Friday, September 30, 2011

WEBApp and Android App

Blogger's New Dynamic Template
I love it.
However, the widgets are is a workaround:

WEBApp Access:

1.  On your iPhone/iPad, click the link:
2.  Add to homescreen

Android Mobile App

Thursday, September 29, 2011

Episode 173/500: Clean Your Dental Bridge

The way to hang onto your bridge-keep it clean.  Other than fracturing of porcelain, getting a cavity around the joint between the tooth and bridge is probably the reason why we see failures of bridges - or - fixed dental prostheses.

Remember - the more time you spend cleaning things you receive from the dentist,  the longer you will keep them - and - the LESS time you will spend in one of the most detested places on earth - yes - my profession of choice.  

Imagine - a beautiful, cool sunny day outside - the boss has given you the day off to spend it doing whatever you want - and your bridge falls off....."You've got to be kidding..."  Maybe you should have cleaned it over the past 5 years and you'd be able to spend that wonderful day any place other than the "chair"...

For myself, I make it a simple routine to spend 5 minutes before bed to fiddle around with my teeth.  (Yes, I brush in the morning and at lunch).  

You know, just like eating....make it routine and it feels weird to break the routine.



Wednesday, September 28, 2011

Episode 172/500: Endodontic Retreatment -Retreat the Retreat?

This is an interesting case just b/c we had to go waaay back in the chart to determine that the patient actually had root canal therapy on tooth #15 (FDI 27), and not just an accessed tooth referred to the endo clinic.  It turns out that #15 was previously treated, then retreated - but not finished....the amount of time between the unfinished retreatment is anyone's guess.  That is a problem.  The prognosis definitely has declined to questionable.

I learned a great way to try to use antimicrobials such as Chlorohexidine (chx 2%) to rinse the apical tissues.

  1. If you're using NaOCl, you must rinse the canals with sterile water/anesthetic to remove all traces of NaOCl.  There is a chance of mixing sodium hypochlorite with chlorohexidine together to form parachloroaniline - toxic......not good.
  2. Irrigate with chlorohexidine 2% - try to get some into the apical tissues if at all possible.  The orifices were 60 file
  3. Let the chx 2% stand for 10 mins.
  4. Aspirate the chx with your irrigation syringe or use an endovac.  Try to keep the canals moist to take advantage of the substantivity effect of chx
  5. Place CaOH.
  6. Wait at least 2 weeks.

What do you think?

Wait until you see the CBCT....



Episode 171/500: Apicoectomy - Root Canal Surgery Part 2/2


Here is part two of the apicoectomy surgery that I completed a month ago.  The patient deployed so I have no idea if her pain resolved or not. However, at her one-week follow-up exam, she was elated to have undergone endodontic surgery. Crazy!
In this video, there are a number learning points that are important points:

  1. To determine where to begin, approximate two thirds of the root, make a dimple in the cortical plate, place a radiopaque material, (such as the foil from a radiograph), and take a radiograph to determine your location.Pray for dehiscence to aid in location determination.
  2. Use methylene blue dye to look for any cracks and insure a continuous PDL space.
  3. Retrograde obturation with MTA can be difficult - consider ortho grade obturation with MTA prior to apical surgery.
  4. Use 6-0, or smaller sutures. (Gortex)
  5. Before suturing, re-approximate the flap and apply pressure for approximately 5 mins to flap.
Hope this helps.


Tuesday, September 27, 2011

Episode 170/500: Endodontic Perforation


Here is a post to hopefully help you in your practice.  Endodontic perforation.....the things people don't want to admit - but happen.

Yes, I've perforated during endodontics 3 times.  2 within 3 years of graduating and most recently last year.  This is last year's case.  Essentially, when I received the case from a general dentistry clinic, the DBu canal was blocked - and I - decided to burrow another hole - with an #6 C+ file.  Smart - definitely not.  Did I learn tons - yes.

Important Points:

  1. The best time to repair a perforation is at the time of perforation.  Don't seal it up and let the patient leave - deal with the perforation at that time, to increase the probability of success for the patient.
  2. Use ultrasonics (either a Piezo or hygiene (Cavitron) to aid in vibrating MTA into location.  It will take several attempts to "get it right."
  3. Learn about MTA.  It's easy to open the package, easy to mix - tough to manipulate.  Practice, Practice, Practice.  - Use model stone to practice placing it.
  4. Use magnification for endodontics.


Sunday, September 25, 2011

Episode 169/500: Pooling Blood Under Tongue - definitely not good.

Here is a white board discussion regarding placement of implants into the anterior mandible.  Typically classified as Type 1 bone (most classifications), the anterior mandible is usually the best bone to place implants in.  However, with the best, comes the problems - thin ridges with lingual undercuts can lead to lingual perforations.
Due to a significant amount of vasculature entering the lingual portion of the anterior mandible, a perforation of lingual cortical plate could be deadly.  Here is one of many case reports:

Isaacson, T.J., Sublingual hematoma formation during immediate placement of mandibular endosseous implants. Journal of the American Dental Association, 2004. 135(2): p. 168-72. 

I haven't experienced this situation (cross my fingers that I don't) - however - a CBCT should be part of your treatment planning preparation. 

Episode 167/500: Implant Placement - The implant won't engage!

Hey folks,

Here is a great learning case. A resident colleague and I placed 2 anterior mandibular implants to support and retain a mandibular complete denture. All went smooth, except that the implant didn't engage.  Yikes.  Neither of them did.   Yikes.  However, because I was the assistant, I wasn't sweating bullets. He was...and I think he turned a few more grey hairs....

However, we both worked together, to figure out a solution.....that is in the next video.

Here is a review of key points that I may have forgotten to mention in the video.....
  1.  During any flap procedure, ensure that you have sufficient visualization. Don't be cheap. Go big or go home.
  2. Flap elevation is fairly difficult on edentulous ridges due to scar formation.  Take your time - well - you really have no choice.
  3.  You need to flatten the osseous crest on an edentulous ridge, because, normally it is thin and jagged....a poor vacation spot for an implant.
  4.  Use a surgical guide for initial placement and/or determination of implant location.
  5.  When placing two or more implants, and there is a requirement for parallelism, use guide pins.
  6.  One-shot osteotomies - Critical.  Don't make the screw hole bigger than the screw.....
The the reason why my colleague and I had problems, was simply due to the fact, that the hole was bigger than screw. Essentially, during the osteotomy process, we ran into a few snags, which I'll explain later on down the road. To keep this explanation simple, the osteotomy became enlarged,  preventing engagement of the implant.  There are a number of solutions, and, I will review those, in a next post.  

In the meantime, let me know what you would do in this situation.  



Episode 166/500: Complete Dentures - Balanced Lingualized Occlusal Scheme - A 2nd Year Dental Student Experience

Hey Guys,

My name is Marko , a 2nd year dental student at The School of Dental Medicine @ GHSU (MCG), in Augusta, GA.

We are currently working on a laboratory set of complete dentures using the Balanced Lingualized Occlusal Scheme.  I just wanted to share some photos & tips that help keep the dentures balanced. The mandibular gingival anatomy is not finished yet as we are only processing the maxilla. You can see there is excessive amount of detailed anatomy in the wax. It is good to have have such anatomy, this is due the fact that a lot of it is gonna be taken away once you polish the processed dentures.

    For a lingualized balanced occlusal scheme to be truly balanced (stable during all excursive movements) you will need TRIPOD support!  In essence, when the patient initiates a left excursive movement, you will want:

  1. The left posterior maxillary teeth to have working scribe lines on the left mandibular posteriors
  2. The right posterior maxillary teeth to have non-working scribe lines on the right mandibular posteriors (that take cares of 2/3 of the tripod support action!) 
  3. Then you will want to have two anterior teeth (canine must be one of them) to have a kissing contacts once the posteriors are about to come of of contacts like you see the the pictures below.
Left Excursive Movement with Canine & Lateral incisors in kissing contacts
Right Excursive Movement with the patient's left side showing non working scribe lines and
 right side showing working scribe lines
You need at least one line on each side, but I went with 3 on each for extra stability (balance).

In protrusion, you still need tripod stability...
The maxillary central incisors are in contact with all the mandibular centrals and laterals
while the posteriors are all in contact as well. 
Protrusive scribe lines

 Final look at the max during flasking

I hope that was helpful. I'm just a 2nd year dental students, if something is wrong, then please correct me. or if you have more tips, please share it.



Saturday, September 24, 2011

Episode 165/500: Implant Placement Ant Mand - Implant doesn't engage.....ahhhhhhh

Mandibular Anterior Implant placement - errors and all

Just like anything, you do enough of something, and you'll learn to deal with those bumps in the road.  File separation in endo, pulp exposure during restorative, oro-antral communication during extractions, etc etc.

What you don't see often online or in journals - is how to manage these issues when they occur.  I'll be honest - it's really tough to blog about errors, mistakes, workarounds.  But, these are the critical learning points.  Why not learn from other's mistakes?  This is what this site is we go.

Here are some scribbles about the points I want to discuss - it's easier to write's more authentic, in my mind.  I have to compile/edit the video over the next few hours, so here is the beginning part...

Episode 165/500: Brushing Batman's Teeth

Our youngest son volunteered to show you folks one way to brush a toddler's teeth - but - he wanted to be Batman.  Ok - no problem.

Take home point:

 Children should not be trusted to brush their own teeth until they can tie their shoes
...and even need to continue brushing/monitor them.

I've treated enough high caries risks children to know that there is a really easy way to save your kids from having to see the dentist.  It's really cheap and easy - brush their teeth for them when they are under 6 years old.

......need I say more......


Episode 164/500: My little brother in Beijing

I'm really, really proud of my little, and only, brother - Chelsey.  He is a musician, emcee, video journalist (NBA china) and now TV show host in China.  Upon reflection - we're fairly similar - jack of all trades.

Chels (yes, for some reason, our mother wanted daughters - I'm calling you out on this one, mom...) has been in China for about 12 years now - and started off learning Mandarin in University in Beijing - and at the same time - playing english music in bars/hotels.  One thing led to another - and here he is.  We've sorted him out with a VPN service so he can update his Facebook, Youtube and Twitter accounts.

If you go to his blog - it's in chinese - however - google has made a decent effort to translate it.....our dad didn't teach us chinese - :(

I have no idea what is going on here...

I'm not really sure what to say about this....

Episode 163/500: Orthodontic Wire Review 101

Here is a basic overview of the different types of orthodontic wires - Stainless Steel, Niti, and TMA.

Every case is fairly different - so - a cook book method to wire use can be fairly useless - but - I'll give it a shot:

Level align derotate - either a round 0.014 or 0.016 Niti wire.  This will provide a light, constant force with no torque placed onto the teeth b/c the round wire doesn't engage the square bracket.

Slight Prescription engagement:  Something similar to a 20 x 20 Niti square wire.  There is still a significant amount of play in between the bracket and the wire - so - full engagement of the bracket prescription will allow lighter, constant forces to be placed.

Prescription engagement:  Eg:  19x25 TMA - it is similar to Niti, but can be bent light Stainless steel.  Not good for encorporating sliding mechanics - it's like sliding a an old rusty bicycle brake cable through the housing - not very easy with out lube.

Check out the Thermal Activated niti......crazy.



I know, I know - it's upside down. 0530hrs and it kept uploading like that
I decided to leave it...

Thursday, September 22, 2011

Episode 162/500: Best Friends or Rivals? CEREC and E4D

We just received the CEREC AC - and next to is - is our E4D machine.  The CEREC 3 machine is hiding all by himself (geriatric now).  I"m excited to see if we can mill implant abutments with the new CEREC.

Episode 161/500: 4 Weeks of Tooth Extrusion - Forced Eruption, "Are we there, yet?"

Here's a recap on the canine that I am extruding.

Okay, here we go. This is the orthodontic extrusion case at about 3 to 4 weeks after placement of the brackets. It's unbelievable the result we have attained. Now, the critical thing, is to keep it there! We are fast approaching the position where I want to have the canine. One of the easiest ways to determine whether or not we need to continue extruding this to, is to look at the orthodontic wire, and as you take a look at it you will see that it is almost flat. Awesome.

What is really neat, is that I'm using a dictation software, because I need to type faster and my hands can't go faster. Actually the software is working fairly well. It feels kind of funny at the beginning of using the software, but the technology has increased to a level, that now it doesn't make any mistakes. Crazy! So, I've actually typed, or spoken this, into a microphone which has taken me only 3 min. versus the usual 15. I did take typing in high school, [to pick up girls], however, I am still not fast enough. This is the 1st time using this software and my wife thinks I'm talking to her. Ha ha. It even typed ha ha.

Then, after approximately 2 weeks....we have a significant amount of coronal movement

2weeks after extrusion

4 weeks out....the wire is almost flat

4 weeks after extrusion

Wednesday, September 21, 2011

Episode 160/500: Bone Graft - Sinus Augmentation During Implant Surgery

Today was one of those days.  Well, actually -  the last few weeks have been one of those months.  Great learning, amazing experiences - and some interesting other events...

In any event, yesterday saw me place a maxillary molar implant that needed a slight sinus augmentation.  Here is a table top discussion of that bone graft - aka - Summer's Sinus Augmentation/Osteotome Technique.

Tuesday, September 20, 2011

Episode 159/500: Tooth Sensitivity - How About Root Coverage?

Root coverage with a connective tissue graft (CTG):  There are a few ways to skin this cat. I've tried 2 techniques:
  1. Langer/Langer Subepithelial Technique
  2. Tunnel Technique
I used Alloderm in both attempts - and they both worked fine.  You can harvest CT from the palate if you want.  I have a huge amount of learning points for both techniques.  Here was my first attempt at a tunnel technique - boy - did I ever learn a ton.  Thankfully, the procedure worked...why do you think this happened?

Yikes.  What happened here?  1.5 weeks post op.

3 weeks post op. Phew.

The Langer/Langer technique is by far, a much easier procedure clinically.  However, the patient has significantly much more postoperative pain from the subepithelial - split thickness flap procedure.  Here is an example (same patient as above) using the Langer/Langer technique (or a modification of):


Chief Complaint:  29 YO female requests coverage of tooth #29 (FDI #45) for cold sensitivity.
Tooth #29:  Miller class 1 gingival recession.  100% root coverage anticipated

Miller Class 1 Defect:  
  1. Recession coronal to mucogingival junction
  2. No interproximal bone loss

...maybe 10% interproximal bone loss....


  1. Sterile water and Saline
  2. Alloderm
  3. Tetracycline
  4. 17% EDTA
  5. 15c blade
  6. 5-0 vicryl sutures with a P-3 needle (go small, not BIG)
  7. Patience
  1. Place tetracycline into sterile water, and into which you place the alloderm 15 mins before use.
  2. Intrasulcular incisions on tooth in question
  3. Releasing incisions - go to bone - Maintain wide base - I've got a connective tissue graft failure to post b/c I didn't abide by this cardinal rule.
  4. Elevate full mucoperiosteal flap initially, then split thickness around the mucoperiosteal junction.  Where is the MCG?  See here....
  5. Rinse exposed root with ETDA (or citric acid, tetracycline, orange juice, vodka..or your drink of choice)
  6. Template Alloderm to fit the recipient bed.
  7. Sling suture around tooth through Alloderm to ensure that the graft doesn't move.  this is a great hint....Thanks Latte Ice
  8. Suture gingiva closed - ensure  root is covered.
Post operative instructions:
  1. No brushing, no flossing for 6 months....just kidding.  1 week.
  2. Medrol Pack - Steriods - Decrease inflammation, especially in these split thickness cases - 6 tabs day one, or the day before surgery, 5 tabs day 2, 4 tabs day 3, 3 tabs day 4 etc etc
  3. NSAIDs
  4. Chlorohexidine rinse BID
Ok, enough text.  Here are the vids.


Poor man's drawing of this technique

End of procedure - Root Covered

Here is the end before the beginning....

Alloderm Preparation

Mid surgery

Sizing up the Alloderm

CT Graft into donor bed

Sling suture that Alloderm into place

Episode 158/500: Crossfit - Take care of your health

Here was today's schedule - I'm not putting this up to compete with single parents ...or anyone actually....I have an amazing wife who understands the residency and Army.  The point is that fitness is critical.....and that you have to make it a priority if you want it....I want it....and....I want to continue to beat my colleagues in the 2 mile run PT test...again....and again....

  1. 0530hrs - Wake and Kaleb - Child #2 wakes - entertain.
  2. Make lunch, get dressed, showered, feed both children
  3. 0645hrs - Leave for work.  Listening to audiobook:  Doug Edwards - Google Employee #59
  4. 0710hrs - Arrive work - Get prepped for pedo oral/nitrous sedation
  5. 0745hrs - Patient failed appt - look for another patient
  6. 0825hrs - Implant patient called and appointed for #14 (FDI 26) implant placement + sinus augmentation
  7. 0930hrs - Patient arrives - placement/augmentation goes smooth
  8. 1139hrs - Too late for Crossfit workout with No Rep....not enough time to be back for 1230hrs
  9. 1203hrs - Cut some table top video about sinus augmentation.
  10. 1230hrs - Prep for md anterior implant placement with Resident Amigo
  11. 1500hrs - Finalize Computer Aided Surgery Treatment Plan online with Becka from  Imagdent (Austin)
  12. 1600hrs - Home w/ family
  13. 1700hrs - Night Routine
  14. 2014hrs - Crossfit workout - (finally) 4 rounds of 800m sprint, 10 x 53lbs Kettleball Swings, 20 Double Unders - 13:48 mins.
  15. ...until midnight - blog and prep for tomorrow - connective tissue graft and endodontic retreatment

Key Points:
  1. I have approximately 60 mins at lunch time for fitness.  Crossfit works well into my schedule.  Max 20 min workouts, 2 min shower, back for business by 1230hrs.
  2. Diet:  You can workout until you're blue in the face, but if you eat like crap, you'll feel like crap and look like it as well.  Try Zone, Paleo, or moderation.
  3. I eat 1hr before workout - 1030hrs and then around 1330hrs.  There is no need to sit and eat for 45mins.  You're wasting your time - unless - you are actively meditating or spiritually attaining peace of mind.
  4. Fitness keeps me sane and awake.  Think of those thousands of years where people had to run/walk/pick for survival.  That was fitness...and no manmade be continued.


Monday, September 19, 2011

Episode 157/500: Molar Intrusion

It is BEYOND my comprehension why this simple technique is so secretive.  Why not intrude a tooth instead of sawing it in half, endodontically treating it, crown lengthening it, and finally crowning it - just to gain restorative space?

Take this case - my treatment planning board case:

Gravity tugged and was successful in pulling down that first maxillary left molar (#14/FDI - #26) - not much space for an implant supported anything.  Chief complaint was the inability to chew and the large space in his smile distal to the canine.

Treatment options:
  1. Nothing
  2. Endodontics, crown lengthening, crown
  3. Segmental osteotomy.......uhm.....ok?
  4. Molar intrusion - You can approximately intrude 1mm/month.  Retention is critical.

  1. Oral Hygiene
  2. No furcations
  3. No localized moderate/severe periodontitis (#14)
  4. Patient was willing

Here's the table top explanation:

Episode 156/500: Fantastic Dental Composite Placement Hint - Part 2/2

Here is Part 1

In the first video, I'm completing the addition of composite - pulling the composite with the brush and speeding up overall placement of this composite.

The second video - Just some finishing techniques to include #25 blade, diamond impregnated brushes and rubber points.

I'll let the videos do the talking.



Episode 155/500: Removable Partial Denture Framework Try In

Dr. K - you have released too many good ideas - and now they're out there for the masses.

Here is one method of trying in RDP frameworks with articulating paper versus Pressure Indicating Paste.  I can't stand that stuff - it gets EVERYWHERE.  Mind you....

  1. Articulating Paper - thin - (lots of it)
  2. High speed with round bur (#4 or #6, or 330 bur)
  3. Patience (I suppose that G'n'R's version may help...)
  1. Wet articulating paper so that it sticks to the abutment teeth.  Crinkle it up a little to get the stiffness out - it adapts better when not new and fresh
  2. Place articulating paper on abutment teeth (occlusal surface)
  3. Insert RDP until no more travel
  4. Review rest seat locations (are they seated)
  5. Remove RDP - look for binding spots on the intaglio (sexy word for inside - tissue contacting surface) surface.
  6. Lightly adjust with high speed and round bur
  7. Repeat
This technique is good b/c I was told in Dental school:

Try in and adjust the binding spots with a slow lab (football bur).  Well - that technique is definitely subpar.

Hope this helps


Sunday, September 18, 2011

Episode 154/500: Fantastic Anterior Composite Placement Hint (Part 1 of 2)

First off, Thanks to Dr. WPG (West Point Grad) - not Winnipeg, Manitoba, Canada - where I graduated Dental School..

Take a look the quick discussion of this technique, and then - go for it.

I've placed composites old school for 10 years, and I even blogged about how I don't have time for using a brush when placing anterior composites....what a fool I was (still am, according to many sources).

This has sped up composite placement by a factor of.....I don't know....600?  Maybe not quite, but take a look.  This is top ten tip #2.

Please - try this out -  take some photos and post them here: under anterior composite placement.



Initial Prep - Real Life Application -
A patient shows up w/ a large class IV restoration and
complains that it keeps breaking off - here's an option for prep design.  
Outline w/ pencil
This was done with a lab handpiece, so easy on the design criticisms - focus on the composite application.

Saturday, September 17, 2011

Episode 153/500: Dental Composite Placement - Driveway Discussion

I never thought I'd ever use a paintbrush to apply resin composite to an anterior tooth.  Never.  Friday's table top exercise changed that forever.  I'm a "let's get this done with the least amount of fooling around" kind of guy and I didn't think that using a paintbrush to apply composite fit into that category.

Well, it does.  As my 4 YO son Liam says, "Well, Actually dad..."  It blows that category out of the water. Seriously.  We're hitting like #2 on the all time top 10 list.

Here is the driveway discussion about the simple ideology behind this technique.  No, it's not new.  It's just never taught - ever - other than by folks describing themselves as cosmetic dentists.  That was the #1 reason I never tried it.  "It's for cosmetics, so it must take time and effort"  BS, Ashley. It's faster and no, you don't have to be self proclaimed cosmetic dentist....just one who cares.



Episode 152/500: Removing composite from enamel (bracket removal)

Dr. PA - you have taught me many, many things so far.  Thank you. (Ortho section)

This is a secret that I can use even during restorative appointments - removing composite from natural tooth structure.  So often, I've wondered how the pros do it.  Now I know.

...and so do you....



Friday, September 16, 2011

Episode 151/500: Extrinsic Stain Removal


Here are 2 cases that I have tried using minimally invasive techniques to remove extrinsic stains.  One was successful and the other, not.  Success really depends on the depth of the stain.  With the acidulated pumice, we're removing microns of enamel - and - if that stain is deeper than that, this isn't going to work.

Some minimally invasive stain removal techniques:
  1. Bleach - eg. carbamide peroxide (400% concentration - just kidding)
  2. Etch and pumice (37% H3PO4)
  3. Commercially available products - Opalustre (6.6% HCl)
  4. Combination of above
  5. Air Abrasion
  6. ?
So, the first case was successful as deemed by the patient.  The chief complaint in both cases is fairly obvious.

If you have any other technqiues, please pass them on.  Here is what the ADA has on their site:



Initial Presentation - "I'd like the stains out of my teeth"

Application of Opalustre

Opalustre didn't quite remove all the dark stain, so we bleached with
30% H202 at the same appointment - 15 mins x 3 applications

Initial presentation following rubber dam removal

 Just like every other website proclaiming their product works...Success

And now, no success with this technique:

Initial Presentation

Result following 2 applications of Opalustre - definitely not successful.
I applied fluoride to the surface immediately following the 2nd Opalustre application.

Episode 150/500: Repair Western Digital External Hard Drive Easily

AHhhhhhhhhhh.  My only drive with clinical videos failed this morning.  I was, choked.  I immediately removed the cover and discovered this little controller card...I knew this had to be the problem.  Here is the drive:

I google searched "My Book 2 TB failed", and this is what I came up with:

In essence, not the quick remedy I was looking for.  I'm a "DIMIIC" - "Do It Myself If I Can" kind of guy.

Well, I fixed it.  Here is my work around - I purchased a new drive, swapped out the controller, crossed my fingers - and it worked.  I then picked up a new generic controller for the new drive and will convert both to generic external drives - moving away from WD b/c WD encrypts the data when it puts it onto the drive.....making it extremely difficult and expensive (potentially) to access that data if your controller fails.

  Also, you can buy the controller on ebay as well, but I didn't want to wait 1 week to see if it wouldn't work.



Thursday, September 15, 2011

Episode 149/500: "Doc, my back tooth hurts to chewing and cold"

"Doc, my back tooth hurts to chewing and cold"  How often do you hear this statement today?  Middle aged male/female, moderately restored dentition, and chewing/cold sensitivity to either the 1st/2nd molar.  Cracked tooth or cracked cusp.  You'd think it would be fairly straightforward - but often it's not (or, maybe it's just me?)  Every case seems to be different, but the same.  Weird.  Take this case:

44 Y.O male presents 2 weeks ago with a chief complaint of, "My lower right tooth hurts to chewing and is really cold sensitive"

HPI:  Patient has experienced above symptoms on/off for the past several months.  Pain is 7/10, fleeting and lingering, and is sometimes spontaneous.   He is not in pain at the moment.

Med Hx:  PTSD, (no meds), NKDA

Diagnostic tests (shortened version):
  1. #30 (FDI #46) - Cold +++, Percussion-no response, Tooth Slooth-DLi Cusp ++ 
  2. #31 (FDI #47) - Cold ++, Percussion-no response, Tooth Slooth-no response
Radiographic Evaluation:  (only 1 straight on PA - should have had a shift)
#30:  Occlusal metallic restoration, osseous crest is intact, following the PDL (starting mesially) from CEJ to apex, there is a slight "thickening" of the lamina dura on the mesial root.  Otherwise, normal PDL space with normal trabeculation

#31:  Occlusal metallic restoration, PDL space/lamina dura WNL and trabecular pattern normal.

  1. #30 Cracked DLi Cusp
  2. #31 Mesial Caries
  1. #30:  Reversible Pulpitis with Normal Apical Tissues
  2. #31:  Reversible Pulpitis with Normal Apical Tissues
  1. #30:  Remove existing restoration and evaluate for cracks under the microscope
  2. #31:  Remove mesial restoration.
Note cracked DLi Cusp - the change in color of dentin is a fairly good indicator

Treatment Rendered (under microscope):
  1. #30: Remove cracked cusp with microscope and place cuspal coverage amalgam
  2. #31: Remove Mesial box of existing restoration - restoration was placed 8 months prior.

Note Mesial Decay on #31.  Cusps shoe'd on #30.
The portion of the amalgam that looks near the pulp is actually
the shoe'd DLi Cusp.  

I called the patient today (2 days later) and the cuspal coverage (amalgam - high caries risk patient) and cracked cusp removal was successful.  However, I find that it is hit and miss with cracked cusp/cracked teeth.  Sometimes this treatment may make the patient more symptomatic and it's critical to inform them me on this one.

What would you do differently?