Internal bleaching makes us smile!

This 13 yr old young lady had some trauma to #8 during a softball game. As you can imagine, the discoloration is of significant concern to the patient.

At the time of the exam, tooth #8 is non-responsive to thermal testing, normal to probing and mildly percussion sensitive. DX: Necrotic w/ SAP. RCT recommended with internal bleaching for esthetic purposes.

RCT completed under microscope assuring that all internal staining is removed from the pulp horns. A coronal barrier is placed in the cervical portion of the tooth. The purpose of this barrier is to prevent bleach from entering the root, passing through dentinal tubules and causing an inflammatory reaction in the pdl. Bleach (Ultradent - Opalescence Endo) is placed in the pulp chamber with a thin, button cavit temporary. Pt is rescheduled for 1 week.

Pt is excited with the new appearance of her tooth.

Final restoration is placed. Endodontists can be a valuable team member in your cosmetic cases!

Value and Limitations of CBCT in Endodontics-Case Report

For the longest time, I have been skeptical of the ability of the CBCT to detect vertical root fractures. Especially in previously treated teeth, where scatter radiation produces artifacts in the image. There has been research(mostly in vitro) supporting CBCT imaging for detecting fractures(Hassan 2009), and there is no doubt that the technology shows exciting promise for use in our field. This case demonstrates both the value and limitations of this exciting imaging system.

The patient first presented six months ago with new crowns on teeth #30 and #31. His symptoms were described as a spontaneous ache and a soreness to mastication that started with the new crowns and felt localized to #31. Diagnostic testing revealed percussion sensitivity and a lingering dull ache to cold on #31, as well as a mild soreness to bite forces on #30. The original root canal treatment and post on #30 were over 15 years old. A diagnosis of irreversible pulpitis was made for #31 and treatment was completed. The mild bite soreness on #30 was attributed to a heavy occlusion and/or some referred pain from #31. Here is our post op radiograph:

The patient reported an episode of severe spontaneous pain lasting one day in the area that started four days after the first visit for #31 and resolved prior to his second visit. This odd experience certainly raised some alarms for me, but when he returned, a new exam and series of diagnostic tests produced nothing of note.

At three months following treatment, the patient reported continued discomfort to mastication in the region. An exam and diagnostic testing produced some continued bite soreness on #30. A new periapical radiograph revealed a possible missed DB canal:

I also speculated on what appeared to be the early formation of a lateral radiolucency on the mesial root that could be the result of a vertical fracture:

However, there were no significant probing depths, only mild symptoms, and no obvious signs of an apical radiolucency. At this point, to aid in our diagnosis, I recommended a CBCT. I reviewed the scan at length individually, and with a periodontist and with an expert from the company. I immediately confirmed the missed DB canal, but also noticed an obvious radiolucency associated with the distal root. What we could not find, independantly or together, was any sign of a fracture in the mesial root or of any lateral bone loss along the root.

It's remarkable the accuracy with which we can pick up the missed DB canal and see the periapical radiolucency (PARL) that was not evident on the periapical radiographs above.

With the new diagnostic information, the decision was made to retreat #30. Of course, I still warned the patient about the risk of losing the tooth if a fracture is found in the root structure. Upon access, I was greeted with the familiar sight of purulent drainage pulsing up the distal with each heartbeat:

Below you can see the missed DB canal before and after post removal: Unfortunately, upon cleaning up the mesial, two fractures were found leading to the MB canal. One along the mesial wall:Another fracture was found along the MB wall: These large fractures probably form a wedge out of the MB root. Unfortunately, they severely compromise the prognosis of our treatment. I cleaned and disinfected the untreated DB canal before placing calcium hydroxide. I then closed the tooth and recommended extraction to the patient. Because of our diagnostic efforts involving a lengthy consult with clinical and radiographic images, the patient was understanding of his situation and appreciative that every effort was taken to diagnose his problem and save his tooth.

In this case, I had high hopes that the CBCT might confirm my suspicion of lateral bone loss around the mesial root. The CBCT was excellent, as it has been in the past, at confirming missed canals. However, it has still not demonstrated to early detect a vertical root fracture prior to an obvious clinical and periapical radiographic presentation.

If anyone has any questions or input, or has had different experiences with the CBCT. Please share them! Also, check out our office's facebook page at www.facebook.com/alpharettaendo where I post new cases regularly.

FAIR Health Consumer Cost Lookup

FAIR Health is an independent, not-for-profit organization that was established to maintain a database to help insurers and consumers determine reimbursement rates for out-of-network charges, and provide patients with a clear, unbiased explanation of the reimbursement process. This first-of-its-kind database will allow consumer to get cost estimates for medical and dental procedures in their geographic area. The database will also help consumer estimate how much their insurer will reimburse for procedures performed "out of network". This website should help patients to clear the cloak of secrecy around the "out of network" reimbursements that the insurance companies work so hard to maintain.

If you think the insurance companies set this up to help consumers understand the insurance process, then think again. This is part of the large settlement following a 2009 investigation by New York State Attorney General Andrew Cuomo that discovered a conflict of interest between the Ingenix database, which was used by insurers nationwide to set reimbursement rates for "out of network" health services. Ingenix happened to be a subsidiary of UnitedHealth, the second largest insurer in the nation. It was determined that Ingenix had a vested interest in helping set rates low so companies could underpay patients for "out of network" services.

You can check out the website, and encourage your patients to use it too!

http://www.fairhealthconsumer.org/