Please DO Read the Endodontist’s  Postop Report

Dentists referring cases to Endodontists for treatment frequently give the post op reports they receive only a cursory glance before proceeding with restoration of the tooth. Many Endodontists have gone away from the concept of a Cavit or Cavit/IRM based temporary restoration to material that has higher compressive strength to try to ensure better durability and strength of the temporary.   In many cases this involves the use of a colored,  bonded core paste material that is used to build up the tooth or seal the access cavity. In my office,  I prefer to use a dual cure blue colored, bonded core paste by Bisco – Rebilda DC. Unlike a tooth colored material, this signals to the patient and to the referral that the final restoration has not been completed and further work is needed to complete rehabilitation of the tooth.

Dentistry has finally begun to understand that the best results are achieved when the orifices are sealed after Endodontics with a bonded material and then immediately followed by some types of core buildup, when necessary.
This provides:
(1) optimum seal for the canal system
(2) increased strength of the tooth making it much less likely that catastrophic fracture will occur prior to restoration
(3) greater protection for the treatment and tooth should the patient have to delay treatment for financial or insurance reasons.

However, there are still some referrals who refuse to allow Endodontists to place such cores and insist that the tooth be temporized and returned to them without placement of such foundational restorations. In such cases, one compromise is that the orifices are bonded with a colored flowable composite material and some sort of spacer, usually consisting of a sponge or cotton is placed over the orifice.  The access is then closed with a bonded material such as core paste and specific instructions are given to the restoring Dentist on the postop report indicating that this seal is only TEMPORARY. It must be removed and the tooth adequately restore. .

Unfortunately, there are situations in which the post op reports are not adequately scrutinized and, seeing a blue material in the orifice, the referring dentist omits to remove the material and preps directly over the temporization. This results in castings that are cemented over teeth with large voids in the chambers that are occupied by either sponges or the cotton pellets. We know that over time, crowns can leak. Eventually, this spacer material can accumulate fluids and possibly result in further symptoms or Endodontic failure.

Patient referred for continuation of treatment of the maxillary left first molar. Referring Dentist could complete locate orifices and was drifting dangerously close to perforating the tooth.

This case shows a maxillary molar tooth that was treated by me and then temporized with  an orifice bond, sponges and the access cavity closed with a blue core paste material. The referring dentist did not read the post op report adequately and prepared the tooth for a crown, not removing any of the old amalgam or the access filling I placed. Evidently, they did not take a bitewing radiograph prior to preparation of the tooth or cementation of the Crown.

The bitewing radiograph revealed a large void in the chamber that corresponded to the exact appearance of the tooth immediately after the endodontics was completed. The temporary access filling and proximal amalgams had never been removed and the spacers were still present. Although the patient was asymptomatic at this point, some 12 years later, it was extremely disappointing to see this obvious error.

Good endodontic treatment is predicated upon the ability to clean shape and then obturate the canal system, taking special care not to leave any voids or areas that may result in a long term failure.  The restoration is the final step in accomplishing this goal, as well as returning the tooth to function. On recall, this patient appears to be asymptomatic but the tooth will always remain a concern in my mind, because of this unnecessary void.

Prior to preparation of the tooth for final restoration, I encourage my referrals to closely examine my post op report and any instructions that are given. Failing to do so may result in lack of recognition of important clinical details that may affect the restoration of the tooth and  lead to long term failure of the case.

Does Loose Abutment Need Endo?

This patient was referred to me for endodontic consideration of the maxillary left cuspid area.  The patient had been complaining of diffuse toothache and sensitivity to liquids. The tooth was part a multi-unit fixed prosthesis. The referring dentist asked me to perform endodontic treatment on through cuspid crown because of the presence of the thermal sensitivity.

Periapical radiography showed no evidence of pathology. When cold liquids were applied to the crown margin by irrigation syringe, the patient reacted positively.

Closer examination of the crown margins revealed discrepancy in the crown fit. At that point I managed to get the tip of an explorer under the palatal crown margin and wedge it between the crown margin and the root. I then applied occusal pressure to the prosthesis with my fingers and closely observed the labial crown margin. This is what happened:

The abutment tooth ( #23) had become loose from the bridge. Rather than treat the tooth endodontically, the patient was referred back to her dentist for bridge removal and cementation. In this case there was no obvious decay and it seemed that the cement had washed out from under the crown. the bridge was recemented and the patient’s symptoms disappeared.

Why is this significant? Because there is a natural tendency for clinicians to want to endodontically treat cases such as these. This eliminates the thermal and liquid sensitivity and relieves the patient’s symptoms. However, it does not address the true problem- the loose abutment. Had I simply treated the case and NOT initially recommended removal/inspection/recementation of the bridge, it is likely that the the endodontic treatment would have eventually be compromised by the leaking crown margins. It is also likely that the crown preparation would have decayed from inside the crown and this critical abutment may have been compromised or eventually lost.

Conclusion
Endodontic treatment is often recommended when crowned teeth are sensitive to thermal stimulus. The best way to prevent this situation is to consider elective endodontic treatment BEFORE the fixed prosthesis is cemented. Teeth with large restorations, fillings close to the pulp, pulp caps, history of multiple crown cementations or preparations close to pulp horns all can result in post cementation thermal sensitivity. Elective endodontic treatment in selected cases can result in better results because the clinician is no longer “afraid” of the consequences of pulpitis. It also allows for the creation of a more “classic” preparation when you are not concerned with the depth of preparation vis a vis the pulp.

BUT we should also remember that the symptoms of a loose prosthesis can also mimic these problems. It is important to closely examine all abutments to make sure that they are not loose. Simply devitalizing a tooth with no regard to the quality of the crown margin can lead to eventual catastrophic failure of the abutment through caries, endodontic failure and possible loss of the tooth.

Are you SURE about your Diagnosis?

This Case of the Month deals with a case in a 67 year old gentleman I saw 25 years ago. Although the case was completed so long ago, the implications of the case stay with me to this day.
The case had already been started in the referral’s office. The patient had complained of a localized fluctuant, soft swelling in the buccal sulcus area of the maxillary right premolars and first molar. The first premolar had been previously accessed by the referral under local anesthesia and the referral said that he was having difficulty locating the apices because of the small canals. He asked me to complete endodontics on this premolar.  (We did not have a cbCT in our office back then)

Upon his arrival I noted the patient had a small bit of extraoral swelling but certainly nothing more than would be expected with a nonvital tooth with acute periapical periodontitis. Intraoral swelling was confirmed. Percussion and periodontal findings were within normal range for the entire quadrant. However, something in the dental history did not make sense.

Closer examination of the first premolar showed no evidence of prior restoration (other than the access temp), This tooth was virgin prior to access. Transillumination showed no evidence of fracture. Yet there was a large radiolucency and associated swelling in the area. Why? Was this tooth originally non-vital and causing the swelling? How could I tell?

To be sure, I pulp tested both the second premolar and first molar again with cold tests. They both responded vital. The cuspid tested poorly with thermal tests so I did a cavity test and actually made a pinpoint exposure before arriving at a positive vitality test. The exposure was sealed with MTA and the cuspid access was restored with composite. All three of these teeth were responsive – they could NOT be the source of the lesion.

I then placed a rubber dam and made further access into the tooth with small working length files.  I was able to obtain apical patency but as I did the patient did note sharp sensations in both canals as I approached the apex. This indicated to me that BOTH canals were vital. This was NOT consistent with an endodontic etiology for the radiolucency and swelling.

The case was completed as usual after having anesthetized the patient but I was concerned.

After completing the endodontics, I removed the rubber dam and attempted an incision and drainage procedure in the most fluctuant are of the swelling. Much to my surprise and dismay, there was no drainage at all, even after blunt probing the incision. I became very concerned.

After completing the endodontics, I removed the rubber dam and attempted an incision and drainage procedure in the most fluctuant are of the swelling. Much to my surprise and dismay, there was no drainage at all, even after blunt probing the incision. I became very concerned.

I told the patient that it was my opinion that the swelling was not caused by an endodontic problem and I strongly suggested that he be referred to an Oral Surgeon for further evaluation and likely biopsy. The patient seemed unimpressed by my diagnosis. I immediately phoned the referral to tell him that I had a “funny feeling” about this case. My intuition and experience told me that there was more here than was originally diagnosed. I insisted that he speak to the patient and make sure that he kept the appointment that my staff had scheduled for him with the Oral Surgeon.

The report was as follows:
Biopsy Specimen: Two irregularly shaped irregularly pigmented pieces of tissue – one 1.3 x .9 x .5 cm, the other 1 x .7 x.4 cm

Microscopic evaluation: The specimen in its entirety consists of malignant lymphoid tissue. histologically, the lymphoid cells are two to three times the size of normal lymphocytes with somewhat vesicular nuclei. Appreciable numbers of mitotic figures are noted within the lesion.

Diagnosis: Malignant Lymphoma, Diffuse, large cell type of tissues from the maxilla. PATIENT REFERRED IMMEDIATELY TO AN ONCOLOGIST FOR RECOMMENDATIONS AND TREATMENT.

Conclusion
In a busy office with high overheads and constant financial pressures, it is very tempting to make a quick diagnosis and access a tooth in an attempt to treat what may initially seem to be endodontically related symptoms. BUT that does NOT relieve us from performing the proper diagnostic tests.

When patients are symptomatic, we MUST reproduce the patient’s symptoms in the chair for proper diagnosis. In some cases, in order to determine vitality, that means a cavity test. Practitioners must be able to substantiate treatment with science, rather than simply an impression, radiographic appearance or that it “looks” obvious.

In this case, attempting access in an anesthetized virgin tooth suspected to be necrotic (and the source of the lesion) but not confirmed – lead to misdiagnosis. In most cases it merely means that another tooth is involved and that too ends up being treated. However, in rare cases like this one, malignancies can be missed. We must always remember that although such lesions are rare, the consequences of not considering them can be catastrophic. The Oral Surgeon said that in this case, while the situation appears NOT to be immediately life threatening -it certainly warrants serious concern and immediate aggressive medical treatment.

Does This Cracked Tooth Need Endo?

This Case of the Month features a problem that is becoming more common every day – Cracked Tooth Syndrome. Many cases are referred to me because the referring dentist suspects that the tooth has a crack but is not sure whether endodontic treatment is indicated. This could be because they are not sure how deep the crack is and whether it involves the pulp. Or, in some cases, once the cracked portion of the tooth is removed, the remaining tooth structure is insufficiently strong to retain the restoration. In that situation, elective endodontics is required, NOT because of the actual damage caused by the fracture ( the pulp is normal) but because a post space is required to properly retain a core restoration and eventual full cuspal coverage.

The first test involved application of biting forces to a standard cotton roll. As we advanced from tooth to tooth, we asked the patient to chew on the roll once and then release. When we got to this molar, sensitivity occurred upon release, again another classic sign. Having identified the tooth , we now tried to identify which portions of the tooth were weak. A Tooth Slooth was applied to each cusp individually until we found that the Mesio-Lingual cusp yielded a positive sharp response. We had our culprit. But the question remained…how do we deal with this? Exactly how “Cracked” was the tooth? How far did the crack go? Did it need endodontic treatment? We would need to remove the restoration to find out more.

Application of a small amount of force to the cusp with the back of a mirror handle resulted in a break at the level just below the gingival crest. ( Although removing weak portion of teeth by causing “intentional” cusp fractures such as this seems drastic. It is certainly better than attempting to salvage the cusp, only to have it break later at a far more subgingival level. That can sometimes result in the need for crown lengthening procedures or extraction if the break is too far apical to be treated.)

We obtained a nice clean surface with no signs of pulpal involvement.

Having determined that the pulp was not involved, we now moved to the stage where we evaluate whether elective endodontics is required. This molar appeared to have good support for the remaining cusps. No other evidence of fractures was visible and the tooth was not in particularly heavy occlusion. I decided that elective endodontic treatment was not required and the case was restored interim with a dressing of IRM.

The patient was asked to monitor the area for a few weeks to confirm symptoms were gone. Correspondence ( including these pictures) was sent to the referral explaining my findings .

It was then up to the restoring Dentist to determine how best to restore the tooth (onlay? Crown?). It is possible that we may have saved the tooth from having further Endodontic treatment, but that will depend on the integrity of the rest of the tooth,  the restoring Dentist’s treatment plan and the pulpal response to further restoration.

Inadequate Emergency Treatment Results in Persistent Symptoms

A 58 year old male patient was seen for emergency treatment regarding the area of tooth #27. the patient had a history of a toothache that resulted in the tooth being accessed by the referring dentist. The patient said he had been in pain for two weeks after the initial access and describe the severity of the pain as 5 out of 10. It was localized to the tooth in gum area and was described as a momentary sharp pain that was sensitive to both hot and cold stimulus. The patient did not report swelling and the tooth occasionally hurt when biting.

Clinical examination of the tooth showed prior endodontic access. Radiographic examination showed evidence of attempted endodontic access but the chamber did not have the classic appearance of one that had been properly accessed.

In cases where it is obvious that a pulpotomy has been performed (and therefore the tooth would naturally NOT respond to thermal stimulus pulp testing), I rarely do a thermal sensitivity test.  But when patients are persistently symptomatic , I always attempt to reproduce the patients symptoms in the chair before commencing or continuing treatment. Application of cold stimulus to tooth #27 reproduced the patient symptoms exactly. This was unusual. Why would a tooth that  had been accessed by the referral still have thermal sensitivity as tested with application of thermal stimulus to the Crown of the tooth?.

Bite wing radiography showed that the walls of the chamber seemed to be mostly intact and there was only a small area of distal pulp horn dentin had been removed from the roof of the chamber. The pulp had been “exposed” without pulpotomy.

I explained to the patient that treatment of tooth #27 had already been initiated but that the pulp tissue had not been completely removed during the emergency procedure.  Completion of the endodontic treatment was required prior to restoration of the tooth with a full Crown.

The patient was anesthetized and the temporary filling was removed. I immediately noticed that all the pulp tissue in the chamber was essentially intact and a substantial amount of pulp tissue remained . This was likely causing the exaggerated response to thermal stimulus and was the reason for the patients symptoms. Endodontic Treatment was performed as usual and the tooth was obturated  with warm gutta percha and sealed with an orifice bond and dual cure core paste composite material in the access . The patient reported resolution of symptoms the following day and has been scheduled for final restoration of the tooth.

,In cases where emergency Endodontic treatment is initiated on a molar, it is important to remove all of the pulp tissue from the chamber. Failure to do so essentially creates a pulp exposure situation in which can increase symptoms and elevate thermal sensitivity.

It is impossible for a tooth that has had prior proper Endodontic access to be thermally sensitive.  For that reason, there is a temptation to consider a possible OTHER tooth as being the source of the patients problem. This can result in us being  be misled..  Attempting to access another tooth to solve the problem would be a clinical error and could possibly result in erroneous Endodontic treatment of another tooth.

It is important to perform all tests, even if we think the answers to those tests might be “obvious”, especially when taking over treatment that has been initiated elsewhere. Those of us who agree to continue such treatment have learned from experience that failing to address the fundamentals of Endodontic diagnosis, even in apparently obvious or “easy” cases can sometimes lead to errors.

Classic Internal Resorption

In this case of the month we revisit an old case that had been previously accessed and left open. This 45 year old female’s maxillary left lateral incisor had a history of deep composite restorations on both mesial and distal sides. She was Hepatitis B positive and also had a history of orthodontic treatment later in her mid 30s..

The apical third showed a fairly large area of internal canal resorption. The apex shows a classic lesion of endodontic origin associated with a necrotic tooth. The patient was asymptomatic with the exception of a draining sinus on the labial aspect.

A working length was established used a K file (Size #40). The canal was cleaned and shaped using standard irrigation protocols ( NaOCL 5.25%)) taking care not to enlarge the apical foramen that appeared to have been resorbed as well. ( It is unknown whether the resorption occurred as the result of pathology or Orthododontics)  This case was done in a single appointment, without placement of medication such as CaOH. A coarse paper point was used to gauge the foramen size and point of termination.

The case was filled with Warm Vertical compaction technique. Post op fill shows good adaptation to the resorbed area and no excess out of the canal space. The case shows good apical control while at the same time filling a large space close to the foramen.

A 4 year recall film shows complete bone fill and healing. Internal resorption cases make up only a small percentage of resorption cases that Endodontists see. Most “internal resorption” cases diagnosed by referring dentists are actually misdiagnosed external resorption.
This is a true internal resorption case with a classic appearance of the resorbed are of the canal. These case respond very well to proper cleaning and shaping although they are not the “Classic canal shape”. Warm vertical obturation with gutta percha is particularly well suited to obturate such cases because warming the material allows it to adapt to these “non-standard” shapes.

Treatment Planning a Trauma Case

This 23 year old patient was seen for examination regarding tooth #11 -the maxillary central incisor. The patient had a significant history of taking a high stick to the face during a hockey game . The coronal aspect of #11 was fractured (Ellis class 3 MID) during the accident. I noted a 5 millimeter probing in the area of the palatal fracture and associated draining buccal sinus. The oblique fracture is typical in that the buccal portion cracks in the mid root while the palatal extent is far subgingival – at the bone Crest. A diagnosis of chronic periodical periodontitis secondary to pulpal necrosis was made . The other maxillary and mandibular teeth tested normally to pulp tests. No other endodontic treatment was required. The patient was lucky, the accident could have resulted in more severe injury.

The determining factor as to whether we wish to restore this tooth is based more upon restorative and other factors rather than endodontic factors. There are three factors that must be assessed before we decide whether to initiate Endodontic treatment and start the patient on the journey to rehabilitate the tooth.

#1. –  The extent of the fracture on the palatal side
There is no question that the tooth cannot be restored as it presented. We will need to either extract it and replace it prosthetically or attempt to somehow obtain access to the fracture area to allow the restoring dentist to place an adequate palatal Crown margin after the Endo has been completed

#2 – The maxillary arch crowding
The anterior maxilla exhibits generalized tooth size/arch size discrepancy. This has resulted in rotation of the centrals about 40 degrees, which makes re-restoration of #11 challenging. In order to even out the centrals in terms of mesial distal width, the restoring dentist would probably have to slice or veneer the virgin #21. Either way, the restored centrals will have reduced mesial-distal width and less than optimal aesthetics.

The ideal scenario would be to place maxillary full arch orthodontics, optimally align the centrals and the rotated cuspid #23,. Ortho hardware would also allow us to perform forced eruption of #11 after endodontics is completed in order to expose the palatal Crown margin.  The maxillary anteriors could then be position for optimal restoration of #11.  to match the virgin #21. This is a far more extensive treatment plan but it would give us the optimal result.

I obtained a consult from a periodontist in my building about the possibility of Perio Crown lengthening. She said that she would like to try to avoid any attempted Crown lengthening procedures on the palatal aspect of #11 because of the amount of hard and soft tissue loss that would need to take place to properly Crown lengthen the tooth. Furthermore she said we may compromise the adjacent papilla should we get recession after the surgery . In THAT case, Endo treatment would be CONTRAINDICATED.

#3 –  Extraction and implant replacement
Lastly, we could extract the tooth and place an implant but that still leaves us with the crowding issue.

By the time we pay for the implant we probably could have had Orthodontic treatment/forced eruption and  restore #11 optimally after the Endo.  

I suggested that the referring dentist create some study models and consult with an Orthodontist to see how to restore this tooth in a manner that is acceptable to the patient in the way of aesthetics, time, and cost.

Treatment Planning a Trauma Case

This 23 year old patient was seen for examination regarding tooth #11 -the maxillary central incisor. The patient had a significant history of taking a high stick to the face during a hockey game . The coronal aspect of #11 was fractured (Ellis class 3 MID) during the accident. I noted a 5 millimeter probing in the area of the palatal fracture and associated draining buccal sinus. The oblique fracture is typical in that the buccal portion cracks in the mid root while the palatal extent is far subgingival – at the bone Crest.  I also noted some significant horizontal bone loss associated with #11. This would prove to be an important observation later in the treatment planning. A diagnosis of chronic periodical periodontitis secondary to pulpal necrosis was made . #31 had an MID incisal chip from the injury as well. But all the other maxillary and mandibular teeth (aside from #11) tested normally to pulp tests. No other endodontic treatment was required. The patient was lucky, the accident could have resulted in a much more severe injury.

We needed to determine whether we wished to initiate Endodontic treatment and embark on the protracted sequence of treatment that would be needed  to rehabilitate the tooth. That decision was based far more upon restorative and other factors rather than endodontic factors. 
I felt that there were three factors that had to be assessed by all the clinicians involved in the rehabilitation:

#1. –  The extent of the fracture on the palatal side
There is no question that the tooth could be restored as it presented. We will need to either extract it and replace it prosthetically or attempt to somehow obtain access to the fracture area to allow the restoring dentist to place an adequate palatal Crown margin after the Endo has been completed

#2 – The maxillary arch crowding
The anterior maxilla exhibits generalized tooth size/arch size discrepancy. This has resulted in rotation of the centrals about 40 degrees, which makes re-restoration of #11 challenging unless we wanted to merely place an implant and recreate the crowded/rotated position of #11  (hardly ideal) . In order to “even out” the centrals in terms of mesial distal width, the restoring dentist would probably have to slice or veneer the virgin #21. Either way, the restored centrals will have reduced mesial-distal width and less than optimal aesthetics unless we dealt with the crowding Orthodontically prior to restoration of either the natural #11 or implant #11.

The ideal scenario would be to place maxillary full arch orthodontics, optimally align the centrals and the rotated cuspid #23,. Ortho hardware MAY also allow us to perform forced eruption of #11 after endodontics is completed in order to expose the palatal Crown margin.  (But I the root was not particularly long and I was unsure about the crestal bone loss that already had occurred next to the fracture site. )The maxillary anteriors could then be position for optimal restoration of #11,  to match the virgin #21. This is a far more extensive treatment plan but it would give us the optimal result.

I obtained a consult from a periodontist in my building about the possibility of Perio Crown lengthening. She said that she would like to try to avoid any attempted Crown lengthening procedures on the palatal aspect of #11 because of the amount of hard and soft tissue loss that would need to take place to properly Crown lengthen the tooth. Furthermore she said we may compromise the adjacent papilla should we get recession after the surgery . In THAT case, my Endo treatment would be CONTRAINDICATED.

#3 –  Extraction and implant replacement
Lastly, we could extract the tooth and place an implant but that still leaves us with the crowding issue and Ortho would likely need to be performed to get teh best results..

The options were many and the choices unclear on presentation.  For those reasons, I suggested that the referring dentist create some study models and consult with an Orthodontist to see how to restore this tooth in a manner that is acceptable to the patient in the way of aesthetics, time, and cost. That may. or may not involve Endodontic treatment of the tooth. Simply Endo treating the tooth without these considerations is below the standard of care, in my opinion.

Treatment Planning a Trauma Case

This 23 year old patient was seen for examination regarding tooth #11 -the maxillary central incisor. The patient had a significant history of taking a high stick to the face during a hockey game . The coronal aspect of #11 was fractured (Ellis class 3 MID) during the accident. I noted a 5 millimeter probing in the area of the palatal fracture and associated draining buccal sinus. The oblique fracture is typical in that the buccal portion cracks in the mid root while the palatal extent is far subgingival – at the bone Crest. A diagnosis of chronic periodical periodontitis secondary to pulpal necrosis was made . The other maxillary and mandibular teeth tested normally to pulp tests. No other endodontic treatment was required. The patient was lucky, the accident could have resulted in more severe injury.

The determining factor as to whether we wish to restore this tooth is based more upon restorative and other factors rather than endodontic factors. There are three factors that must be assessed before we decide whether to initiate Endodontic treatment and start the patient on the journey to rehabilitate the tooth.

#1. –  The extent of the fracture on the palatal side
There is no question that the tooth cannot be restored as it presented. We will need to either extract it and replace it prosthetically or attempt to somehow obtain access to the fracture area to allow the restoring dentist to place an adequate palatal Crown margin after the Endo has been completed

#2 – The maxillary arch crowding
The anterior maxilla exhibits generalized tooth size/arch size discrepancy. This has resulted in rotation of the centrals about 40 degrees, which makes re-restoration of #11 challenging. In order to even out the centrals in terms of mesial distal width, the restoring dentist would probably have to slice or veneer the virgin #21. Either way, the restored centrals will have reduced mesial-distal width and less than optimal aesthetics.

The ideal scenario would be to place maxillary full arch orthodontics, optimally align the centrals and the rotated cuspid #23,. Ortho hardware would also allow us to perform forced eruption of #11 after endodontics is completed in order to expose the palatal Crown margin.  The maxillary anteriors could then be position for optimal restoration of #11.  to match the virgin #21. This is a far more extensive treatment plan but it would give us the optimal result.

I obtained a consult from a periodontist in my building about the possibility of Perio Crown lengthening. She said that she would like to try to avoid any attempted Crown lengthening procedures on the palatal aspect of #11 because of the amount of hard and soft tissue loss that would need to take place to properly Crown lengthen the tooth. Furthermore she said we may compromise the adjacent papilla should we get recession after the surgery . In THAT case, Endo treatment would be CONTRAINDICATED.

#3 –  Extraction and implant replacement
Lastly, we could extract the tooth and place an implant but that still leaves us with the crowding issue.

By the time we pay for the implant we probably could have had Orthodontic treatment/forced eruption and  restore #11 optimally after the Endo.  

I suggested that the referring dentist create some study models and consult with an Orthodontist to see how to restore this tooth in a manner that is acceptable to the patient in the way of aesthetics, time, and cost.

Treatment Planning a Trauma Case

This 23 year old patient was seen for examination regarding tooth #11 -the maxillary central incisor. The patient had a significant history of taking a high stick to the face during a hockey game . The coronal aspect of #11 was fractured (Ellis class 3 MID) during the accident. I noted a 5 millimeter probing in the area of the palatal fracture and associated draining buccal sinus. The oblique fracture is typical in that the buccal portion cracks in the mid root while the palatal extent is far subgingival – at the bone Crest. A diagnosis of chronic periodical periodontitis secondary to pulpal necrosis was made . The other maxillary and mandibular teeth tested normally to pulp tests. No other endodontic treatment was required. The patient was lucky, the accident could have resulted in more severe injury.

The determining factor as to whether we wish to restore this tooth is based more upon restorative and other factors rather than endodontic factors. There are three factors that must be assessed before we decide whether to initiate Endodontic treatment and start the patient on the journey to rehabilitate the tooth.

#1. –  The extent of the fracture on the palatal side
There is no question that the tooth cannot be restored as it presented. We will need to either extract it and replace it prosthetically or attempt to somehow obtain access to the fracture area to allow the restoring dentist to place an adequate palatal Crown margin after the Endo has been completed

#2 – The maxillary arch crowding
The anterior maxilla exhibits generalized tooth size/arch size discrepancy. This has resulted in rotation of the centrals about 40 degrees, which makes re-restoration of #11 challenging. In order to even out the centrals in terms of mesial distal width, the restoring dentist would probably have to slice or veneer the virgin #21. Either way, the restored centrals will have reduced mesial-distal width and less than optimal aesthetics.

The ideal scenario would be to place maxillary full arch orthodontics, optimally align the centrals and the rotated cuspid #23,. Ortho hardware would also allow us to perform forced eruption of #11 after endodontics is completed in order to expose the palatal Crown margin.  The maxillary anteriors could then be position for optimal restoration of #11.  to match the virgin #21. This is a far more extensive treatment plan but it would give us the optimal result.

I obtained a consult from a periodontist in my building about the possibility of Perio Crown lengthening. She said that she would like to try to avoid any attempted Crown lengthening procedures on the palatal aspect of #11 because of the amount of hard and soft tissue loss that would need to take place to properly Crown lengthen the tooth. Furthermore she said we may compromise the adjacent papilla should we get recession after the surgery . In THAT case, Endo treatment would be CONTRAINDICATED.

#3 –  Extraction and implant replacement
Lastly, we could extract the tooth and place an implant but that still leaves us with the crowding issue.

By the time we pay for the implant we probably could have had Orthodontic treatment/forced eruption and  restore #11 optimally after the Endo.  

I suggested that the referring dentist create some study models and consult with an Orthodontist to see how to restore this tooth in a manner that is acceptable to the patient in the way of aesthetics, time, and cost.

Lorem ipsum dolor sit amet, consectetur adipiscing elit. Vestibulum vel dui nec elit lobortis ultricies. Proin convallis tempus est et placerat. Donec dapibus felis sed ultricies suscipit. Cras aliquet malesuada risus nec gravida.

Nullam enim quam, tristique vel congue id, cursus eu tortor. Etiam aliquet, velit non sodales cursus, massa mauris aliquam ligula, a pharetra ipsum est vel nulla. Nulla accumsan neque sit amet scelerisque eleifend.

Ut eu placerat tortor, et posuere diam. Phasellus sollicitudin dolor nec enim mattis mattis. Interdum et malesuada fames ac ante ipsum primis in faucibus.

Immature Molar Apex Case

An 11 year old girl presented in my office with carious exposure of tooth # 36, the mandibular left first molar. The patient had been in pain for four days and described the severity of the pain of as 5 out of 10. The pain was localized to the tooth and was described as sharp, aching, throbbing and shooting. It was equally sensitive to hot and cold stimulus as well as eating and with sweets. The pain was relieved by use of NSAIDs. The tooth sometimes hurt when she bit on it .

Clinical examination revealed A virgin tooth with a deep, discolored occlusal fissure and likely carious exposure. The tooth was sharply responsive to pulp tests.

Radiographic examination showed deep caries to the level of the pulp horns and incompletely developed apices.

In situations like this we wish to try to maintain the apical vitality as long as possible to allow for completion of the development of the apical root. A decision was made to perform an MTA pulpotomy in the hope that we could maintain vitality to allow for full root development.

The patient was very cooperative a good mandibular block was achieved. Rubber dam was placed  and caries was excavated resulting in a pulp exposure. A deep pulpotomy was performed on the tooth. Bleeding was controlled with the use of H2O2 and pressure over the pulp stumps. Once the pulp had stopped bleeding, MTA putty was placed over the pulp stumps and a tooth was closed with bonded core paste . The patient was placed on follow up  recall to assess apical development and whether further endodontic treatment would be required .

Recall images were taken both at one year and two years post-op . They show complete apical development and the tooth remains completely asymptomatic. I explained to her parents that treatment went extremely well and in the absence of any symptoms or apical pathology I believed that this tooth could be restored with a matching composite restoration and that this may be all that is required to rehabilitate the tooth.

Clinicians presented with this scenario have to be careful not to immediately jump in and extirpate the pulp in its entirety as they would do with conventional Endo treatment. This creates a situation where the apices are large and sometimes difficult to both clean and obturate. This also involves removal of root dentin during the cleaning and shaping of the canal system.

A better option is to try to maintain as much tooth structure as possible, just as we did in this case. Children at this age have an extremely fast healing mechanism and pulps with large, open apices seem to respond extremely well to even such drastic procedures as removal of the coronal pulp.  In this case because the apical tissues remained vital and healthy, apical development continued. Both the referral and the patient’s parents were pleased we could perform conservative procedures on the tooth while at the same time relieving the patient’s symptoms.

Calcified Molar Case Needs Tx Plan

This 55 year old Asian patient was seen on  for consideration of elective endodontic treatment regarding tooth # 46. The patient presented with a lost restoration/composite temporization and significant calcification of the canal spaces. The patient was completely asymptomatic. His hygiene was very poor and he had heavy plaque accumulations and generalized chronic periodontal disease with significant bone loss and pocketing ( D #47!!) The tooth was probably treated with some type of calcification inducing pulpotomy procedure, which is not uncommon outside North America.

I told the referring Dentist that attempting to find the canals in such cases can result in significant risk of perforation and ruining the tooth. Because of the lack of pathology and symptoms, sometimes cases like are best managed by simply preparing a post space into the D root and then restoring the case as is.  It is unlikely that the patient will develop symptoms with such little pulp tissue in the canals. Even if the tooth does become symptomatic, the case would likely need to be handled with Endo surgery. However, considering his hygiene level, I would be VERY reluctant to perform any Endo surgical procedures on him with his current state of home care. Unfortunately, extraction of #46 and 3 unit bridge replacement #47-45 is NOT an option due to the Perio disease and 10 mm distal pocketing in #47.

The above diagram was helpful in trying to explain the issues, but I was unsure whether the patient had an appreciation (or was willing to be an active participant) in the treatment we were proposing. 

So, are we willing to try to treat such a case?  A very wise Prosthodontist once told me ” You can’t care more about the patient’s teeth than they do”.  Without cooperation form the patient in dealing with the myriad of other issues in his mouth, it would be foolish to try to perform complex Dentistry that he does not appreciate nor will he maintain. These factors are best considered and discussed between the General Dentist and patient BEFORE referral.

Lateral resorption Affects Preparation Technique

This 45 year old patient was sent to me for examination regarding diffuse radiating symptoms in the anterior mandible. The referral’s note said:
Please examine patient to check lower left. We think #32 is the problem. Patient feels pain radiating whole lower left side. Pain is on/off, comes in waves. When it hurts it really hurts. We referred patient to to an Oral Surgeon in 2005 to extract #31. The patient remembers it as being a tough extraction.”

The patient was relatively asymptomatic upon presentation. Clinical tests showed positive response to percussion and biting pressure on the #32 abutment of the bridge but this was difficult to interpret because of the connection to the other healthy abutment. Palpation of the buccal gingival area of the retained root was normal. Chewing was positive as well, but again, this was somewhat ambiguous due to the attachment to the other bridge abutment. Pulp test showed no responses to cold or hot in #32 pulp tests, but again, these results could be false because they may not yield  reliable results when they were performed through a casting. Gingival probings were normal.

Periapical radiography showed the presence of a 3 unit bridge #41 -32 with good margins with evidence of a retained root tip in the position of tooth #31. I thought this unusual considering that the original extraction was performed by an Oral Surgeon, who usually don’t leave root tips in place. There were no unusual radiolucent findings associated with the root tip. of #31.  I was not sure of the reason for the original extraction. (Trauma?)

Cone beam tomography revealed a small radiolucent area at the apex of tooth #32. In addition to the retained root tip, I noted that there was an area of root resorption on the mesial midroot aspect of #32. I was not sure whether this may have caused by the effects of the original trauma, attempts to remove the central incisor during extraction or whether it was simply idiopathic.  In any case, any Endodontic treatment that was being considered had to take this area of minimal dentin into consideration during canal preparation.

I explained to the patient that there was radiographic evidence that the pulp of this tooth may have undergone necrosis and that in order for us to rule out the tooth as a source of his discomfort we would need to first (a) do a cavity test and if so (b) endodontically treat # 32 through the Crown.   I also mentioned that I noted an unusual area of mesial resorption and there was a small chance that preparation of the canal could lead to exposure of this lateral area but that every effort would be made to keep the access and canal preparation conservative and avoid communication with this reserved area.

A rubber dam was placed and access was made through the Crown without anesthesia. The pulp was found to be non responsive and when we accessed the chamber we confirmed pulpal necrosis. The canal was cleaned and shaped using minimal preparation techniques (Edge rotary Ni-Ti files)  and obturated with F-M  gutta percha cones and vertical compaction of warm gutta percha. The access was closed with composite. It was especially important for us to be conservative with canal shaping to prevent the possible communication with this resort area and possible extrusion of filling materials into the lateral side of the root. Fortunately, the canal was straight and access was quite easily performed. The patient’s symptoms resolved with Endodontic treatment.