Thursday, February 12, 2015

How could a necrotic tooth be soothed by cold? Part 1

CC:  53 YO Male with a chief complaint of "I need my root canal finished, pointing to tooth #28.
HPI:  Pt had a pulpectomy #28 approx 6 months previous.  He has been asymp since.
Med:  No meds, no med conditions, -ve allergies, -ve tobacco

2 months ago, I completed endodontic therapy on tooth #28.  It had been initiated approximately 6 months prior and the finish was uneventful.  During a scan of the patient's radiographs, I noticed that #4 had a periapical radiolucency.  After pulp testing, I determined that the tooth was necrotic - we then planned to initiate endo treatment through the crown.

#4 shift shot

#4 Straight on PA
CaOH #4 (I'm not happy with the poor radio-opacity of the CaOH) Note interprox decay #5

6 days ago, I initiated treatment on tooth #4.  It was a standard pulpectomy:  instrumented the canal to a #25 file, 6 % NaOCl and QMix + Endoactivator.  I placed CaOH and helped splash it around the canal with the endoactivator.  I called the patient the day following, and other than the typical pain from anesthesia, he was fine.  6 days later, he presented with the following complaint:

My upper right tooth has been aching since this morning.  I need to drink cold water to keep the pain down.  It was ok during the weekend, but this morning, (day 6), I woke up and it started hurting.  My pain is approximately 6/10.

"Can you point with one finger where the pain is coming from", I asked.  He points to roughly between #3 and 4.

Ok - what am I thinking at this point?  "Cold water makes it feel better" -  classic remedy for irreversible pulpitis.  But wait, #4 was necrotic!  There was nothing in the tooth when I accessed it.  How could there be symptoms from a pulpless tooth?  I ran the following tests:

Extraoral:  No swelling, tenderness, pain, redness
Intraoral:  No swelling, fistula, pus

Tooth             Cold          EPT         Probing           Percussion       Palpation
#2                   -ve             80              <3mm             Norm               -ve
#3                   -ve             80              <3mm             Norm               +ve
#4                   -ve             80              <3mm             +ve                  +ve between #'s 3&4
#5                   norm          44              <3mm             Norm               -ve
#6                   norm          40              <3mm             Norm               -ve

So, there I sat, thinking about looking for a horse and not a unicorn.  I had just completed the pulpectomy on #4 and he was is asymptomatic following treatment, until a few days later.  Had I opened pandora's box?  What about that postural thing?  He felt fine sleeping until he woke up.  Sinus irritation issues secondary to instrumentation of #4?
So, just to make sure that there wasn't something out of the ordinary with the pulpectomy of #4, I decided to re instrument #4, remove the CaOH, and see what was up.  And as I expected.  Nothing.  No heme, no pus, nadda.  This was completed without anesthesia (the patient was totally comfortable), and the patient noted that his symptoms had been relieved (somewhat) following treatment.  I left the canal patent (no CaOH) "just in case", there may have been a need for expansion of fluid.  I mean, we're going against all the things that I had been taught in my residency - almost everything except for leaving the tooth open.  That, I did not!  The patient was dismissed and I was planning on calling him in the morning.

6 hours later.............the pain had returned....

To be continued.  Keep in mind the cold water thing.

Tuesday, June 3, 2014

Episode 400/500: Extraction or Retreatment - Traumatized Maxillary Incisor

A 50 year old male presented a few weeks ago with a fistula draining from between teeth #'s 8 and 9 (11/21).

CC:  I have this pimple on my gums and it comes and goes - over the past few weeks.
History:  I fell on the ice many years ago, had a root canal and crown - and haven't had any problems since.  (It happened 30 years ago)
Med:  No meds, no medical conditions, non smoker (BP 124/79 P 66)
CE:  Intra oral:  No swelling, pain, erythema.  Fistula (draining slightly btn #7/8)

            Probing        Mobility             Cold                 EPT
#6       <3mm           Miller 1       ++ fleeting              80
#7       <3mm           Miller 1       No response            80
#8       <3mm           Miller 1       No response            80
#9        <3mm           Miller 1       No response            80
#10      <3mm           Miller 1       ++ fleeting              80
#11       <3mm           Miller 1       ++ fleeting              80

Now, the problem was trying to figure out the reason for the lateral radiolucency on #8.  Why was it coming from this tooth in the first place?  The patient had been asymptomatic for 30 years and why all of a sudden was this tooth causing a problem now?  Was it the poor obturation or the position of the post?  I talked with several colleagues and we determined that a possible reason for this presentation is a root fracture.


#7:  Necrotic pulp w/ asymptomatic apical periodontitis
#8:  Previously treated w/ chronic apical (lateral) abscess - also - Non restorable due to fracture
#9:  Necrotic pulp w/ asymptomatic apical periodontitis

#8 Deductions in thinking:
1.  Previous history of trauma.  There is always a possibility of root fracture fol trauma.  It's interesting that #7 has significant calicification and #8 has a very wide pulp chamber/canal.
2.  Location of post.  The most apical extent of the post is at the lateral RL (radiolucency).  Careful though - when you look at the fracture pictures, it appears it may be coincidence that the post is at the same level as the RL as the fracture is vertical.
3.Location of the RL.   Although there is an undefined apical extent of a RL lesion on the 3 teeth in question, the lateral position of the RL on #8 gives us some clues about the nature of the problem.  Look at the lateral bone destruction as outlined in red on #8.  This was on the palatal portion of #8.

I discussed treatment options with the patient and he elected to continue treatment with an FDP from #11-22 (7-10).  For implant treatment, he will require significant osseous augmentation (block graft) and significant soft tissue augmentation.

Extraction of #8 was uneventful.  I stained it with methylene blue dye to aid in visualizing the crack.  I always find it interesting when I can't probe anything >3mm and you find out it after extraction the tooth is cracked/fractured.

So, keep this diagnosis in your back pocket when you see those atypical lateral RL's.  When associated with an endodontically treated tooth, it may require something other than a retreatment.
Add caption

Root fracture, endodontics, allthingsdentistry

cracked tooth, root fracture, allthingsdentistry

Monday, October 22, 2012

Episode 398/500: Crown Removal - Richwill Crown Removal Tabs

There are a number of ways to remove crowns - not that you typically want to remove definitely luted crowns - but - there are the times when it "just has to be done".

Just like this morning.....

Chief Complaint: 55 YO female presents with a chief complaint, "my crown is loose - can you cement it back on?"

There are many things that run through my mind when a patient presents with this scenario, including:

  1. If it fell off, what's the success going to be if I just cement it back on?
  2. How many times has it fallen off?
  3. Did it fall off - or - did the tooth/core fracture?
History of Present Illness:  The patient's crown on tooth #13 (FDI #25) was dislodged over the weekend and caused some discomfort.  The tooth has been previously endodontically treated and the full coverage restoration was placed approximately 5 years ago.  

Clinical Exam: Tooth #13 crown was still intact intraorally and on the preparation.  By using an explorer and engaging the palatal crown margin and lifting coronally, I was able to start moving the crown.

Radiographic Exam:  Tooth #13 has been previously endodontically treated and does not appear to have a post placed in either canal.  Periradicular tissue is normal (radiographically)

So - the story continues - as I am about to remove the crown, I"m thinking that perhaps I had better capture a triple tray impression of the quadrant to ensure that if the crown/tooth fractures, I will at least have a "go-by" stent to fabricate a provisional restoration.  The other option is of course, to take/make alginate impressions - however - this is a sick parade/emergency patient and there really isn't time.  I suppose that as I reflect - I could have taken alginate impressions and rebooked her for another appointment.  Either way - here we are.

Anyways, long story short - the crown wouldn't come off and I suspected that she had fractured her core.  After provision of some local anesthetic (you'll see why if you look at the photo), I just couldn't get the crown off w/ hemostats (my crown removal forceps were at our other clinic). So, we scrounged around and found these friends - the Richwill Crown removers.  These are great little friends that only work in specific situations - and this was one of them.  Dental versions of jujubes, these guys, once heated and placed on the crown you intend on removing - make life just a little easier.  However, just like the instructions say - ensure that the opposing dentition is intact, or you may be removing a restoration from the opposing arch as well.

The little tag of tissue was most likely the culprit causing the patient some discomfort when the crown was rocked to the buccal.  This discomfort was also a great hint that most likely the tooth/core was fractured.

Now what to do?!

Here are the instructions for these green friends.
richwill crown remover, crown, removal, fractured crown, dental crown,
The crown removed from it's resting place of 5 years.  The white core material appears to be a composite core buildup.  
There was no post placed, and it's hard to determine how
much ferrule was used.

richwill crown remover, crown, removal, fractured crown, dental crown,

richwill crown remover, crown, removal, fractured crown, dental crown,
I'll be $4 that the little tissue tag was causing the discomfort when
I tried to remove the crown w/out local anesthesia.

richwill crown remover, crown, removal, fractured crown, dental crown,
Ok, the crown is off.

Now what?

Saturday, October 6, 2012

Episode 397/500: Endodontic Access Help - C+ files

I've moved into another clinic (with 12 other clinicians) and I'm really appreciative of the great things that I learned during my residency.  Such simple things that even now I take for granted - are either not shared with others - or - we have information/marketing overload.  "EVERY product is amazing" nowadays.

Our endodontic cabinet is an absolute zoo.  There are remnants of file systems and products from many other clinicians and I hope not to be one of those folks - but - I probably will.  So here I am, standing infront of this huge filled cabinet and I'm trying to determine what's required and low and behold, there are no #6 files.  Of course, there probably are folks reading this right now and think, "I don't even use #6 files".  Well, uhm....ok.

For the rest of us, there are #6 files and C+ files.  C+ files are just a little more stiff than the conventional #6 files and allow you to apply just "a little" more apical pressure.  Careful - these ones have a cutting tip and who knows where that tip may cut into if you're not diligent.

k file, c+ file, dentistry, endodontic file, endo file, mirror, ndodontics
C+ files in their little carrying case. Ever used a mirror with an endo ruler milled  into the handle?

k file, c+ file, dentistry, endodontic file, endo file, mirror, ndodontics

C+ files are made in the #6,8,10 and 15 file sizes.  There are, however, a few other files out there that appear to accomplish the same thing.  The first time I heard about them was today, when I searched PubMed for any literature on c+ files.

This literature article popped up:

 2012 Oct;38(10):1417-21. doi: 10.1016/j.joen.2012.05.005. Epub 2012 Jun 29.

Mechanical behavior of pathfinding endodontic instruments.

Try these and others out - they make just make that afternoon a little easier.

Sunday, September 30, 2012

Episode 396/500: Literature Supported Clinical Decisions

In the middle of searching the literature for justification of clinical decisions (pin retained amalgams, resin bonded amalgams, provisional materials), the guy from farnamstreet blog sends out this TED talk video.  BTW, Farnam Street blog is a great place for  all sorts of things - and - I like it b/c the tag line is essentially the same as me - "Mastering the best of what other people have figured out"  I have created essentially very little - but - I have been taught a huge amount and continue to learn from my colleagues everyday.

Although the speaker (Ben Goldacre) is talking about medicine, it is definitely applicable to dentistry.  The crux of the issue is that typically only positive results in research is published.  No one cares to publish negative findings (ie -voodoo magic does not disinfect endodontic canals).  That's obvious - or is it?

Let's talk about dental implants.  There is a tip in here, so hang on.  No patient wants a dental implant.  They want a restoration....... that is perhaps supported by a dental implant.  I know, I know - I hear what you're saying - that's an obvious statement you just made.
But, what I"m really talking about are anterior, implant supported restorations - the esthetic ones.  How many times have I looked at pictures in journals (I can't read) and the author has some photos showing his/her work and I sit back and think, "the esthetics probably could have been better managed using conventional fixed prosthodontics or removable prosthesis"  Wow, going back in time?
The industry is currently at a point where any edentulous parking spot in a patient's oral cavity should be restored with an implant.  In our clinical practice (which is much different from where a patient has to pay for something), each time a patient presents with an edentulous space - they already know enough to be dangerous regarding dental implants.  "Doc, can I get an implant?"  I hear that at least 4 times a day - and that's ok.  However, so many clinical variables have to be considered before treatment planning for the "sliced bread". 

Would your treatment option be different if the adjacent teeth were
heavily restored?

(You know, the best thing since sliced bread statement... )
 How many times have I looked intraorally and thought - I don't think I could have restored/placed that implant any better - but - this restoration looks like junk esthetically.  Is this the best we can do? 
I'm for dental implants - however - there is more to prescribing this treatment than appears in the literature.  The literature only talks about survivability of implants - that is - how successful the titanium screw is - not the esthetic component.  There are no long term randomized trials discussing implant esthetics - and - isn't that what the patient really wants?  

What's esthetics?  Well - just imagine your implant patient sitting and laughing out loud, having a great time with his/her friends and at one point, a friend points and asks- "what's wrong with your gums/tooth?"  (Perhaps alcohol is involved to aid in relaxation.)  "Uh.....nothing?"
The patient may have settled for the poor esthetics b/c they sat through 8 hours of tooth extraction, impressions, implant surgery, abutment impressions, crown placement, etc.  But when the rubber hits the road - they won't be impressed if their friends can see it and they spent $x dollars.

A study titled "Prospective randomized clinical trial of dental implants: Poor esthetic outcomes"
definitely wouldn't get published.

Care of :

If you were a manufacturer of dental materials would you want a negative finding published especially -  if you paid and sponsored that researcher to do that research?  Probably not.  The Endo Blog (where I picked up the implant crown picture) has a great overview regarding endodontics and implants.  I appreciate their aspect b/c I totally forgot about treatment options before the tooth is extracted.

Therefore, before rushing to prescribe an implant to "fill a space", it's key to understand that it is really the restoration that the patient wants.  Yes, 95% of the time, the implant itself (ie titanium screw), will function.  However - how likely are you able to place an esthetic restoration on top of that boat anchor?  Esthetics is key, and I am by no means a master of that.

So, what am I saying here?  Clinical practice is difficult.  You are bombarded with advertisements, sales persons, reps, continuing education - etc etc.  Now, it's apparent that even the literature is biased as well (we all knew that).  How to make a clinical decision?  Talk to peers, review the literature and treatment plan thoroughly based on your own experiences.  It's called practice for a reason - and - you won't know of those products that had negative results, yet, are still available.