this walks in your tooth #19 office…cloud2.snappages.com... · 2016-05-02 · this walks in your...

This walks in your office…

This patient has had severe headaches, ear aches and lower left jaw pain for weeks.

He went to his general dentist, oral surgeon, his physician, the emergency room, and an ENT spending close to $4000 out of pocket but to no avail.

Tooth #19They did x-rays, conebeam scans, and blood work nothing showed up.

He was placed on pain meds and antibiotics but only got temporary relief.

Nobody could diagnose his problem and they though he wanted drugs or just crazy.

What would you do?

Extract?

Wait?

Pulp Test?

Pulp and Peri-Apical Testing

Endo-Ice (Normal)

Tooth Slooth (Pain upon biting and releasing on DB cusp only)

Micro-Crack just into the pulp horn

Dx: Partially Necrotic Pulp with Crack

Rico D. Short D.M.D [email protected] @@@@yyyy

Diplomate, American Board of Endodontics ppp ,,,, fffAssistant Clinical Professor MCG School of Dentistry

RELAX - DON’T EXTRACT!

Dr. Short is a board-certified endodontist in private practice near Atlanta in Smyrna, Ga. He also serves as an expert consultant to the Georgia Board of Dentistry, and is an assistant clinical professor at the Medical College of Georgia School of Dentistry. Dr. Short is also a published author (including the Journal of Endodontics) and a featured national lecturer. He can be reached at [email protected].

Disclosure: Dr. Short reports no disclosures.

Apex Endodontics P.C “Getting to the ROOT of your Problem”

577 Concord Road Suite A

Smyrna, Georgia 30127

CourseObjectives

Discuss Endodontic Diagnosis

Evaluate Pulpal & Periodontal Relationships

Evaluate & Discuss Dental Trauma

Discuss Regenerative Endodontic Procedures

Discuss Retreatment vs Extraction and Implant

DIAGNOSIS

DiagnosisStarts off by LISTENING TO THE PATIENT!!!

WHAT IS THE CHIEF COMPLAINT??

These subjective findings combined with results of diagnostic tests provide the critical information needed to establish the diagnosis.

DIAGNOSIS

MEDICAL HISTORY

DENTAL HISTORY

Often a SOAP format is used ~ Subjective Objective Appraisal Plan

DIAGNOSIS

ENDODONTIC TREATMENT RECORD

DIGITAL AS WELL

DIAGNOSIS(DENTAL HISTORY)

LOCALIZATION - “CAN YOU POINT TO THE OFFENDING TOOTH?

COMMENCEMENT - “WHEN DID THE SYMPTOMS START?”

INTENSITY - “HOW BAD DOES IT HURT ON A SCALE FROM 1 TO 10?”

DIAGNOSIS(DENTAL HISTORY)

PROVOCATION - “WHAT CAUSES IT TO HURT?”

DURATION - “HOW LONG DOES THE PAIN LAST WHEN IT STARTS?”

DIAGNOSIS(EXTRAORAL EXAM)

VISUAL AND PALPATION

FACIAL SYMMETRY

Loss of definition of the nasolabial fold on one side of the nose may be the earliest sign of a canine space infection.

DIAGNOSISEXTRAORAL EXAM

NOTE: ANGIO-EDEMA OF THE UPPER LIP

DIAGNOSTICRADIOGRAPH

TOOTH #10 HAD A HISTORY OF TRAUMA

MUST SEE THE APEX AND AT LEAST 2 MM BEYOND

The Dx was: NECROTIC PULP WITH ACUTE APICAL ABSCESS

ENDODONTIC TREATMENTACCESSED

CLEAN AND SHAPED

MEDICATED WITH CALCIUM HYDROXIDE FOR 1 MONTH

PLACED ON ANTIBIOTICS FOR 10 DAYS

PATIENT RETURNED WITH NO SWELLING!

ENDODONTIC TREATMENT COMPLETED

2 YEAR RECALLNICE HEALING

DIAGNOSIS(INTRA-ORAL EXAM)

SOFT TISSUE EXAM

INTRAORAL SWELLING

LOOK FOR SINUS TRACTS AND TRACE WITH GUTTA PERCHA

DIAGNOSIS(INTRAORAL EXAM)

PALPATION ~ FINGER

PERCUSSION ~ MIRROR HANDLE

MOBILITY ~ FINGER AND MIRROR HANDLE

PERIODONTAL PROBING ~ PERIO PROBE

DIAGNOSIS(PULP TESTING)

Tooth #2 Pulp Tested Cold + but not extreme

Percussion Sensitive

Draining Sinus Tract but could not trace on the lingual

DIAGNOSISPARTIALLY NECROTIC PULP

TOOTH #2THE MB AND DB WAS VITAL

PALATAL WAS NECROTIC

VERY DIFFICULT TO DIAGNOSE

Tooth #3 WNL

ENDODONTIC TREATMENT ON TOOTH #2

CALCIUM HYDROXIDE COMPLETION

RESOLVED SINUS TRACT

2 WEEKS

DIAGNOSIS??

Dens Invaginitus

DENS INVAGINITUSMalformation of teeth resulting from an infolding of the dental papilla during tooth development.

Affected teeth show a deep infolding of enamel and dentine starting from the foramen OR even tip of the cusps which may extend deep into the root.

Teeth most affected are maxillary lateral incisors

M.HULSMAN International Endodontic Journal(1997) 30 79–90

HOW TO DIAGNOSE??

PULP TESTING

PERIODONTAL TESTING

PULP TESTING(COLD TEST)

ENDO ICE (Manufacturer: Coltène/Whaledent Inc.)

Spray on Cotton Pellet NOT Q-TIP!

HOLD ON TOOTH FOR 5 SECONDS

PULP TESTING(HEAT TEST)

WARM WATER BATH ISOLATED WITH RUBBER DAM

HEATED GUTTA PERCHA

MOSTLY TEST FOR NECROSIS

WAIT AT LEAST 10 SECONDS

PULP TESTINGIF A PATIENT WALKS IN SIPPING ON COLD WATER THEN THE PULP IS PROBABLY NECROTIC

COLD MAKES NECROTIC TEETH FEEL BETTER!

COLD CAUSES THE GASES IN THE TOOTH FORMED BY BACTERIA TO CONTRACT REDUCING PRESSURE IN THE TOOTH!

PULP TESTING(ELECTRIC)

EPT OR ELECTRIC PULP TESTING

VERY GOOD FOR CALCIFIED PULPS

CAN’T USE WITH CROWNS, COMPOSITES,OR AMALGAM


DOES NOT TEST THE HEALTH OF THE PULP JUST THE VITALITY!

Numeric readings on the pulp tester have significance only if the number differs significantly from the readings obtained from a control tooth tested

Seltzer S, Bender IB, Ziontz M. The dynamics of pulp inflammation: correlations between diagnostic data and actual histologic findings in the pulp. Part I. Oral

Surg Oral Med Oral Pathol. 1963;16: 846.


FALSE POSITIVES RESPONSES

Partial pulp necrosis

Patient's high anxiety

Ineffective tooth isolation

Contact with metal restorations

MAKE SURE YOU USE TOOTHPASTE AS A CONDUIT


FALSE NEGATIVE RESPONSES

MORE THAN 90% Calcific Obliterations in the root canals

Recently traumatized teeth

Immature apex

Drugs that increase patient's threshold for pain

Poor contact of pulp tester to tooth

PULP TESTING(LASER DOPPLER FLOWMETRY)

A DIODE IS USED TO DETECT BLOOD FLOW IN THE PULP

It measures the velocity at which the red blood cells are moving.

Very accurate but expensive.

Stroblitt H, Gojer G, Norer B, Emshoff R. Assessing revascularization of avulsed permanent maxillary incisors by laser Doppler flowmetry. J Am Dent Assoc. 2003;134: 1597.

PULP TESTING (PULP OXIMETRY)

It is designed to measure the oxygen concentration in the blood and the pulse rate inside the tooth.

A pulse oximeter works by transmitting two wavelengths of light, red and infrared, through a translucent portion of a patient's body. (Tooth)

Very expensive and cumbersome

PULP TESTING(SPECIAL TESTS)

BITE TEST

TEST CAVITY

STAINING AND TRANSILLUMINATION

SELECTIVE ANESTHESIA

PULP TESTING(BITE AND PERCUSSION TEST)

PERCUSSION (Using Finger or Mirror Handle) ACTUALLY TEST THE LIGAMENT NOT REALLY THE PULP

BITE TESTS CAN ACTUALLY TEST BOTH

BITE TESTS WITH TOOTH SLOOTH CAN DETECT CRACKS!

PULP TESTING(TEST CAVITY)

NOT ROUTINELY USED

CAUSES IRREVERSIBLE DAMAGE

DRILL UNTIL PATIENT SAYS OUCH WITH NO ANESTHESIA

PULP TESTING(STAINING AND

TRANSILLUMINATION)BOTH HELP DETERMINES THE PRESENCE OF A CRACK

METHYLENE BLUE IS USED FOR STAINING

INTENSE FIBER OPTIC LIGHT SOURCE

PULP TESTING(SELECTIVE ANESTHESIA)

USE WHEN PULP TESTING IS INCONCLUSIVE

SELECT QUADRANT OF PAIN WHERE PATIENT IS DESCRIBING

PDL INJECTION IN THE DISTAL SULCUS AND MOVE ANTERIORLY UNTTIL PAIN IS ELIMINATED

DIAGNOSISWHO’S READING THE X-RAY?

CAN BE VERY SUBJECTIVE

In a study by Goldman and colleagues, there was only 50% agreement among interpreters for the radiographic presence of pathosis.

When the cases were reevaluated several months later, the same evaluators agreed with their own original diagnosis less than 85% of the time. WHAT IS THIS?

Periapical Cemental Dysplasia

Definition: This is a radiographically distinctive condition which produces fibro-osseous proliferations that replace bone and periodontal ligament tissues at the apex of one or more teeth.

Though radiographic alterations are visible, clinical abnormality is seldom appreciated. Nutrient Canal

Key features of Cemento-Osseous

Black females (<75% of all cases); with a strong prevalence around 30-40 y.o.

Mandibular incisors

Multiple involved teeth may be involved

Staged Development

Involved teeth are vital

Often find lesions without cariesAckerman GL, Altini M. The cementomas - A clinico-pathological reappraisal.

J Dent Ass South Africa 1992; 47: 187-194.

STAGES OF PCD

Stage of bone and cementum deposition-

Mixed Radiolucent/Radiopaque lesions

Maturation Stage

Hard tissue deposition continues creating primarily radiopaque lesions

Can take up to 20 yrs to mature

Waldron CA: Fibro-osseous lesions of the jaw. J Oral Maxillofac Surg 1993; 51: 828-835.

STAGES OF PCD cont’dOsteolytic Stage-Radiolucent lesion

Stage of Bone and Cementum Deposition-Mixed lesion

Maturation Stage-Radiopaque lesion

Thakkar NS, Horner K, Sloan P: Familial occurrence of periapical cemental dysplasia. Virchows Archiv A Pathol Anat 1993; 423: 233-236.

DIAGNOSIS(CONE BEAM TOMOGRAPHY)

The image is captured as a series of three-dimensional pixels, known as voxels.

Studies show that CBCT can be very predictable in demonstrating anatomic landmarks, bone density, bone loss, periapical lesions,and root resorptions.

Should not be seen as a replacement for conventional dental radiography, but rather as a diagnostic adjunct.

Hargreaves, Kenneth M.; Berman, Louis H. (2015-09-23). Cohen's Pathways of the Pulp Expert Consult Elsevier Health Sciences.

DIAGNOSIS(CONE BEAM TOMOGRAPHY)

CBCT can show great detail in many planes of vision but can also leave out important details if the “slice” is not in the area of existing pathosis.

The decision to use CBCT imaging for assessment of traumatic injuries should be based on the diagnostic yield expected and in accordance with the “as low as reasonably achievable” (ALARA)

Hargreaves, Kenneth M.; Berman, Louis H. (2015-09-23). Cohen's Pathways of the Pulp Expert Consult Elsevier Health Sciences.

ADVANTAGES OF CBCTACCURACY OF ANATOMY OF AREA

EFFICIENT - SCAN TIME IS USUALLY 1 MINUTE OR LESS

PROVIDES CHOICES FOR FIELD OF VIEW (FOV) REDUCING RADIATION EXPOSURE

CBCT image can be reconstructed in many formats with which the oral care provider is already familiar like a Pan or Ceph

Qu XM, Li G, Ludlow JB, Zhang ZY, Ma XC. Effective radiation dose of ProMax 3D cone-beam computerized tomography scanner with different dental protocols. Oral Surg Oral Med Oral Pathol Oral Radiol Endod

2010;110:770–6.

ADVANTAGES OF CBCTVERTICAL ROOT FRACTURES

Scientists found that in vitro studies showed CBCT imaging has a significantly HIGHER sensitivity than Peri-apical radiographs in the detection of vertical root fractures in UNFILLED teeth.

The chief reason for choosing CBCT imaging for certain cases is the 3-dimensional image reconstruction of the area of interest, which may enable direct visualization of the fracture line.

Talwer et. al Role of Cone-beam Computed Tomography in Diagnosis of Vertical Root Fractures: A Systematic Review and Meta-analysis JOE

2016 Volume 42, Issue 1, Pages 12–24

DISADVANTAGES OF CBCT

DENTIST MUST BE WELL TRAINED TO READ CBCT TO AVOID MISSING NON-ODONTOGENIC ISSUES

MAKE SURE EQUIPMENT IS ALWAYS PROPERLY CALIBRATED

Gutierez et al. have argued that the usual desktop computer display is not adequate for accurate diagnostic radiology.

CBCT is not sufficient for soft tissue evaluation.

Farman AG. Self-referral: an ethical concern with respect to multidimensional imaging in dentistry? J Appl Oral Sci 2010.

DISADVANTAGES OF CBCT cont…

It can only demonstrate limited contrast resolution, mainly due to relatively high “SCATTER” radiation during image acquisition.

SOME SOFTWARE PROGRAMS CAN LIMIT OR REDUCE THE “SCATTER”

VERTICAL ROOT FRACTURES (VRF) AND CBCT

VRF can only be seen if the primary imaging beam is within 4 degrees of the fracture plane.

Image artifacts arising from root-filling materials hinder VRF detection.

Currently INSUFFICIENT evidence to suggest that CBCT is a reliable test in detecting VRFs in ENDODONTICALLY or Root Canal treated teeth.

Cheng et al. Cone-beam Computed Tomography for Detecting Vertical Root Fractures in Endodontically Treated Teeth: A Systematic Review JOE 2016 Volume 42, Issue 2, Pages 177–185

2015 AAE POSITION CONE BEAM CBCT

CBCT should be used only when the patient's history and a clinical examination demonstrate that the benefits to the patient outweigh the potential risks.

CBCT should not be used routinely for endodontic diagnosis or for screening purposes in the absence of clinical signs and symptoms.

Clinicians should use CBCT only when the need for imaging cannot be met by lower dose two-dimensional (2D) radiography.

PULPAL AND PERIODONTAL

RELATIONSHIPS

PULPAL AND PERIODONTAL RELATIONSHIPS

Which one is the MOST important?

Dental Pulp (nerve, blood vessels)

Peri-apical Attachment (ligament, bone)

Healthy periodontal

tissue provides

nourishment and support for a tooth s

roots.

The relationship

Unhealthy pulpal tissue or an infected pulpal space

can contribute to loss of the periodontal attachment.

©American Association of Endodontists

Definition:   Dental Pulp - a small

mass of loose connective tissue, blood vessels, and nerves located in a chamber within the dentin layer of a tooth

  Periodontal attachment - the supporting structures of a tooth including the ligament, cementum, alveolar bone, and gingiva

While pulp vitality may not often be affected by periodontal disease, evidence exists that

periodontal disease can affect the health of the pulp.

HOW? ©American Association of Endodontists

Tooth # 8 Perio Issue Causing Necrotic Pulp #31

Seltzer S. et al The interrelationship of pulp and periodontal disease. Oral Surgery, Oral Medicine, Oral Pathology Volume

16, Issue 12, December 1963, Pages 1474–1490

Diagnose and Treat?? TOOTH #18

FURCAL DEFECT??

Necrotic pulp Chronic apical periodontitis (abscess) with a buccal sinus tract

TRACED THE SINUS TRACT

Endo with MTA in the distal canal

6 month recall

ENDO PROBLEM MANIFESTING AS PERIO

Teeth # 14 and #15 (Patient in Pain)

Pulp test first – teeth vital Palatal swelling

Perio or Endo? Perio issue only!!...Don t Do Endo!!

Important rule of thumb: A healthy pulp rules out

endodontic treatment.


Teeth 18 and 30 -teeth vital and patient swollen (How would you treat?)

Perio Problem!! ( Endo possibly later!!!)   Periodontal condition directly causing pulpal

changes via bacteria through accessory canals.   Teeth are vital and usually have a normal pulpal

stimuli. Treatment consists of proper periodontal therapy

first then endodontic treatment if needed!!

Classification of disease   PULPAL

* Normal * Previously treated * Reversible pulpitis (recent

restoration) * Irreversible pulpitis (symptomatic vs.

asymptomatic – deep decay on/close to pulp)

* Necrotic

  PERIAPICAL * Normal * Acute apical periodontitis

(pain to percussion) * Chronic apical

periodontitis (lesion present no pain)

* Acute apical abscess (swollen)

* Chronic apical abscess (sinus tract)

Accurate Diagnosis is KEY!!   Radiographs alone do

not provide enough information to make a correct diagnosis!

  Always use the

periodontal probe and all necessary endodontic diagnostic tests in a clinical assessment before recommending any treatment.

Pulpal/Periodontal Lesions

  Pulpal lesions   Periodontal lesions   Combined lesions


Lesions fall into one of three categories based on their etiology

Pulpal lesions

  Strictly pulpal in origin

  Resolved with endodontic treatment


Pulpal lesions Mandibular first molar with large periradicular lesion extending into furcation.


Deep probing into a narrow-based sinus tract that has exited through the sulcus.


Following root canal treatment.


Nine-month recall – no probing into sulcus.


Nine-month radiograph indicates a favorable response to treatment.

Further follow-up is recommended.


Tooth #30

Disassembly with Calcium Hydroxide Completion 6 month recall

Pre-op Post-op

Periodontal lesions

  Strictly periodontal in origin   Resolved with periodontal treatment alone


Vertical pocket on mesial of mandibular molar. Tests indicate

a vital pulp.


One year after periodontal surgery and bone grafting. Significant osseous regeneration is noted. Tooth responds within normal limits

to pulp tests. ©American Association of Endodontists

Combined lesions   Primary pulpal lesions with secondary periodontal involvement

  Primary periodontal lesions with secondary pulpal involvement


Combined lesions 1

Primary pulpal, secondary periodontal combined lesion


Preoperative radiograph


When the periodontist reflected the labial gingiva over this tooth, complete

dehiscence of bone was noted. Root planing was performed.


At four months, the periodontist noted that probing depths were

only 3 mm.


Upon re-entering the area, complete bone regeneration in the area of the

dehiscence was noted. ©American Association of Endodontists

Combined lesions 2 Primary periodontal, secondary pulpal combined lesion


Root canal therapy was initiated and the patient was referred to a periodontist for evaluation.


Possible Lateral canal

At three months post-op, after completion of root canal treatment and a bone grafting procedure

by the periodontist, periapical healing is progressing. Gingival tissues appeared healthy.


After one year, the periapical lesion continued to improve, and the distal periodontal defect still appeared to be doing well. The tooth probed within normal limits and the gingival tissues

appeared healthy.


Two years after surgery, the periradicular lesion had healed, while the periodontal

defect remains virtually unchanged.


When the etiology is removed, the

potential for healing exists.


Tooth # 18…what s going on? Tooth # 18 with CaOh placed Gutta Percha

MTA

1 year recall…uh oh!!! 3 year recall Tooth #18 pre- op and 3 yr post op

A HEALTHY PULP RULES OUT ENDODONTIC TREATMENT!!!

DENTAL TRAUMA

Traumatic Dental Injuries

Rico D. Short D.M.D

[email protected] Diplomate, American Board of Endodontics

Assistant Clinical Professor MCG School of Dentistry

Objectives on Trauma:

•  Trauma Examination •  Pulpal management and treatment •  Types of injuries

KEEP IMMATURE TEETH ALIVE!!

Maintaining vitality in the injured immature tooth

Who Gets Hurt?

Examination of Trauma Patients •  Medical History •  Clinical Exam •  Radiographs

Medical History

•  Neurological Assessment

•  History of Injury

Clinical Exam

•  Extraoral Exam •  Intraoral Exam •  Radiographs

Extraoral Exam •  General

Condition •  Head and

Neck Findings •  Facial

Fractures •  Soft Tissue

Exam

Intraoral Exam •  Dental Exam •  Pulpal Evaluation

Pulpal Evaluation

Not always accurate!

Radiographs

Various Views

EMERGENCY MANAGEMENT OF THE AVULSED TOOTH

GUIDE www.aae.org

EMERGENCY AND FOLLOW-UP MANAGEMENT OF OTHER DENTAL ALVEOLAR INJURIES

GUIDE www.aae.org

Vital pulp promotes root development

Apexogenesis (need vital pulp)

ApexogenesisPulp must be vital and an open apex

Tooth #19

APRIL 2013 COVER ARTICLE

Apexogenesis Technique

Access and Remove “diseased pulp” with a new diamond only 2-3mm

Irrigate with 1/2 strength NaOCl

Irrigate with Saline

Irrigate with 2% Chlorhexidine (Not Peridex)

Place sterile cotton pellet over pulp to tamp it dry.

Mix MTA (white) and Place at least 3mm on top of pulp

Place moist cotton pellet and Cavit/IRM for at least 3 days (Some literature says MTA sets in 4 hours)

Restore tooth

The Pulp Ready for MTA or BCRRM putty

2 year recall

6 month recallMTA placed with Cavit

(7 year old female) Fell down and traumatized tooth 9 – non vital

8 week follow up - vital 1 year follow up calcification

2 year recall – more calcification/symptoms

Tooth # 9 - @ 3yrs later Tooth #30 with open apex and vital pulp MTA Pulpotomy

1 year recall with apical closure progressing Pre-Op and 1 year Post-Op

For the Non-Believers 2 year recall

Apical Closure Open Apex

5 years later - Necrotic Apexification (non-vital pulp)

Apexification

Apexification

Pulp must be necrotic and an open apex

Trauma on #8 and #9 7 years old

Access,Irrigated,CaOH Powder (USP) #8 and

CaOH Paste #9

1 Month Recall Repacked #8 Completed #9

6 Month Recall Apical Barrier

6 months Obturated #8

CompletionImmediate Apexification

Tooth #10 (previous RCT & Apicoectomy)

lesionopen apex

l

Access,Disassembly, and Disinfect

Apical Gauge (size 130)

MTA Calcium Hydroxide

Paste Powder or

Calcium Hydroxide mechanisms of action

•  Induces necrosis of ALL cells in experimentally induced inflammatory resorption

•  Reduce PDL inflammation •  Inhibit clastic cells

•  Stop bacteria entering the canal •  Kill any bacteria that have entered the canal during the injury •  CaOH2 inhibits fibroblasts so

–  Osteogenic healing response dominates –  Favours ankylosis and replacement resorption (bone

fuses to root)

Hammerstrom et al – EDT 1986

Pulp Capping •  Small Pulp Exposure •  Soon After Injury

Pulpotomy •  Large Pulp Exposure •  Hours or Days After Injury

Case #1 Case #1 (continued) Luxation Injuries

World Health Organization Classification

Minor Luxation Injuries • Concussion • Subluxation

Major Luxation Injuries •  Lateral Luxations •  Extrusive Luxations •  Intrusive Luxations

Lateral Luxations

Extrusive Luxations Intrusive Luxations Definitions •  Extrusive

Luxation –  Partial displacement

of the tooth out of its socket

•  Lateral Luxation –  Displacement of the

tooth in a direction other than axially. This is accompanied by crushing or fracture of the alveolar socket

Andreasen FM, Andreasen JO. Extrusive Luxation and Lateral Luxation. In: Andreasen JO, Andreasen FM, Andersson L, editors. Textbook and Color Atlas of Traumatic Injuries to the Teeth. 4th ed. Oxford: Blackwell Munksgaard; 2007.

Andreasen et al. 2007

Pulp Testing •  Shocked pulp

–  Approximately half of the teeth with luxation injuries do not respond to pulp tests

–  A return of a positive sensibility response is usually within 2 months, but can be seen up to 1 year

•  Following trauma a vital pulp may exist without a viable

nerve supply. A vital tooth may not respond to a pulp test

Bhaskar S, Rappaport H. Dental vitality tests and pulp status. J Am Dent Assoc 1973;86:409-411.

Andreasen FM, Vestergaard Pedersen B. Prognosis of luxated permanent teeth- the development of pulp necrosis. Endodontic Dental Traumatology 1985;1:207- 220. Textbook and Color Atlas of Traumatic Injuries to the Teeth. 4th ed. Oxford: Blackwell Publishing Ltd; 2007. Andreasen FM. Transient apical breakdown and its relation to color sensibility changes after luxation injuries to teeth. Endodontic Dental Traumatology 1986;2:9-19.

Clinical Features •  Extrusion

–  Clinical •  Appear elongated •  Bleeding from the pdl •  Mobility present

–  Radiographic •  Increased pdl space

(occlusal and PA)

•  Lateral Luxation –  Clinical

•  Crowns displaced lingually

•  Percussion- high metallic •  No mobility

–  Radiographic •  Increased pdl space

(Usually seen only in an occlusal)

Andreasen JO, Andreasen FM. Essentials of Traumatic Injuries to the Teeth. 2nd ed. Copenhagen: Blackwell Munksgaard; 2000.

Andreasen et al 2000

Repositioning

•  Want to do as atraumatically as possible – Can elicit further trauma – Wound approximation benefits pulpal

and pdl healing – Occlusal and esthetic demands

usually require repositioning

Traumatic dental injuries: a manual. 2nd ed. Oxford: Blackwell Munksgaard; 2003.

Repositioning •  Extrusion

– Local anesthetic generally not necessary

•  Lateral Luxation – Local anesthetic needed and forceps

may be necessary –  If delayed (>3- 4 days) reduction

should be deferred and the tooth allowed to realign itself or orthodontically

Andreasen FM, Andreasen JO. Extrusive Luxation and Lateral Luxation. In: Andreasen JO, Andreasen FM, Andersson L, editors. Textbook and Color Atlas of Traumatic Injuries to the Teeth. 4th ed. Oxford: Blackwell Munksgaard; 2007. Andreasen FM, P.B. V. Prognosis of luxated permanent teeth- the development of pulp necrosis. Endodontic Dental Traumatology 1985;1:207- 220.

Stabilization •  Splinting

–  As short as possible and as long as necessary

–  Rigid or prolonged splinting can lead to replacement resorption and ankylosis

–  RECOMMENDED: A passive and flexible splint that maintains physiologic tooth mobility

Andreasen JO. The effect of splinting upon periodontal healing after replantation of permanent incisors in monkeys. Acta Odontol Scand 1975;33:313- 323. Nasjleti CE, Castelli WA, Caffesse RG. The effects of different splinting times on replantation of teeth in monkeys. Oral Surg Oral Med Oral Pathol 1982;53:557- 566.

Courtesy of Dr. Sonia Chopra

Stabilization

•  Recommended Types –  Wire- composite

splint •  0.3 or 0.4 mm

wire diameter better flexibility than 0.5 mm

Oikarinen K. Comparison of the flexibility of various splinting methods for tooth fixation. International Journal of Oral and Maxillofacial Surgery 1988;17:125-127.

Stabilization •  Other types:

–  Titanium Trauma Splint (TTS)

–  Monofilament Nylon Line

•  There is no benefit in extending the splint to more than one adjacent firm tooth

Ebeleseder KA, Glockner K, Pertl C, Stadtler P. Splints made of wire and composite: an investigation of lateral tooth mobility in vivo. Endodontic Dental Traumatology 1995;11:288- 293.

von Arx T, Filippi A, Lussi A. Comparison of a new dental trauma splint device (TTS) with three commonly used splinting techniques. Dent Traumatol 2001;17:266- 274.

von Arx et al. 2001

Antrim DD, Ostrowski JS. A functional splint for traumatized teeth. J Endod 1982;8:328- 331.

Stabilization

•  Time

–  Extrusive Luxation:

•  2 weeks

–  Lateral Luxation: •  4 weeks

Flores MT, Andersson L, Andreasen JO, Bakland LK, Malmgren B, Barnett F, et al. Guidelines for the management of traumatic dental injuries. I. Fractures and luxations of permanent teeth. Dent Traumatol 2007;23:66- 71.

Postoperative Instructions •  Goal is to reduce plaque •  Brush teeth with a soft

tooth brush after each meal

•  Use of chlorhexidine 0.12% mouthrinse twice a day for 2 weeks

Internal Resorption

Internal Resorption Features

•  Tooth (pulp) is usually vital •  Oval shaped increase of pulp space

–  Can occur anywhere along the root canal –  Giant cells resorb dentine towards periphery

•  Possible causes –  Trauma –  Necrosis + infection of coronal pulp –  But – Unknown in most cases!!!!

Tooth #10 with Internal Resorption (IR)

IR lesion

File measurement and CaOH2 placed

Completion

IR lesion filled

Trauma on 8 and 9

Tooth 8 - What is going on?

9 year old had trauma to teeth 8 (avulsion) and 9 (intrusive luxation)

CaOh for 1 month Completion

MTA

1 year recall 3 year recall 5 year post op

MTA – our miracle material What is MTA?

•  Mineral Trioxide Aggregate has the ability to encourage hard tissue deposition similar to Calcium hydroxide effect. Also both have the same biological and histological properties.

MTA Used for •  Perforation Repair •  Trauma •  Resorption •  Apexification and Apexogenesis •  Surgery root end filling material •  Regeneration Techniques

KEEP IMMATURE TEETH ALIVE!!

Maintaining vitality in the injured immature tooth

REGENERATIVE ENDODONTICS

Regenerative Endodontics

Dentistry Today March 2015

Regeneration/RevascularizationPulp must be necrotic and an open/immature/blunderbuss apex

Patient’s own stem cells are reactivated to promote healing

Stem Cells are located in the apical area around Hertwigs Epithelial Root Sheath

Anesthetize and Access

No Instrumentation with Files!

Lightly Irrigate with 1/2 strength NaOCl

Rinse with Saline

Irrigate with 2% Chlorhexidine (not Peridex)

Dry with Paper Points

Place CaOH2

Place Cotton Pellet and Cavit for 1 month

1st Visit 2nd VisitAnesthetize only with Polocaine or Carbocaine (No Epi)

Access

Irrigate with 17% EDTA

Dry with Paper Points

Initiate Bleeding With File Out of Apex

Place (Bio-Ceram Putty - Brassler) over the blood clot ~ MTA works but it stains enamel and dentin

Place cotton pellet and Cavit

Restore with composite within 1 month

Tooth #20 (Regeneration) Clinically Tooth #20 CaOH placed with

Cavit

1 month (completion with MTA)

1 year recall (Root Closure & Vital) Amazing...

Staining (with MTA not with

Bioceram)

Regeneration Tooth #20 with BCRRM

Tooth Accessedused Irritants

Placed CaOh and Cavit

Leave for 3 weeks

Final Visit

Anesthetize with No Epi

RDI

Irrigate with 17% EDTA

File Out Apex for bleeding and clot

Place BCRRM

2 year recallNo Staining & Apex Closed

Pre-Op and Post-Op Tooth 9 Regeneration with Bioceram (Brassler)

Isolation, Irrigation, CaOH 1 month

BioCeram Placed6 month recall Root Maturation No discoloration

Apex Closing

Tooth #9 Regeneration/Vital

If it looks unfamiliar refer!

RELAX....DON’T EXTRACT!!!

ENDODONTIC RETREATMENT VS EXTRACTION AND

IMPLANT

Do Root Canals Fail or Do

Patients Fail to HEAL???

“Post-Treatment Disease” in many instances not Endodontic failure!

SHIMON FRIEDMAN COINED TERM IN 2002

We will discuss...WHY?

ETIOLOGICAL FACTORS OF POST-TREATMENT

DISEASE

Persistent or reintroduced intraradicular microorganisms (E. faecalis, Candida A.)

Extraradicular infection (Actinomyces Israeli, bacterial plaques)

Foreign Body reaction (lentil beans, cellulose fiber)

True Cysts (self sustaining-won’t heal after endo) vs. Pocket Cysts (heal after endo)

- Sundqvist G. et al Essential Endodontology 1998gyygygygy

Up to 40 million endodontic cases are treated annually!@75% of root canals are treated by the general dentist

On average, endodontists perform nearly 25 root canal treatments a week, while general practitioners perform less than two.

@46% of general dentist refer to

Endodontist

What is the average success rate for Root Canal

Treatment by an Endodontist?ENDODONTIC TREATMENT= 90-95% (Kerkes et al. JOE July 1978 / Swartz, Skidmore, and Griffen JOE May 1983)

RETREATMENT = 80-93% (Toronto Study 2004 / Allen et al. JOE 1989 / Bergenholtz et al. Scan J Dent Res 1979)

SURGERY (Apicoectomy) = 40-78% (Toronto Study 2004 / Allen et al. JOE 1989 / Nordenram et al.

Endodontist In Training

COMMON CAUSES OF FAILURE:

LEAKING RESTORATIONS

ROOT FRACTURES

UNTREATED CANALS

INADEQUATELY CLEANED CANALS

OPERATIVE ERRORS

When should retreatment be considered?

EVALUATE THE PERIODONTAL STATUSPERIAPICAL OR BITEWING XRAY

ATTACHMENT APPARATUS

PERIODONTAL PROBING

MOBILITY

CROWN TO ROOT RATIO

EVALUATE RESTORABILITY

PERIODONTAL SUPPORT

STRATEGIC VALUE

REMAINING TOOTH STRUCTURE

RETREATMENT WITH 5 YEAR RECALL

RETREATMENTWORKS!

Assess Patient Concerns

Expectations

Motivation

Cost $$$

The Impact of Saving A Tooth is Priceless!

Retreatment

Less expensive than implant

Reduces the need for surgery

Improves the surgical prognosis

More expedient than an implant

Extraction/Implant

Non-restorability

Guarded periodontal prognosis

Split Tooth

Vertical Root Fracture

Tooth #30 with buccal sinus tract

2 years later...

© American Association of Endodontists

Have you heard?? Implants are more successful than root canals??

ENDO ON TOOTH 10

LARGE AREA OF INFECTION

CALCIUM HYDROXIDE PLACED

3 WEEKS WITH MEDICATION

UH-OH MOMENT!

A PIECE OF GUTTA PERCHA BROKE OFF WHILE CONE FITTING.

APICAL SURGERY??

SIX MONTH RECALL

AREA HEALING WELL!

“A LITTLE GUTTA PERCHA WON’T HURTCHA”

DON’T TREAT THE RADIOGRAPH!

2004 Journal of Endodontics 8 year Follow Up

1.4 million RCT’s Delta Dental Databse 96% Survival!

Survival96%

Endo Sx0.7%

Re-Tx0.4%

Extraction2.9%

Fig 2. Pie chart illustrating the outcomes of 1,463,936 root canal-treated teeth with an eight-year follow-up. Data is from Delta Dentainsurance database and represent patients from all 50 states of the United States. (Source: Salehrabi and Rotstein. Endodontic treatment outcomes in a large patient population in the USA: an epidemiologicastudy. Journal of Endodontics 2004; 30(12):846-50. Reproduced with permission.)

© American Association of Endodontists © Ameri© AAmermeri©©© Ame© A©© AmerAAAmmememeAmeri© A©©© Ame AmerAmeriAAAAAAmeriAmemmm© Ammeeeeri© Amerrii©©© AAAAmmeeerrriiiiican Asscanncaanan annncccccan ccanacanannnnncccccaannnnn oc

“Restored endo

treated teeth & single tooth

implants have

similar failure rates” Doyle

2006 JOE

International Journal of Oral Maxillofacial Implants 2007

OUTCOMES

40

50

60

70

80

90

100

Implant

RCT

Follow-up (Months)

6 12 24 36 48 60 72 Last

Surv

ival

(%)

Fig 5. Derived from a meta-analysis comparison of the survival rates of the restored endodontically treated tooth and the restored single-tooth implant. (Source: Iqbal and Kim. For Teeth Requiring Endodontic Treatment, What Are the Differences in Outcome of Restored Endodontically Treated Teeth Compared to Implant-Supported Restorations? International Journal of Oral Maxillofacial Implants 22(Suppl):96-119, 2007.)

Academy of Osseointegration META-ANALYSIS STUDY ON MEDLINE, EMBASE, PUBMED

57 Studies ~ totaling 12,000 Single Tooth Implants

13 Studies ~ totaling 23,000 RCT Teeth

NO DIFFERENCE IN SURVIVAL OVER 8 YEARS

“TO TREAT A COMPROMISED TOOTH WITH ENDO VS IMPLANT MUST BE BASED ON CRITERIA OTHER THAN TREATMENT OUTCOME.” ~ 2007

Why are so many good teeth extracted now?

Money???

Ignorance???

Incompetence???

It’s not your tooth???

Combination of the above???

Endo vs ImplantCan’t really compare “SUCCESS”

Natural vs. Man Made (attachment apparatus vs. osseointegration)

Most Implant research use the term “Survival” which has a different criteria

Both have similar failure rates according to Doyle et al...

Tooth # 20 Success or Failure?

IMPLANTS ARE GREAT IF A NATURAL TOOTH

CAN NOT BE SALVAGED!!

Survival rate is equal to endodontic treatment. qqqqqq(Doyle S. J Endod 2006 and Iqbal M. 2007 Intl J Oral Maxillofac Implants 22)

IMPLANT COMPLICATIONS...

HEMORRHAGE

NEURO-SENSORY DISTURBANCE

ADJACENT TEETH DEVITALIZATION

MANDIBULAR FRACTURE

AIR EMBOLI...SOMETIMES FATAL (DWYAR 1992)

IMPLANT ABUTMENT SCREW LOOSENING

IMPLANT FRACTURE

INADEQUATE OSSEO-INTEGRATION

BISPHOPHONATE COMPLICATIONS

(2012 Goodacre, C. Loma Linda University)

IMPLANT COMPLICATIONS cont..

History of:

Smoking

Periodontitis

Peri-Implantitis

Minimum Bone

Poor Oral Hygiene

Duyck J, et al. Failure of oral implants: etiology,symptoms, and influencing factors. Clin Oral Investig 1998;2 (3):102-114

INFECTED IMPLANT WITH SINUS TRACT ON

Implant Complications cont…

Studies show 38.7% of patients had complications in the first 5 years after implantation*

Implant supported complications occurred at more than DOUBLE the rate of tooth supported*

After 10 years in function, Lang et al. found biological and technical complications in about 50% of the cases.**

*Pjetursson BE et al. A systematic review of the survival and complication rates of FPDs after an observation of at least 5 years. Clin Oral Implants Res.2004;15(6):625-642

**Lang NP, et al. A systematic review of the survival and complication rates of FPDs after an observation of a t least 5 years. II. Combined tooth-Implant supported FPDs. Clin Oral Implants

Res.2004;15(6):643-53

Signs of Implant Failure

Mobility

Pain

Pathology

Radiolucency

Causes of Implant Failure

Overheating of the bone

Lack of initial stability

Under or Over preparation of the osteotomy

Contamination of the implant surface

Post Loading Failure (Occlusal overload, Dehiscence, Recession, Poor Implant Position)

Tomasi C et al. Clinical research of per-implant diseases-quality of reporting, case definitions and methods to study incidence, prevalence and risk factors of peri-

implant disease. J Clin Periodontol.2012;39(suppl12):207-223.

New Research Linking Implant Failure to Antidepressant Drugs

The use of antidepressants QUADRUPLES the risk of implant failure, with those odds DOUBLING again for each year of antidepressant use, according to research at the University of Buffalo (UB).

Implants require new bone to form around them to heal properly, but antidepressants decrease the regulation of bone metabolism.

According to the Centers for Disease Control and Prevention (CDC), more than one in 10 Americans older than 12 use antidepressants, making it the second most prescribed type of drug in the United States.

Let’s Save Some Teeth!

Endodontic Retreatment

ENDODONTIC RETREATMENT Tools...

Proper Access Burs

High Magnification

Excellent Illumination

Ultrasonics

Solvents

Mirco-surgical Instruments

New Technology Cone-Beam CT

A digital x-ray scanner mounted on a rotating arm

Gives more accurate and detailed information than traditional x-ray

Aids in diagnosis and treatment

ULTRASONICS & TIPS SOLVENTS...

MODIFY INSTRUMENTS TO REMOVE

INSTRUMENTS

Devices to Remove or Go Through

Restorations

Crown and Bridge Tapper

Metalift

Zirconium Based (SS White Z bur)

Removing Gutta Percha

Rotary Instruments (Gates Glidden, Pro-Taper)

Heat (Touch-N-Heat)

Ultransonics (Enac by Osada)

Solvents (Chloroform)

Any combination of these

Removing Carrier-Based Obturators

(Thermofil, Gutta-Core,etc.) Magnification

Illumination

Ultrasonics

Heat

Rotary Instruments

Solvents (Chloroform)

Microforceps

Removing Paste (Sargenti, Resins)

Magnification

Illumination

Ultrasonics

Solvents


Removing Silver Points

Magnification/Illumination (Global Microscope)

Ultrasonics (Enac)

Solvents (Chloroform and Sodium Hypochlorite)

Pliers/Microforceps (Stigletz)


SURGICAL MICROSCOPE (GLOBAL)

Magnification up to 25x!

Case #1 Tooth #19

GP and Periodontist Extract/Implant

5 Year Recall

Nice Healing

Case #2 Thermofil Retreatment Case

Tooth #19

1 year Recall

Tooth #7 Thermofil

Gutta Percha?

Plastic vs Silver Pointat Apex?

Case #3 Tooth #15

Paste and Silver Point

Disassembled and place CaOH2 paste

Obturated and located an MB2 Before and After Case #4

Tooth #8 Chief Complaint: “My front teeth are sore and I have a bump on

Retreat? Apicoectomy?

Extract/Implant?

Retreat!!

Sinus tracton 8 & 9

One Visit Retrx with MTA to seal

perforation

Six Month Recall

MTA

Gutta Percha

One Year Recall (same retrx #9)

Before and After (One Year Recall)

Pro Root MTA (Mineral Trioxide Aggregate)

Composed of Portland Cement,Bismuth Oxide (opacifier),Calcium, Silicon, & Aluminum

Made exclusively by Dentsply Tulsa

“Miracle Material”

Available since 1993 developed by M. Torabenejad

Expensive (~$100/gram)

MTA (various uses)

Perforations

Apico-Retrofills

Apexification

Apexogenesis

Pulp Capping

Case #5 Med. Compromised - HIV

Tooth #30

Before and After One Year Recall

Case #6 Extract?? vs Retreat??

Removed Silver Post Placed Calcium Hydroxide Obturated with MTA

One Year Recall Healing!!

Case #7 Retrx Tooth #30 with furcation issue?

Disassembled and placed CaOh2

Obturation with Gutta Percha Six Month Recall

Healing in furcation!

Case #8 Tooth #3

(size/location lesion)

Retrx Tooth #3 (located MB2)

Caoh2

2 weeks completion

Six Month Recall (Healing!)

Case #9 Tooth #3 with Sinus Tract and

Overfill

OVERFILL!!! Retrx Tooth #3 located MB2

Tooth #3 Six Month Recall

Healing!!

Case #10 Tooth #30

Patient in Pain!Tooth #30

Thermofil

Broken File

One Visit Retreatment

Case #11 Retrx #30 (large post

with resorption)

Resorption

Tooth #30

CaOh2 (2wks) Completion

MTAMTA

Tooth #30 (6 month recall)

Resorption Healed!

Case #12 Retrx Tooth #30

Tooth #30 Tooth #30 (3 mesial roots!)

Retreat on Tooth #25 (Failed RCT and Apico)

Access and located lingual canal

Calcium Hydroxide (3 portals of Exit) Completion with MTA

6 month recall

Healing!

Success... Tooth 6 Invasive Cervical Resorption

IR

HCHHHHHHHH

Calcium HydroxideCompletion

GP in Apical 1/3 MTA in Middle and Coronal 1/3

4 year recall

“Getting To The Root of Your Problem”

Amazon, Barnes and Noble, i-tunes bookstore

THANK YOU!!

[email protected] ~ drricoshort

Facebook ~ Apex Endodontics P.C

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