Endodontic Healing with Perforation Repair

This patient came to my office in March of 2003. She had two large "all porcelain" bridges done a year and a half earlier between #22-#27. Teeth #24 & #25 were diagnosed as necrotic with Chronic Apical Periodontitis. Endodontic therapy was initiated.

To my dismay, a suprabony perforation was created on the distal of #24.

After a little redirection, the canals were located and then instrumented and obturated.

Both teeth were obturated with gutta percha. Because the perforation was suprabony, Geristore was selected as the repair material. Since geristore is a resin, it will not wash out, making it ideal for a defect above the level of crestal bone. The patient was informed of the perforation defect and its repair.



Typically I would re-evaluate this case 6 months to a year following completion. This patient chose not to return until another tooth needed endodontic treatment.
The patient reported no symptoms and our recall film at 3 yrs 9 months shows complete healing of the apical radiolucencies.
Retaining these teeth with endodontic therapy allows for healing of the bone and maintains the crestal level of the bone as well as provides more life from the recently placed porcelain bridges.

Fractured Tooth

This patient came in today with a necrotic tooth #14. She had a draining sinus tract on the palatal and recounted a history of massive palatal swelling. Diagnostic tests found #14 Necrotic Pulp with Chronic Apical Abscess.
The tooth had a MO amalgam & O amalgam. Patient also has a history of bruxism with cuspal fractures on other teeth.

Upon access, a crack running down the distal wall and a crack running down the mesial wall both took a left turn and met across the pulpal floor. This tooth was then diagnosed as non-restorable and an extraction was recommended.
Had this tooth been crowned previously, it may have been saved. When patients exhibit severe patterns of occlusion with bruxism, I would recommend cuspal coverage at an earlier stage.
If you have difficulty making this recommendation to your patients, I would be glad to send you some pictures from my photographic collection called, "Teeth that might not have fractured if they had been crowned". You could make a nice picture book with these photos.

Treatment of Patients taking Bisphosphonates

Bisphosphonates are a group of drugs that are commonly prescribed in the prevention and treatment of resorptive bone conditions. These would include osteoporosis, bone metastasis associated with breast & prostate cancer, multiple myeloma, Paget's disease & other conditions that cause chronic bone fragility.

Some common bisphosphonates would include Aredia(pamidronate), Fosamax(alendronate), Zometa(zolendronate). These drugs work by inhibiting osteoclast formation. Osteoclasts are cells with the ability to break down bone. These drugs come in an oral form and IV form.

There has been recent concern regarding this class of drugs and the increasing awareness of a rare side effect known as osteonecrosis of the jaw (ONJ). ONJ is the inability of the bone to heal. Signs & symptoms may include gingival ulceration with exposure of the bone, pain or swelling in the jaw, infection of the jaw & altered sensation. ONJ occurs more frequently in the mandible than the maxilla.

Treatment of ONJ is very difficult. Treatments that have had limited success include surgical wound debridement, bone resection, antibiotics & hyperbaric oxygen. Prevention is the best treatment for ONJ.

Recognizing patients who are taking these drugs, and eliminating any treatment that would cause direct trauma/irritation to the bone is essential (extraction, implants or any type of surgical procedure). Patients who are taking or have taken the IV form of these drugs are at a higher risk of ONJ.

For additional information regarding recommendations and treatment guidelines for patients using bisphosphonates: click here

(Source: Endodontics Colleagues for Excellence, Winter 2007, Bisphosphonate-Associated Osteonecrosis of the Jaw. American Association of Endodontists)

CASE REVIEW



This patient came to my office after having broken the crown off of tooth #13. Recurrent decay was to the level of the crestal bone. The root was very short. The patient is currently being treated for multiple myeloma. Her past treatment have included IV bisphosphonates. Due to history of IV bisphosphonates, an extraction of #13 is contraindicated due to her high risk of ONJ.

Endodontic treatment is completed to remove any source of infection and the tooth is "banked". Banking indicates removing decay, completing RCT and placing a permanent access restoration with no intention of restoring the crown of the tooth.

Finding a Calcified Canal

This patient came in for treatment of #11. Single root, single canal, no crown, you would think that this would be an easy root canal. However, notice the calcification of the canal. Sometimes when the crown is gone, it is difficult to determine the long axis of the tooth. You can see the the original access is getting slightly off centered toward the distal & lingual. This wise dentist knew to stop before a perforation occured.

If you look closely (select the image to enlarge), you can see the difference in color between the primary and secondary dentin. You can actually see where the canal used to be, before it calcified in. Right in the center of that secondary dentin is a small white speck. This is where the dentinal chips have accumulated in the canal. That little white spot is the remnant of the canal.

Micro-opener used to open the canal.

The rest of the case goes without a glitch.

Root Amputation

This tooth had been retreated once, and was failing to heal. Over time, an increase in the radiolucent lesion around the MB root was detected. The patient was then presented the options:
1. Root canal surgery to treat the MB root
2. Extraction & tooth replacement
Since the crown was in good shape, the patient wanted to try and save the tooth. The patient was informed that we would surgically expose the tooth, evaluated the root end. If no fractures are found, then we would recontour the root end (apical resection) and then place a reverse filling (retrofilling) in the end of the root. Patient was also informed if a crack is found down the length of the root, we'll have to review other options.

After flap reflection and curretage and apical root resection. You can see that there is only a small bridge of bone across the buccal of the MB root.

A crack is seen on the palatal side of the MB root. The patient at this point is informed of the fractured root. He is given the option to stop and extract the tooth, or proceed with a root amputation.

Here you can see the MB root has been removed. The gutta percha is exposed. A retropreparation and retrofilling must still be completed to prevent coronal leakage into the canals system.
A root amputation is a great way to buy some time for this tooth. It allows the patient to retain the natural tooth, but I make sure the patient knows that if another root becomes fractured, they will have to remove this tooth.

Following the retropreparation. I have sometimes seen root amputations performed without doing a retropreparation and retrofill. That would be the same as doing a root canal without placing a permanent restoration. Bacteria will leak in and contaminate the root canal.

Retrofilling placed. In this case, it was a glass ionomer.

Final Film. After root amputation is completed. It is important to reduce the occlusion to make sure that all occlusal forces are directed over the remaining roots. While a root amputation is not the best call for all patients, we should be aware of this treatment option and the service that it can provide to our patients.

Ultrasonic Irrigation

During endodontic treatment, our goal is to remove all pulpal tissue and micro-organisms, by-products from within the root canal system. We know that the root canal system is not only made up of the main canal, but may have isthmuses, fins, webs, anastomoses & other irregularities. These variations in the canal shape are impossible to cleanse mechanically. We must rely on our irrigant to reach the places that our files cannot reach. Opening the canals to a large enough size for the irrigant to reach the apex is an important step. I also like to use what I call "ultrasonic stirring". I use an ultrasonic instrument to "stir" or "vibrate" the irrigant as it sits in the canal. Below is a little video clip showing how I do this.

A recent randomized, single blind study published in the Journal of Endodontics supports this practice as a way achieve more effective canal sterilization. Carver, Nusstein, Reader & Beck showed that canals cleaned and irrigated normally, followed by a one minute ultrasonic irrigation with an ultrasonic needle in a MiniEndo unit resulted in statistically significant (p = .0006) reduction in CFU count and positive cultures (p = .0047). Logistic regression showed that ultrasonic irrigation was seven times more likely to yield a negative culture. Source: Carver, K., Nusstein, J., Reader, A., Beck, M. In Vivo Antibacterial Eficacy of Ultrasound after Hand and Rotary Instrumentation in Human Mandibular Molars. Journal of Endodontics 2007;33:9:1038-1043.

There are many ways to perform ultrasonic irrigation. I simply irrigate the canals normally using a disposable syringe and 5.25% NaOCl. Then I use a small stirring tip attached to my ultrasonic handpiece. I am certain there are other products on the market, but I like to use the instruments that I already have.

Holistic Dentistry

This patient was referred to my office today. He had not slept for 3 days. He was in terrible pain. This tooth had recently been prepped for a crown by his holistic dentist. Maybe the holistic dentist did not see the apical lesion before he started the crown, but the tooth became symptomatic. His holistic dentist had recommended extraction of #30.
He decided to get a second opinion.
The tooth was diagnosed with a necrotic pulp and symptomatic apical periodontitis. He elected to save his tooth with endodontic therapy.

With good follow up, we'll see that the apical lesion has healed, and he will be glad that he got a second opinion, and retained his natural tooth. I think that is pretty holistic!

Endodontic Healing

This is a typical case of endodontic healing. This tooth was diagnosed with a necrotic pulp & chronic apical periodontitis. The periodontal probings were normal. The apical lesion was very large and extended up the lateral side of the tooth. This could be described as a "J-shaped" lesion which is sometimes indicative of a vertical root fracture. Since the perio attachment is normal, this is diagnosed as purely an endodontic lesion.

Endodontic treatment complete.

At one year recall, the lesions is almost completely healed. The periodontal probings are normal and the patient is completely asymptomatic. Proper endodontic diagnosis & treatment not only saved this tooth, but saved this bridge as well.

Cracked Teeth

Here are a few teeth that I have seen in my practice. Some of them were treated endodontically, and others simply needed cuspal coverage. It is my recommendation that when you find teeth like these, that have cracks and signs of stress, that you recommend cuspal coverage. Before crowning them, I would recommend a thorough endodontic evaluation, including percussion, biting (tooth sleuth), probing and thermal testing to evaluate pulpal status. If the tooth passes all of these tests and the pulp is normal, then I would recommend cuspal coverage.

Even though these amalgams are conservative, multiple enamel cracks are evident. Signs of stress are everywhere. This tooth needs cuspal coverage before it becomes necrotic, fractures a cusp, or develops a fractured root.

Cracks like these through the marginal ridges generally extend down the pulpal wall.

When you find a tooth that has cracks on the mesial and distal marginal ridge, the tooth is under extreme forces. If left untreated, the buccal and lingual sides of this tooth will continue to flex and the cracks will eventually meet in the middle and the tooth will become non-restorable.

I'm no practice management guru, but I know if you identify the cracked teeth already in your practice, do proper endodontic evaluation, and protect your patient's teeth with cuspal coverage, you will be doing them a great service and building your practice at the same time. If your patients question the need for cuspal coverage of cracked teeth, send them over for a consultation with your endodontist. We see teeth everyday that could have been saved if they had only been crowned earlier.

This last image is what I call the "Past, Present & Future Cracked Tooth". Past (#3-extracted), Present (#4-buccal cusp fracture), Future (#5-MMR crack waiting for buccal cusp to fracture). Proper diagnosis & treatment will save your patients time and money.

Resorption of Endodontic Sealer

Endodontic sealers play an important role in the obturation (filling) of a root canal. The sealer coats the walls of the canals and fills the space between the root canal filling material and the root. Their antimicrobial activity likely plays a very important role in the overall documented success of endodontic therapy.

There are many kinds of endodontics sealers. They can be grouped into these categories:
1. Zinc Oxide-Eugenol (Roths)
2. Chloropercha (Kloroperka)
3. Calcium Hydroxide (Sealapex, CRCS, Apexit)
4. Polymers (AH26, AHPlus, Diaket, Endofill, Resilon)

I am using a Roth's sealer in my practice. Here are a couple of reasons that I like using a Roth's sealer.
1. Antimicrobial - the Zinc oxide has well known antimicrobial activity
2. No need to remove the smear layer - since I am using a gutta percha filler, I prefer to leave the smear layer
3. Resorbabilty - any sealer that is extruded past the apex will resorb over time.

Here is an example of a case where a significant amount of sealer was extruded.

At a 2 year recall, you can see that the majority of the sealer has resorbed.

Pulling a Pulp

The dental pulp tissue is the living tissue inside of the tooth. It is made of blood vessels, nerve, lymph & connective tissue.
If this tissue become inflammed or necrotic (dead), it must be removed. Occasionally, the pulpal tissue might be completely healthy, but because the remaining tooth structure is too weak, we electively remove the pulp, complete a root canal for "restorative purposes". In other words, we remove the pulp, so that we can use the internal structure of the root to help build up the tooth in preparation for a new crown.
This video clip shows the removal of the dental pulp from a tooth required endodontic treatment for restorative purposes.

Cracked Tooth

When a crack extends from the occlusal (chewing) surface towards the root, we call it a cracked tooth. These cracks may be very small or very large. The crack often causes damage to the pulp of the tooth. Primary symptom of a cracked tooth is pain upon chewing. This pain may be irregular and sporadic.

The depth and position of the crack determines whether the tooth is restorable. If the crack is in the coronal portion of the tooth, then placing a crown with prevent futher flexing of the tooth as well as prevent bacterial leakage through the crack.

A crack extending down the root surface is also commonly referred to a root fracture. Root fractures can be difficult to diagnose. Often they are associated with a deep, narrow, periodontal defect. However, a draining abscess can also cause a deep narrow pocket, which can easily be confused with a root fracture.


In the picture above, the extracted tooth has been dyed. The periodontal ligament picks up the stain. You can see that in the area of the crack, the pdl has broken down and a deep, narrow periodontal defect has developed on the line of the crack.

A cracked tooth that is not treated will worsen and lead to loss of the tooth. Early diagnosis and treatment are essential in preserving these teeth.

Dentigerous Cyst

This patient was referred to my office for endodontic evaluation. The patient had a prior RCT with some localized, intermittent pain & swelling.


My clinical exam revealed #31 normal to percussion, perio defect on distal >14mm. Radigraphs revealed resorption of the distal root, and extensive bone loss on the distal of #31. Due to the strange resorptive pattern and bone loss around the impacted wisdom tooth, the tooth was referred to a surgeon for evaluation.

The oral surgeon performed an incisional biopsy with extraction #32.
The lesion was diangosed as a dentigerous cyst. Following this diagnosis, the patient was again seen for a excisional biopsy.

Pathology Review: Dentigerous Cyst is the most common developmental odontogenic cyst. It is a cyst that comes from the separation of the follicle from an uneruped tooth. This cyst encloses the crown of an unerupted tooth and is attached to the tooth at the cemento-enamel junction. These cysts are most commonly involve the Md third molars and secondly the Mx canines. These cysts can grow quite large and can cause painless expansion of the bone and also displace an involved tooth. About half of the time, this cyst will cause root resorption. Treatment includes enucleation of the cyst with the removal of the unerupted tooth. Marsupialization occasionally done with very large cysts to decompress the cyst. Prognosis is excellent and recurrence is rare if completely removed. There has been some discussion of dentigerous cysts that have undergone neoplastic transformation to ameloblastoma or other neoplasm. (Source: Waldron, Charles. Oral & Maxillofacial Pathology, 493-495, 1995)

Endodontic Retreatment

This patient came in with RCT #29 completed 7 years earlier. She reported dull ache, had a gold onlay and obvious apical lesion. Clinically, tooth was mildly sensitive to percussion, normal probing depths. Diagnosis: Prior RCT with Phoenix Abscess. Retreatment indicated.

During retreatment, a lateral canal was opened, irrigated & obturated. No fractures seen under the microscope.

At 3 months, the patient was asymptomatic and apical healing noted. This lesion is classified as "healing" due to the decrease in apical lucency since the retreatment.

At 15 month recall, the patient is asymptomatic and lesion is "healed", despite failure to place coronal restoration.

Swartz, Skidmore & Griffin (1983) in an evaluation of 1007 endodontically treated teeth found that the #1 reason for failure was inadequate restorations. They also found that overfills caused 4 times as many failures.

This patient was encouraged to get coronal coverage on this tooth ASAP.