Partners In Patient Care: Assisting in Treatment Planning - Cracked Teeth

The endodontists at Superstition Springs Endodontics are partners in your patient care.  One of the many ways we assist with the quality treatment of your patients in addition to endodontic diagnostics is in evaluation of restorability.  With the benefit of the dental operating microscope, we are able to excavate decay and evaluate cracks in your patient's tooth.  Every crack is unique and the extent, depth, discoloration, pulpal status, patient occlusion and parafunctional habits should all be considered in the treatment planning a tooth with a crack.

Cracks that go below the cemento-enamel junction and are not able to be completely removed when the buildup is placed or completely covered by the new crown will likely affect the long term prognosis of the tooth.  These types of cracks are best evaluated under the magnification of the microscope.  Additional tools such at staining and transilluination are also frequently used tools in the endodontist's evaluation of a crack.

Patients should be given the options and prognosis and helped to make the treatment decision that is in their best interests and meets their desires.

The following case demonstrates this process and usefulness of the microscope.

Pt is referred for endodontic evaluation/treatment.  Tooth is diagnosed with irreversible pulpitis, normal periapex and gross distal decay.  RCT recommended.

Distal decay is removed, mesial amalgam removed.  Crack identified on the mesial wall of the pulp chamber.

Further excavation reveals the extent of the mesial crack - going below the CEJ and starting to enter the root.  Patient is informed of the extent of the decay and the options: 1. Complete RCT, buildup and crown with guarded long term prognosis 2. Extraction and replacement with implant or bridge  Pt elects extraction in this case.

Is Your Endodontist A Partner in Patient Care?

What does it mean to be partners? On a recent episode of the The Profit, starring Marcus Lamonis, he was coaching two business partners on what it means to be partners.  Simply put, "partners need to help each other".  Partners recognize the strengths in each other and value those strengths.  Leaders in business have one goal in mind and that is to make the business successful and add value any way you can.

Is your endodontist a partner in your patient care? What kind of help does your endodontist provide to your practice?  At Superstition Springs Endodontics, our goal as your partner in your patient care is to make your patient's dental/endodontic treatment successful and add value to our relationship any way possible. This includes:

• Providing the highest quality endodontic treatment
• Seeing your patients when they need to be seen
• Being available for consultation and emergency treatment
• Assisting in treatment planning - especially determining restorability (diagnostic excavation) and evaluation of cracks/fractures - procedures which are often poorly reimbursed
• Supporting your treatment plan and helping in patient education
• Providing additional restorative work as requested (posts, cores, access fillings, minor crown lengthening)
• Effective communication regarding patient care
• Standing behind the work that we do
• Providing high quality continuing education to help your practice
• Searching for unique ways to build your practice (referrals, online reviews, marketing ideas, networking)

If this is the only time you find yourself needing to refer to
an endodontist, you are probably not working together
as true "partners in patient care".

As endodontists, the most fulfilling professional relationships we have with general dentists are those where we feel like partners in the treatment of your patients. These partners recognize our special skill set, specialized armamentarium and how that will benefit their patients saving them time, money and a providing a great experience.  These partners are comfortable enough to call or text us anytime with questions, concerns or feedback.  They are good at case assessment and rarely need to be "bailed out" of difficult cases.

In upcoming blog posts, we'll show some cases that demonstrate how we at Superstition Springs Endodontics work together with general dentists as partners in patient care.

Finding Calcified Canals Using A Microscope

Antibiotic Cross Sensitivity Chart for Quick Reference

This is a great chart for reference regarding antibiotic allergy cross sensitivity. Source

Dental Computed Tomography (CBCT) to Identify Dental Sources of Maxillary Sinusitis

CBCT by J. Morita Veraviewepocs 3De

As endodontists, the use of CBCT (Cone Beam Computed Tomography) has allowed us to cross this barrier and diagnose dental pathology which is adversely affecting the maxillary sinuses.  These images also allow us to communicate more effectively with patients and physicians who are trying to manage and treat these chronic sinus issues.  In order for dental and medical specialists to work together, new paths of communication must be developed.  CBCT (3D imaging) is helpful in bridging the communication gap between dentistry and medicine.

The following cases demonstrate the usefulness of CBCT in identifying odontogenic sources of chronic sinusitis.  Several radiographic findings are pointed out which help identify odontogenic sources for chronic sinusitis.  These common findings seen with high resolution CT imaging include:

1. Perforation of the floor of the Mx sinus
2. "Halo effect" elevation of the floor of the Mx sinus
3. Thickening of sinus membrane adjacent to odontogenic infection
4. Air bubbles in the sinus suggested of an acute sinusitis

CBCT for DIAGNOSIS
CBCT (J. Morita Veraviewepocs 3De) demonstrates a large periapical radiolucency around the buccal roots of #15.  The sagittal view shows elevation in the floor of the sinus (halo effect).  Coronal view shows arrow pointing to a missed mesio-buccal canal causing the endodontic infection. Air bubbles seen in the maxillary sinus are indicative of an acute sinusitis. Endodontic retreatment is required BEFORE sinus treatment.  Failure to address the odontogenic source of the sinus infection will result in recurrent sinus infections.

CBCT for DIAGNOSIS
CBCT (J. Morita Veraviewepocs 3De) demonstrates a large periapical radiolucency around the mesio-buccal root.  The sagittal and coronal views both show elevation in the floor of the sinus (halo effect) as well as perforation of the floor of the sinus.  Endodontic treatment is required BEFORE sinus treatment.  Failure to address the odontogenic source of the sinus infection will result in recurrent sinus infections.

CBCT for DIAGNOSIS
CBCT (J. Morita Veraviewepocs 3De) demonstrates a large periapical radiolucency around the buccal roots of #3.  The sagittal and coronal views both show elevation in the floor of the sinus (halo effect) as well as perforation of the floor of the sinus.  Endodontic treatment is required BEFORE sinus treatment.  Failure to address the odontogenic source of the sinus infection will result in recurrent sinus infections.

Fortunately, these high definition images also identify the problems with previous endodontic treatment and the solutions to remove the odontogenic source of infection.  These common endodontic findings include:

1. Missed (untreated) canals in a previously treated root canal
2. Short filled canals in a previously treated root canal
3. Iatrogenic damage in a previously treated root canal

Proper endodontic treatment of the dental infection is the first step in addressing the chronic sinusitis of odontogenic origen.  If sinus symptoms persist, following endodontic treatment, then referral to ENT is recommended.

Is This Tooth Bothering My Sinuses?

"Is this tooth bothering my sinuses?" For years patients with chronic sinus issues have asked this question at the dental office.  Unfortunately, there has been a communications gap between diagnostic medicine and dentistry in this overlapping area of practice.  Endodontists are experts diagnosing pulpal disease, but not trained in diagnosis of sinusitis. Most otolarygologists (ENT) physicians, and especially rhinologists, are experts in sinus diagnosis, but not trained in evaluating dental and pulpal infection, which may be a source of infection for the sinuses. Most sinus CTs are not including the teeth and rarely are medical radiologists evaluating the teeth in their reads.

In cooperation with Dr. Tim Haegen of the Arizona Sinus Center, a division of Valley ENT, we have been able to help patients with chronic sinus issues. Many of these patients have bounced from ENT to ENT looking for answers, some have had continuous courses of antibiotics and some have had sinus surgery, only to continue to have chronic sinus issues. With some interdisciplinary education between endodontics and otolaryngology, familiarization with each other's diagnostics and terminology and the use of medical and dental CT imaging, we are working together to diagnose and treat the often time overlooked odontogenic sources of sinusitis.  The use of 3D imaging between disciplines has helped to bridge the gap of communication between medical and dental specialists trying to help patients with sinusitis and dental infections.

The following case demonstrates how proper understanding of endodontic and ENT imaging, diagnostics and terminology facilitate proper diagnosis and treatment.

This patient presented to Arizona Sinus Center for evaluation of chronic sinus issues.  She presented with chronic, unilateral nasal and facial symptoms, along with foul smelling nasal discharge.  Nasal endoscopy was performed and findings include:



FINDINGS:

• Nasal septum - superior deviation to right, mucosa intact, no perforation or crust
• Right inferior turbinate - normal
• Right middle turbinate - edematous
• Right middle meatus - closed; edematous medialized uncinate. Tissue is pulsatile. No purulence or polyps.
• Right posterior choanae - normal
• Left inferior turbinate - normal
• Left middle turbinate - normal
• Left middle meatus - open, no mucopus or polyps
• Left posterior choanae - normal
• Nasopharynx - no masses

RADIOGRAPHIC FINDINGS:

 Complete opacification of the right frontal sinus.

Partial opacification of the R ethmoid sinuses.

Complete opacification of R maxilliary sinus, superior septal deviation to the right, bilateral opacified concha bullosas.

Molar #2 and #3 have periapical radiolucency (PARL), one of which is dehiscent into the maxillary sinus and buccal gingival sulcus.  This may be the most important diagnostic information in the CT scan.  Too often, radiologists and otolaryngologists are not looking at this part of the scan - if it is even included in the field of view.

Following evaluation, the following impressions were recorded.

Impression:

• Nasal Obstruction
• Deviated nasal septum
• Frontal sinusitis, chronic
• Maxillary sinusitis, chronic
• Ethmoidal sinusitis, chronic
• Dental caries, unspecified
• Disturbances of sensation of smell and taste

 With these radiographic findings and clinical impressions, the patient was then referred to Superstition Springs Endodontics for evaluation and definitive treatment of the maxillary molars #2 and #3.  Due to the complete opacification of multiple sinuses along with bony erosion of the medial orbital wall, the possibility of endoscopic sinus surgery was discussed.  Discussion included risks of failure to treat the infection within the sinuses as well as failure to remove the source of the infection, which in this case has to include the dental source of infection.

Pt presents for endodontic evaluation of #2 and #3 following ENT identification of possible dental abscess adjacent to Mx sinus.

Endodontic diagnosis, including CBCT, determines that tooth #2 has a prior root canal with a root fracture and extraction is recommended.  Tooth #3 has a prior RCT with apical abscess - caused by a missed MB#2 canal during the initial root canal treatment.  Retreatment of the root canal #3 is recommended.

Endodontic retreatment with microscope locates the previously missed MB#2 canal.

MB#2 canal is debrided and irrigated with NaOCl.

PostOp radiograph shows all 4 canals have been properly treated.

PeriApical RadioLucency (PARL) seen at apex of MB root - which had a missed canal on initial treatment.

6 month recall following endodontic retreatment shows healing of the PARL.

After 6 months, extraction of tooth #2 and retreatment of tooth #3 has shown periapical healing.  The potential odontogenic source of the sinus infection has been eliminated.  Since the Mx sinus continues to show opacification, the patient is referred back to Dr. Haegen for continued sinus evaluation and treatment.

Why See An Endodontist?

Dental Operating Microscope used by endodontists

The endodontists at Superstition Springs Endodontics are experts in endodontic diagnosis and have extensive experience with CBCT.  In addition, endodontists are specially trained to perform the most difficult endodontic cases.  Maxillary molars, most closely associated with the maxillary sinus, almost always have 4 canals.
A common reason for root canal failure on Mx molars is inadequte cleaning, and often completely missing the MB#2 canal.  Endodontists using an operating microscope are able to find and treat the MB#2 (4th canal) more effectively and efficiently.  Endodontist are also trained to perform endodontic microsurgery when traditional endodontic therapy is unsuccessful.

When endodontists and otolaryngologists work together, they can provide the best care for patients with odontogenic sinusitis. 

Preventing Root Canal Perforation by Case Selection

This patient came to Superstition Springs Endodontics in June 2009.  Her general dentist had started RCT on #3 but was unable to locate the MB canal(s).  A perforation was made during the efforts to find the MB canals.  We have taught the generalists in our community that the most successful and fulfilling way to practice endodontics depends upon careful case selection.  Proper case evaluation can:

1.  prevent lost chair time without reimbursement
2.  prevent loss in patient confidence
3.  prevent clinician frustration

The Endodontic Case Assessment Form from the AAE, can help clinicians determine the difficulty level of treatment - before therapy is started. This is how this case should have been classified - prior to starting treatment. 

 

 

 The treatment for this tooth was RCT completion and repair of the iatrogenic damage using Mineral Trioxide Aggregate (MTA).

Fortunately, with good repair materials, the prognosis for a tooth like this is still good.  A 7 year recall finds the tooth in full function and asymptomatic.

However, proper case selection will make your practice of endodontics more fulfilling, less stressful and ultimately, more successful.

Congressman Paul Gosar to Speak at 2016 Spring Into Dentistry Seminar on Feb. 19th

This year's Spring Into Dentistry Seminar will feature Congressman (and Dentist) Paul Gosar from Arizona's 4th Congressional District.  We are excited to have him as our guest speaker and hear about his unique perspective as a dentist and a congressman.  We hope you can join us!

Apicoectomy on Mx Molar - All Three Roots Through A Buccal Approach

Endodontic surgery on maxillary molars is usually limited to the MB and DB roots - through a buccal approach.  Surgical treatment of the palatal root often requires a palatal surgical approach, and is therefore rarely done.  In this particular surgical case, due to the root anatomy and size of the periapical lesion and osteotomy, all three roots were accessed through a buccal surgical approach.

Surgical PreOp

Root resection of all three roots using a buccal approach

Retrofills with MTA

Post-Op radiograph

1 year recall. Patient fully functional and asymptomatic.  Radiographic healing evident.