Idiopathic Osteoslerosis

This patient presents as a 30 year old, white female. Asymptomatic tooth #19 was identified in a routine radiographic exam. Clinical findings: normal to thermal testing, normal to percussion, normal to probing, slight pain to biting on lingual cusps. DX: Normal pulp & periapex

The radiopacent area on the mesial root is noted and diagnosed as an idiopathic osteosclerosis. As a quick review, this is a designation for a uniformly radiopacent lesion that cannot be attributed to any inflammatory, dysplastic or neoplastic source. They may also be found in other locations. Most commonly found in patients between 20 & 40 years old and may have a female predilection. Also appears more commonly in black population. 90% of cases are seen in the mandible, usually in the 2nd premolar/molar area.

No treatment is indicated. Little change is usually seen in these lesions.

Another term that is often used interchangably is condensing osteitis or focal chronic sclerosing osteomyelitis. While looking identical, these lesions are associated with necrotic pulps and are believed to be a result of chronic, low grade inflammation. The interchangable use of these terms can be somewhat confusing. However, accurate pulpal diagnosis will help determine whether the radiolucent lesion is the result of inflammation caused by a necrotic pulp (condensing osteitis) or truly idiopathic (unknown) origin (idiopathic osteosclerosis).

(Source: Neville, Damm, Allen & Bouquot. Oral & Maxillofacial Pathology, 445-446, 1995)

Herodontics?

This root canal was done just over four years ago. The patient presented with pain to percussion, and an 8 mm buccal probing was present. The RCT had been completed 2 years previously and recently became symptomatic.
DX: Prior RCT w/ Symptomatic Apical Periodontitis.
Treatment recommended: Non-surgical retreatment, perforation repair with possible need for endodontic surgery. Prognosis: guarded.

As you can see, the MB canal is very calcified. Calcification of this kind would make this case a very high level of difficulty. The MB canal was missed and the furcation was found, instrumented & obturated. Proper case selection can help prevent this type of complication. However, if this does occur, one would expect to find bleeding and the tactile sensation of the pdl/cortical bone is very different from the canal. Length determination films, working films or final films should also identify the perforation. I would recommend immediate referral to an endodontist for treatment of an iatrogenic event such as this.

Retreatment completed. MB canal located and treated. Furcal perforation repaired with MTA. Patient placed on recall to watch the area and see if endodontic surgery will be required.

Recall at 2 years & 3 months. Patient reports complete function and no symptoms. The 8mm periodontal probing has dissappeared. This tooth is considered "healing", and scheduled for a 1 year recall.

You can call it "herodontics", but that tooth is functional, apical bone looks good, periodontal pocket has disappeared. This will be a fun case to watch over time.

Endodontic Success

This patient presented today with a dull, radiating ache in the lower right quadrant. Clinical examination finds #29 sensitive to percussion, normal probings with prior RCT (30 years). A short obturation is evident. Adjacent teeth #30 & #28 have normal pulps . #29 is diagnosed with Prior RCT & Symptomatic Apical Periodontitis. Retreatment is recommended & completed.


I think that it is great that a root canal, done sometime in the late 70's, can be retreated, using modern techniques and equipment and be functional for another 30-40 years. Unless that root is fractured, there is nothing better than a natural tooth.

Surgical Repair of Post Perforation

This patient presented without pain but presence of draining sinus tract in the buccal attached tissue over #7. The position of the draining sinus tract directly at the level of the post, normal periodontal probings and evaluation of the radiograph made me suspicious of a post perforation. (note the widened ligament to the level of the post, and completely normal appearance at the periapex)
Options discussed included retreatment or apical surgery. Since the crown is all porcelain, we decided to treat surgically.

Ochsenbein-Luebke surgical flap was selected to prevent recession of marginal gingival, and minimal loss of crestal bone. The periodontal attachment was still in tact following flap reflection despite the loss of buccal bone adjacent to the perforation.


Metal tip of the post was visible without any removal of any buccal bone.

The post was counter-sunk using a high speed handpiece.

Preparation of the root. Note that this was not the apex of the root. This repair was being done on the mid-root surface.


Geristore was selected as the restorative material. Since Geristore is a bonded material, moisture control is important. Astringedent was used for hemostasis and the root was acid etched, primed and bonded.

Geristore placed in the preparation and cured.

Geristore was contoured to the root surface.


Final film. This will be an interesting case to follow. Expect a good result and repair of boney defect. We'll continue to monitor this tooth over time. Endodontic surgery has provided a valuable service to this patient prolonging the life of this tooth, the crown and hopefully regenerating the boney defect. Stay tuned for updates!

Vertical Root Fracture

This 92 year old patient came into our office for evaluation of #7. She reported no pain, but had a sinus tract between #6 & #7. Probing around #7 appeared normal.

The radiograph appeared to show some lateral radiolucency at the level of the post. The post also appeared slightly off angle with the root canal obturation. Despite the lack of narrow probing depths, I suspected a root fracture.

At this point, we decided to verify that fracture by disassembling the restoration. The patient was informed that if the root was fractured, then she we would not be able to save the tooth.



After simultaneous removal of the post and crown, multiple vertical root fractures were identified. A lingual, and distal fracture are seen in this image.

A mesial root fracture is seen in this angle.

Visualizing a fracture is the only certain way to diagnose a root fracture. This procedure is not well reimbursed, if at all. It will certainly require time that could be used for more productive treatment. However, if it was my tooth, I would want to know it is fractured before extracting it.

I suspect that a possible application of the new cone beam dental CT's will help with diagnosis of vertical root fracture.

Placement of MTA

Mineral Trioxide Aggregate (MTA) is a great material for retrofills, root perforation repair, direct pulp capping, apexification & apexogenesis. This material is mostly used by specialists, under a microscope. However, new applications, such as direct pulp capping, will make this material more commonplace.
Unlike most dental materials, MTA requires moisture to set up. Since moisture control is one of the largest challenges in working with most dental materials, this actually is a positive characteristic of this material.

Using this material is like playing with wet sand. You can add or remove water to the consistency that you like. If you put too much water in it, it runs. If you put too little water in it or it dries out, it crumbles. If you put just the right amount of water in it, it becomes packable, just like wet sand.  It takes a little practice, but once you learn how to manage the moisture, it's great to work with. The material does dry out while you use it, so additional water can be added to return it to your desired consistancy.



There are few specialized instrument that aid in the placement of MTA. Carriers are made in all shapes and sizes. These work just like an amalgam carrier on a much smaller scale.




Another useful carrier is made from a plastic block and a simple hand instrument.


Handling MTA will take a little practice, but once you learn how to mix and handle it, you will find it is a great material to work with.

The following video clip shows the placement of MTA as a retrofill during an apicoectomy surgery.

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Our upcoming seminar will be held on Thursday, May 8th, 2008. Please call or email to register.

Intentional Reimplantation

Reimplantation of an avulsed tooth is a well known and accepted treatment following a traumatic dental injury. Preservation of vital cells in the periodontal ligament allow reattachment of the tooth in the alveolar socket. Rates of success at 5 years reported in the literature ranges between 70% - 91% (1).

The main factors limiting the success of this treatment are the amount of time the tooth is out of the mouth, disruption of the periodontal ligament and bacterial contamination.

Although not common or well known, intentional removal and reimplantation of a tooth is an effective mode of treatment for teeth that cannot be treated with traditional endodontic surgery. This strategy can be particularly helpful in lower second molars where proximity to the mandibular nerve and thickness of the buccal bone make endodontic surgery difficult.

Intentional reimplantation allows the clinician to control the variables that would limit the success of a reimplantation following traumatic avulsion. Atraumatic extraction, minimal time out of the mouth and aseptic technique, allow a clinician to perform apical procedures that otherwise could not be performed.

Again, while not commonplace, intentional reimplantation is a treatment option that can be considered in special cases. It may offer your patient a final opportunity to retain a natural tooth, when endodontic surgery is not an option.

This case was actually an UNintentional, intentional reimplantation. Let me explain. This patient presented to our office with a bridge from #27 to #29. Significant buccal decay was present. The general dentist and the patient wanted to try and maintain this bridge.

Her dentist placed an amalgam root surface filling under the buccal margin of the bridge. A distal periapical radiolucency developed. I was then asked to complete the RCT on the tooth. Since the anterior abutment was loose, we decided that to remove the bridge, complete the endodontic treatment, and retrofit a post and core back to the bridge. Hardly an ideal restorative solution, but a solution that worked for the patient in her particular circumstance.

While attempting to remove the bridge, the entire tooth came out. At this point, this became an intentional reimplantation case.

Within a matter of minutes, we did a retroprep and MTA retrofill.

The anterior abutment of the bridge was then permanently cemented on and the posterior abutment re-implanted into the socket.

This patient returned last week for a 3 month re-evaluation. The tooth was sensitive for a while, but she now reports no sensitivity or swelling and she can now chew nuts on that side!
If you look closely you can see that the distal lesion has healed. While this is a very short term result, the healing of the apical lesion, lack of symptoms would indicate initial success. We will continue to monitor this tooth over time. Look forward to updates!

Sources:

1. Nuzzolese E, Ciruli N, Lepore MM, et. al. Intentional Dental Reimplantation: A Case Report. J Contemp Dent Pract 2004. August;(5)3:121-130.

Gates Glidden Drills

I know that all the manufacturers are encouraging you to shape the canal oriface with their special oriface shaping files, but I still like to use the gates glidden drills to open the upper third of the root canal system.

Quick research this morning indicates a gates glidden drill costs me $3.12 and a NiTi rotary instrument costs me $7.15 (taking into account the endodontist's bulk discount).



Call me "old fashioned" but why anyone would want to pay twice as much for an instrument that takes twice as long to do the same job is beyond me. The gates is non-end cutting and also improves the direct line access into the canal, which will help prevent separation of your rotary files. The shaft of the gates is somewhat flexible and usually, if there is a separation, it will separate high on the shaft and is easily removed with a pair of cotton pliers.

If I had to guess, I would guess that nineteen out of twenty times a gates glidden drill breaks, it breaks high on the shaft. That being said, here is a case where the gates separated in the mid-shank area. When this occurs, it just the same as if a rotary file separates. It can be just as difficult and time consuming.

Pre-Op #19

Gates Glidden #3 separated in MB canal.

Technique for removal is the same as with a rotary instrument. Visualize it, ultrasonic instrumentation around the instrument until it loosens, and retrieve.

All said, I would much rather use a gates glidden to open the upper third of the canal for all the reasons described above. Can anyone give me a better reason to use a rotary file to do the same thing?

Herpes Zoster (Shingles)

This patient had an apicoectomy on #4. Six days later while traveling out of town, he began to have severe pain and lesions form on his face. He came to our office for evaluation of the surgical area. As you can see, he experienced the classic outbreak of herpes zoster (shingles).

For a brief review, after initial infection with the VZV (chickenpox), the virus goes into a dormant state in the dorsal spinal ganglia. The re-activation of this virus causes herpes zoster. The reactivated virus will become apparent in the distribution of the affected sensory nerve. Zoster occurs in 10-20% of individuals, and increases with age.
As opposed to the herpes simplex virus (HSV), single recurrences are generally the rule.
Predisposing factors for reactivation of the virus include, immunosuppresion, treatement with cytotoxic drugs, radiation, malignancy, age, alcohol abuse & dental manipulation.


Clinical features begin with pain in the epithelium of the affected sensory nerve (dermatome). Typically one dermatome is affected. Prodromal pain often accompanied by fever, malaise and headache is usually present for 1 to 4 days before the outbreak of the cutaneous or oral lesions.
Involved skin will exhibit a cluster of vesicles on an erythematous base. After 3 to 4 days, the vesicles become pustular & ulcerate. Crusting develops after 7 to 10 days. The exanthem usually resolves within 2 to 3 weeks. Scarring can occur.
Pain lasting longer than 1 month following a shingles outbreak is known as postherpetic neuralgia. Most of these will resolve within a year.

Treatment for herpes zoster is mostly supportive and symptomatic. Fever should be treated with antipyretics without aspirin. Lesions should be kept dry and clean to prevent secondary infection. Topical or systemic antipruritics can be given to decrease itching. Corticosteriods have been used to minimize associated neuralgia. High dose acyclovir can decrease duration of the exanthem and severity of pain.


In this case, special consideration was given to the involvement of the eye. Proper referral to medical and dental specialists is important to prevent permanant damage to affected areas such as the eye.

Photographs used with patient's written permission.
(Source: Neville, Damm, Allen & Bouquot. Oral & Maxillofacial Pathology, 188-191, 1995)