In summary, a definitive diagnosis followed by a treatment that removes the etiology of the root resorption is necessary to achieve an optimal prognosis.

Abstracted by Michael J. Sardzinski, DMD and Carol L. Hwang, DMD, Postgraduate Endodontics, University of Florida College of Dentistry, Gainesville, FL.

Scientific Session III Charles McNeill, DDS (San Francisco, CA) Differential Diagnosis of Orofacial Pain This session reviewed the prevalence of orofacial pain, its neural pathway, and the different categories of orofacial pain. It was followed by a review of testing modalities and treatment options available for the diagnosis and management of these chronic pain patients.

Dr. McNeill described the occurrence of orofacial pain as being quite common in today's society. Considering an incidence of orofa- cial pain in the last six months, 22% of patients will have experienced one or more episodes. A basic review of the pain pathway was provided, focusing on the trigeminal nerve's course through the descending trigeminal nucleus complex, noting the high degree of convergence that occurs at subnucleus caudalis with cervical nerves two and three.

Intracranial and vascular pain disorders were described. Non- vascular etiologies ranged from infections to neoplasias. Vascular disorders include acute ischemic cardiovascular disease, temporal arteritis and carotid or vertebral artery pain referred as intra or extraoral pain.

Neurovascular pain disorders, primarily headache disorders, in- cluded migraines, cluster headache, chronic paroxysmal hemicranial headache, and most prevalent in this group, tension-type headache. While tension-type headaches are described as a bilateral pressing or tightening pain emanating from the temporalis muscles, they have traditionally been diagnosed as TMJ pain.

Common neuralgias of the head and neck include pre-trigeminal, trigeminal, and glossopharyngeal. Trigeminal neuralgia is classically described as a unilateral facial or frontal pain with a duration of a few seconds to two minutes. Normally found along the distribution of the second or third divisions of the trigeminal nerve, a trigger point incites episodes of sudden, sharp, knife-like, severely intense paroxysmal pain. Additionally, there are other neurogenic facial pains, which do not fulfill the criteria of neuralgia and include atypical odontalgia and sympa- thetically maintained pain. The latter is most likened to deafferentation pain, experienced in phantom limb or tooth phenomena.

Pharmacologically, Dr. McNeill regularly employs the use of antidepressants as an adjunct to analgesics in modulating orofacial pain, especially that of atypical odontalgia. He emphasized the necessity to initiate antidepressant therapy with a low dose and titrate up to therapeutic levels or until characteristic side effects are present.

Extracranial pain disorders, such as metastic carcinomas of the bones of the jaws and skull or muscular strains and sprains of the neck, are often a source of orofacial pain. Teeth and related oral structures and the temporal mandibular disorders (TMD) are all prevalent etiologies in orofacial pain.

Epidemiologic studies indicate that 75% of TMD patients present with signs, 33% present with symptoms, but only five to seven percent require treatment for various disorders of the TMJ. Dr. McNeill indicated that dentistry has traditionally treated TMJ patients who are asymptomatic but have joint sounds. He advocates not treating asymptomatic joint noises.

Masticatory muscle pain includes episodic tension-type head- ache, mixed musculovascular headache, cervicogenic headache, fibromyalgia, myositis, myospasm, and local myalgias. The etiology of the muscular pain may be intermittent ove ruse (localized microtrauma), peripheral nociceptive sensitization or CNS hyperexcitability,

The clinician should be aware of the patient who is exhibiting selective cooperation, has no interest in home care, has changed dentists frequently, has an urgent desire for treatment, or is looking for the "magic bullet." This patient may have a psychogenic component underlying his/her chief complaint of orofacial pain.

It was emphasized that only through a comprehensive history, physical exam, and use of diagnostic modalities can one arrive at a diagnosis. Byasking open-ended questions, vital information regarding the patient's chief complaint, history of primaryincident, medical/dental/ personal history can be obtained. Following a comprehensive history, a physical exam that includes the head and neck; the temporal mandibular joint and cervical area; masticatory and cervical muscles; a neurologic exam; a neurovascular evaluation including cranial nerves V, VII, IX, X, Xll; and an intraoral exam is essential.

Management of these patients follows the medical model, using a multi-discipline philosophy. Treatment modalities vary from education and self-administered home care to cognitive behavioral intervention altering a habit or lifestyle trend. On the other hand, a great many of our patients will benefit from pharrnacologic therapy and/or physical therapy. Pharmacologic agents may include one or a number of non-narcotic analgesics, muscle relaxants, vapor coolant sprays, local anesthetics, or antidepressants.

Dr. McNeill reiterated that orofacial pain i's multifaceted and that only through the utilization of medicine's multi-disciplined approach can a diagnosis and appropriate treatment plan be achieved.

Abstracted by Stephen T. Mclnerney, DDS, Graduate Endodon- tics, University of Detroit Mercy School of Dentistry, Detroit, MI.

Scientific Session IV Immediate Implant Placement into Extraction Site Richard J. Lazzara, DMD, MScD (W. Palm Beach, FL) and Wo Paul Radman, DDS (Dallas, TX)

According to Brannemark (1985), "osseointegration is a direct structural and functional connection between ordered living bone and the surface of a load carrying implant." In discussing this basic concept of implantology for the endodontist, Dr. Radman began his presentation with his personal perspective, expressing the need for training endodon- tists in the placement of immediate implants and incorporating this treatment into their practices. This training would provide an appropriate service (or treatment alternative) tothe patient and allow the established endodontist to remain competitive with recent graduates. He empha- sized the need for diagnosis and treatment planning for implant place- ment. He compared the concept of implant to traditional nonsurgical root canal therapy, from determining '~vorking length" to "obturating the osteotomy." He believes the concept of implants in an endodontic practice should be termed "beyond periapical surgery," since this is the next logical treatment progression.

Dr. Radman's basic requisites for success are biocompatible materials, the implant locked into bone, a reasonable close fit to bone, good surgical technique for both soft tissue and bone, and an unloaded implant during the healing phase followed by the implant loaded with even distribution of occlusal forces. Indications for immediate implant placement which are common to endodontic practice include post placement problems, non-restorable teeth, horizontal root fracture, internal and/or external root resorption, vertical root fracture, non- repairable perforations, and retained diseased primary teeth. Contra- indications are a purulent tooth socket and a lack of bone for stability. Advantages of an immediate implant include healing potential of the socket, the need for one surgical procedure, and accelerated resto- ration time for the patient.

Dr. Lazzara's discussion centered on the step-by-step manage- ment of the immediate implant site. The advantages, according to this speaker, are ideal implant position, the possibility of a longer implant, a reduction in treatment time, and the combination of osseointeg ration and bone regeneration at the same time. The presence of the implant will prevent resorption preserving foundation bone. Indications for immedi- ate implant placement include traumatic tooth loss, caries, internal/ external resorption, endodontic complications, root fracture and ad- vanced periodontal disease. Contraindications include acute infec- tion, inability to debfide the socket walls mechanically, and inability to stabilize the implant.

Is this procedure predictable? From the radiographic view, one should see a tapering of the crestal bone at the implant collar with horizontal bone level at the first or second thread of the implant. Bone