photos can be enlarged sufficiently to allow patients to truly visualize and understand the dentist’s findings, recommendations and treatment results. Notations can be made directly  on the images, which not only is helpful to patients, it serves as an excellent record of what has been discussed with the patient, further legally safeguarding the clinician.

Digitization of an office involves a lot of planning, significant expense and particularly rigid adherence to securing data and performing proper backups. If you are considering replacing your existing software or moving to a more digital environment for your clinic, I strongly recommend that you consider putting two computers in each operatory to take full advantage of this technology.

Hardware failures will inevitably occur overtime and contingency plans must be made so that if this occurs, your office can be up and running quickly and without delay. That is why it’s important to have very good support locally and online from whichever hardware and software supplier you choose. You should ALWAYS be backing up your data either via remote internet connection (with alerts as necessary) AND a second physical hard drive taken home at the end of each day. You can NEVER have too many backups.

One other factor that is not frequently understood by older clinicians is the cost of moving from conventional records to digital records. Legacy clinicians who have many thousands of patients in their practice will need to eventually move these records to digital form, which frequently involves scanning of individual charts, documents and radiographs. This can be an extremely tedious and expensive procedure. That is why it is important for practices to initiate digitization as early as possible to avoid these costs.

In the past, practices were evaluated on the basis of perceived practice numbers and a percentage of goodwill. Today’s practice valuations rely on statistics and while goodwill may play a small part in the practice worth, ultimately it all comes down to what you can prove numerically in digital form with things like production numbers, number of patients, demographics, percentage of insurance based dentistry, etc. Although  the cost of moving to this kind of digitization may initially be large, failure to have this information available to today’s practice valuators means that your practice may be essentially worthless. It is only as valuable as you can prove with real numbers. Digitization of your practice now may be expensive but it may be the only way in which you can preserve the perceived value and justify the sale price when the time comes for you to sell.

The www.Endoexperience.com  website has been very fortunate in recognizing the need for both security and access . We have designed the site in such a way that both patients and clinicians can be confident that their information and interaction with the site is secure .

Allowing patients to register online as well as filling out medical and pain histories and consent forms, permits us to decongest the reception area. These forms can be filled out at home, at the patient’s leisure.

Once our referrals become aware of how easy it is to access the www.Endoexperience.com portal and refer a patient, their workload is reduced . Furthermore, their ability to access all of their patients data 24 hours a day allows them to check upcoming appointments, patient status, download chart notations that may have made and access any letters or reports that Dr. Kaufmann has created, as soon as they are generated.

One last consideration: In an online survey that I did about 10 years ago, very few dentists who answered the question said that they were using encrypted mail to send images, letters and reports via E mail. Recognizing that sending this kinds of information using conventional mail was a violation of PIPEDA (essentially equivalent to US HIPPA)  protocol, the CDA has since created a service to do this. Unfortunately, this involves generation of a zip file or sending of a key to the receiving party, which generates more work and decreases efficiency.

Our www.Endoexperience.com site has 128 bit encryption that allows referrals to SECURELY access this data WITHOUT the need for these extra steps. Although privacy concerns about Dentally relaed health data have not been an issue until now, it is possible that in the future Provincial Dental associations or Provincial Governments may prohibit the use of regular E mail for transmission of patient data. If so, having a way to effortlessly access patient data, correspondence, reports and images in a secure manner may become a necessity.

 

 Guidelines for Emergency Endodontic Diagnosis and Treatment

Efficient and accurate Endodontic emergency diagnosis depends upon three factors:

(1) The ability to obtain the right information from the patient (Listen to what the patient is telling you!)

(2) Using the patient’s dental history, your experience and intuition in those cases where the diagnosis is not clear-cut.

(3) The clinician’s ability to adhere to sound diagnostic principles that most often includes the ability to reproduce the patient’s current complaint in the chair.  If you cannot reproduce symptoms with Endodontic tests, there is a good chance that the problem is not endodontically related. Attempting treatment on a tooth without a firm diagnosis can often result in error, embarrassment and significant adverse financial consequences for the patient and clinician.

Essential Endodontic Clinical Tests

1. Thermal Tests

Thermal tests are helpful in determining the presence of pulp vitality

• Cold Tests –            Useful for diagnosing Reversible or Irreversible Pulpitis
• Heat Tests –             Essential for diagnosing Irreversible Pulpitis

2. Electric Tests

The EPT is useful ONLY for determining the possibility of non-vital pulp. Electric tests cannot be used to determine stages of pulpitis. Number values given by these machines are meaningless. The EPT has become less popular as a pulp test because of its inconsistency. Metallic restorations, secondary dentin formation and immature apices can affect EPT readings.

3. Percussion

Indicates the condition of the periodontal ligament and supporting structures.

4. Palpation

Can indicate periapical involvement.

5. Cavity Test

In any case of suspected necrosis, the cavity test remains the Gold Standard in order to obtain definitive proof of lack of vitality of the coronal pulp. Since pulp pathosis occurs coronally-apically, there is always a possibility of having vital tissue in the apical third of a tooth when the chamber is found to be non-vital. In multi-rooted teeth, caution must be exercised, as it is also possible to have necrosis in one root and vital tissue in the canal of an adjacent root.

6. Transillumination and Occlusal Tests

With the ever increasing numbers of fractured teeth and teeth with CTS (Cracked Tooth Syndrome) it is important to examine cracks in marginal ridges and to use a Tooth Sleuth on individual cusps. While a fractured cusp or crack does not by itself indicate endodontic involvement, it can often explain symptoms in unrestored or minimally restored teeth.

Radiography and Diagnosis

Ideally, a cone beam tomograph should be available for ANY case that is being endodontically treated. If there is one rule regarding endodontic diagnosis it is: “Take another film”. (With thanks to Dr. Seymour Melnick of Boston University- LONG before cbCT’s were available !! )

Periapical radiography can often miss problems under restoration margins due to angulation of the film. Bitewing radiography can be useful in detecting these caries, faulty margins and relative depths of restorations.   Where a cbCT is NOT present, at a minimum, a second periapical film, taken at a slightly different angle, must be taken. It can often can often show additional roots or evidence of additional canals. Draining areas, pockets, sinuses or fistulae should always be traced to source with a gutta-percha cone. Resist the temptation to use an anesthetic when inserting the tracer.  Administration of local anesthetic prevents being able to use a cavity test as the final test of pulp vitality.

Recall radiographs should always include both periapical and bite wing views to examine for periapical pathology and marginal integrity of castings – and where previous radiolucent findings were present or with ANY retreatment, a follow up cbCT is indicated .

The Thermally sensitive tooth with no periapical symptoms

The problem is the coronal pulp. Treatment is complete pulpectomy (if there is sufficient time). This will relieve the thermal symptoms and allow the patient to be rescheduled for completion of endodontic treatment when time allows. Pulpotomy can sometimes be used in multiple canal teeth without periapical involvement.

The Periapically involved Tooth

Teeth with periapical involvement will have signs that may include percussive sensitivity, periapical palpation sensitivity and/or swelling and sometimes visible radiographic periapical pathology. Relief will be most predictably obtained by complete pulpectomy. Canals should be broached, irrigated and cleaned to approximately size #15 or #20 instrument (if possible) with electronic confirmation of working length. In this way, the minimal remaining pulp remnants have little possibility of increasing the periapical inflammation. Always use small files. Beware of forcing material out of the apex. The occlusion is relieved and the patient is placed on anti-inflammatory medication. Antibiotics are rarely required.

Post Treatment Exacerbation – (Blow Up)

In rare cases, you may need to place the patient on antibiotics if they develop post pulpectomy blow up.  This usually occurs 48 hours after treatment and is due to pushing debris out of the apex. It is more often associated with necrotic or retreatment cases. Pathology is due to inoculation of the periapical area with pulp content and bacteria, inadvertently introduced into this area by a file.  Working lengths must therefore be accurate. Use an apex locator to prevent being long with files. If the case blows up, there will be PDL inflammation. The tooth will extrude and periapical palpation sensitivity and swelling will occur. The first 48 hours post-treatment are the most critical. Good communication follow-ups by staff-members prevent cases from getting out of control.  Antibiotics should be given in those cases where swelling is reported. It is important to start the medication early and to ensure that the patient does NOT apply heat to the area externally.  THERE IS NO SCIENTIFIC BASIS FOR GIVING ANTIBIOTICS AS A “PROPHYLAXIS” IN THE CASE OF THE SINGLE APPOINTMENT TREATMENT OF AN ASYMPTOMATIC NECROTIC TOOTH.

 

Periapical Abscess

The tooth will exhibit no signs of vitality. Mobility can be very high due to the periapical inflammation. There may be intra and extra-oral swelling. Often the tooth will feel “high” due to PDL thickening. Percussive sensitivity is often acute and these teeth should never be intentionally percussed. Some have distinct periapical lesions associated with the tooth but many rapidly developing cases come on so quickly that radiographic changes may be minimal at time of presentation.

Treatment consists of establishing drainage through the canal (if possible). Incision and drainage should be performed in the case of obvious fluctuant swelling or if the abscess has pointed as the result of administration of antibiotics. Amoxicillin 500 mg 2 stat 1 q.i.d. (depending on the case) remains the drug of choice but the author has recently moved toward away from Clindamycin to Azithromycin 250 mg q24hr (5 days including loading doses) as recommended by the most recent AAE guidelines. Antibiotics are only given until such time as the canal can be accessed and cleaned. Then the medication is stopped.

Post Treatment Discomfort

The most common reasons for post-operative discomfort in endodontic treatment are:

1) Failure to adequately relieve the occlusion
2) Failure to maintain apical control of instruments resulting in tearing or abuse of the apical foramen areas.
3) Pushing necrotic debris or canal irritants out of the apex into the periapical tissues

In (1), ask the patient if NSAIDs relieve the discomfort. If so, check the occlusion in centric and lateral excursions. Ensure adequate clearance and take the tooth out of occlusion if necessary. Prescribe additional NSAIDs and check with the patient again in 48 hrs.

In (2), check for wet canals (if in mid treatment) and open the case for drainage if necessary.  Ca(OH)2 medicaments can be helpful in these cases. If the case has been completed with large amounts of sealer excess, proceed as in (1). Surgery may be necessary in cases where there is gross tearing, transportation or perforation of the apex.

In (3), determine how severe the periapical symptoms are. Prescribe analgesics for discomfort and antibiotics if the area is beginning to exhibit more diffuse swelling.

If you are confident in the apical seal and quality of the Endo treatment, resist the urge to reopen the tooth for 48-72 hrs. Allow the antibiotic and NSAIDs to work. Most cases will resolve once the body has dealt with this extruded material. Immediately “re-opening ” the case by attempting to remove the gutta-percha filling and getting to the apex with instruments can induce additional periapical inflammation, further material extrusion and tear the apex. It will also necessitate complete re-instrumentation and refilling of the case, which can only delay healing and increase periapical inflammation.

 

Pretreatment – Is it worth the Effort?

Pretreatment involves preparing a tooth for Endodontic treatment. Many endodontically involved teeth are heavily broken down or carious. Some involve deep fractures, subgingival proximal caries or faulty margins. The need for proper isolation of a tooth during Nonsurgical Endodontic treatment demands the use of rubber dam. Adequate isolation and proper asepsis during treatment can only be achieved when the portion of the tooth to be clamped is in a reliable condition, the clamp is secure and the dam seals the tooth be be treated. Failure to adequately pretreat a tooth can result in contamination of the working area through rubber dam leakage, clamp disengagement or loss of reference points. Pretreatment does require extra effort on the part of the dentist and slight added expense to the patient. However, this is more than made up in the ease of treatment and asepsis of the working area both during and after treatment. It also gives reasonable assurance that the tooth will be protected until it is restored.

Types of Pretreatment

1. Removal of all caries and defective restorations
   
   In order to consider any tooth for endodontic treatment, we first must determine if it is restorable. There is nothing more embarrassing for clinician than to complete endodontics through a crown, only to find that the remaining tooth is not restorable and must be extracted. This can be prevented by removing all caries and defective restorations from the tooth and examining for adequate remaining tooth structure. If you are satisfied that the tooth can be restored, move to step 2.
2. Gingivoplasty/Gingivectomy with scalpels, Electrosurgery or Lasers

In some cases, caries, fractures or defective restorations are subgingival. Teeth with caries is just below the gingival crest can occasionally be treated by judicious use of a scalpel, electrosurgery or gingivoplasty where hyperplastic or excessive gingival tissue is removed to allow placement of a rubber dam clamp. In severe cases, such as those with muco-gingival involvement, those that require osseous recontouring or apical repositioning, referral to a Periodontist may be necessary before initiating endodontic treatment.   There is no point in treating the case endodontically if attainment of proper biologic width, a healthy periodontal condition and proper patient hygiene is not achievable.

3. Reinforcement of the remaining tooth structure
Sometimes a tooth will be so broken down that insufficient solid tooth remains to use a rubber dam clamp. On other occasions the clamp may be able to be placed, but the post operative fragility of the remaining tooth poses a serious risk of vertical or cusp fracture. (Loss of a reference cusp during treatment can mean inaccurate working lengths.) In those cases, reinforcement of the tooth is necessary.

For many years banding of teeth with copper or orthodontic bands was the method choice. With the development of deeper curing light cured composites and fast setting bonded core pastes, banding of teeth has become less common. However, the copper band offers one advantage that these other technologies do not… the ability for the rubber dam clamp to securely engage the soft copper of the band and not come loose. As much as I dislike taking the time and trouble to place a copper band on a tooth (a well fitting band in a tooth with previously deep proximal restorations can take 20 min. or more to place), I invariably love the results. The case is much easier to treat, isolation is easily achieved and the rubber dam remains secure throughout the treatment. The tooth also has much less chance of post-operative loss of seal or fracture. The properly contoured copper band can also serve as an excellent temporary restoration in cases where patients cannot afford to have the tooth restored immediately, or where other, more important treatment dictates that the tooth remain unrestored for a few months.

Copper Band Placement Steps:

1. Band size selection is VERY important  – Select a band that fits snugly around the tooth but not so snugly that it cannot be removed. It should also not be so large that it has big overhangs. Anneal the band to soften the copper, if necessary. (Heat to red hot in open flame and quench in alcohol in a dappen dish). This renders the copper dead soft.
2. Place the band over the tooth and score the inside and outside of the band with an explorer to indicate the height of the occlusal surface. Cut the band with scissors to and check for fit.  Notch one side of the occlusal surface of the band to allow the copper to be pushed down and contoured to fit the occlusal areas. The band should draw off the tooth and be able to be placed in the tooth easily. In some rare cases, the proximal surface(s) may need to be reduced to allow it to be seated.
3. Polish band with Joe Dandy disc and rubber wheels to smooth the outside surface of the band. Dry and isolate the tooth with Dri-angles and cotton rolls
4. Mix ZnPO4 Crown and Bridge cement. Two types of consistencies of mix are necessary:
   (1) typical C&B loose cement – used to cement the band. Place cement on inside of band and seat by hand. Contour the Cu band as necessary with a band pusher.
   (2) A second mix is made by immediately adding more ZnPO4 powder to the first mix to create a “doughy” ball of cement. Be careful with this mix, as too much powder can cause immediate set.  Place powder on fingers to prevent the cement from sticking to your gloves and push the ball of cement on to the occlusal surface of the tooth, ensuring adaptation to any proximal surfaces.  Some excess may be visible around the band edges but proper contour and fit will ensure that it is not excessive.  Use band pusher to contour the apical and coronal portions of the copper band to adapt to the tooth as well as possible. Once cement becomes doughy, stop all manipulation and wait for the cement to harden.
5. Once the cement is set rock hard, flick out any proximal excess with a plastic instrument or scaler.  Trim band and cement from band margins to create smooth occlusal surface and check occlusion. Perform final polish of trimmed band areas with green rubber wheel or points.  Tell patients that while this may feel as hard as permanent restoration, the copper still can be deformed or cement seal broken if it is abused. Tell them to treat it “like a temporary filling”.

Your rubber dam clamp will now easily bite into the soft copper and the rubber dam with be securely placed. When removing the clamp be sure to open the forceps and disengage the entire band completely before removing the dam. Failure to do this when minimal tooth structure is left can dislodge the band and require you to replace it again!