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The Secrets of Predictably Successful Endodontics Part II Dr. Andre K. Mickel
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Andre’ K. Mickel DDS, MSD, MDiv
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LET EVERYTHING THAT HAS BREATH…Praise the Lord!
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God, Family…then Endodontics
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My Favorite Rotary System
• Fast • Effective • Only need one file!! • Inexpensive • BUT… A BIT FRIGHTENING!
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YOU WANT TO KNOW ABOUT ROTARIES ??
OPEN UP, I CAN SHOW YOU BETTER THAN I CAN TELL YOU!
The Secret to Success…
• Seeing your work primarily as a service to others and not as a means of personal gain (video)?
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DO NO HARM
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Case Scenario
● 25 y.o. caucasian female ● Chief complaint: “Burning pain in my top front area; it burns to touch it” ● Medical history: noncontributory ● Dental history: 6 RCTs performed 6 months ago by general dentist ○ No pain prior - but constant pain ever since ○ Patient’s understanding of why tx was performed: “deep decay” ● Pain meds: NSAIDS - no relief
Case Scenario
● Clinical and Radiographic Exam ○ Pertinent Findings: ■ Severe pain to touch teeth and soft tissues in the anterior area ■ Constant pain 10/10. Felt swollen, but not clinically detectable
Case Scenario ● No treatment was done. Patient referred to Oral Medicine and Orofacial Pain clinic
● Diagnostic bilateral injections relieved the pain. Presumptive Diagnosis of Trigeminal neuropathic pain. Gabapentin 300mg t.i.d.
● Came back 3 weeks later with photophobia and nausea consistent with Migraine. Topiramate 25mg-100mg b.i.d.
● Came back for an emergency visit with severe pain and autonomic symptoms. Patient was placed on 10 liter/min oxygen for 20 minutes and immediate relief was noted.
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Case Scenario ● Final Diagnosis: Cluster Headache
● Brain MRI was made to rule out any CNS neoplasms
● Pain was completely relieved by 60mg Prednisone for 5 days
● Daily therapy of Verapamil t.i.d. Showed adequate symptom control
DO NO HARM
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This Photo by Unknown Author is licensed under CC BY-NC-ND
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Holmes and Rahe Life Change Index Scale
Holmes and Rahe Life Change Index Scale
As clinicians, effective communication provides a baseline in the establishment of patient-provider trust when treating an anxious or fearful patient. Considering the apprehensiveness exhibited by patients recommended for Endodontic procedures, recognizing dental anxiety allows for a more timely and accurate diagnosis. Learning simple techniques to desensitize a patient’s unpleasant expectations will pave the way for more time efficient encounters.
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Other Nonpharmacological options for the management of dental anxiety
pleasing scents Rapport building giving patients a sense of control Distraction- visual and/or aural Increased information on the experience cognitive behavioral therapy Systematic desensitization Computer-assisted relaxation learning Behavioral changes Hypnosis Relaxation therapy
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A root canal is just like: Baking cookies at grandma’s !
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Soft and Relaxing Music OR…
…Frank Sinatra and RCT’s
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Yummmm…Can you smell them??
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Patient Management
CAUSES OF FAILURE
2. Lack of AMBITION to move past mediocrity COMMUNICATION: MUST “SOLERize” Patients
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Square on Open Posture Lean In Eye Contact Relax
What is SOLER? SOLER is mainly focusing on your attending skills in a counseling session. Gerard Egan created this theory and acronym to assist new counselors in a therapeutic setting, understand how to put their clients at ease through their body language.
What is S.O.L.E.R ?
The Gerard Egan Soler Theory describes techniques for active listening . It can be valuable when helping another person as it will make them feel cared for, involved, respected and understood.
S.O.L.E.R S= Square On O=Open L=Lean In E=Eye Contact R= Relaxed
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Solar theory 1: Square on The first important part is how you posture yourself in relationship to your client. Your face facing the clients face shows that you are engaging, interested and actively listening. You can have your shoulders turned a little away to dispel any feelings of intimidation, but your face should be square onto the clients face.
Square on…
Soler theory 2: Open
This openness refers again to posture. Ensuring that arms and legs are not crossed will convey a sense of ease to your client. As mentioned above, this openness in body posture will stop feelings of intimidation from occurring.
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Open posture while listening
Solar Theory 3: Lean in
By leaning towards your client, a sense of care and genuine interest will be conveyed to the other party. Simply leaning forward will automatically make them feel that their concerns are being heard and understood and this will instill further ease and facilitate openness.
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No No No!!
Lean in while listening…
Soler theory 4: Eye contact
This interest is further enhanced by eye contact. Maintaining eye contact shows interest and concern. However, it is important to vary the eye contact so that the other party does not feel threatened or intimidated.
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When they look you in the eyes…look back…and don’t blink!
Solar theory 5: relax
This is an obvious, but sometimes forgotten aspect. One must relax before your client. If you are fidgeting or showing any anxiety, this will be conveyed. They will either think you are not interested in them, or they will take on your tension, or possibly both!
NO NO NO…
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COMMUNICATION: RELAXED!! “SOLERize” Patients
Psychological aspects of endodontic pain
Within the scope of Endodontics, pain management is a critical entity in securing patient trust.
Emphasizing the importance of pain management, special care should be taken to enhance patient experience and reduce procedural chair time. S.O.L.E.R is used to connect psychologically with patients to aid in reducing anxiety and fear in regards to treatment plan acceptance, patient compliance and post-operative pain.
Psychological aspects of endodontic pain
. It’s been determined that the best predictors of post operative pain are pre-operative pain/swelling- Walton & Fouad.
. Best predictors: Level of pre-operative pain and anxiety- Torabinejad
. Concluded that apprehension causes reduced pain threshold- Hargreaves & Keiser
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Psychological aspects of endodontic pain
Patients who never received Endodontic treatment experienced high levels of dental anxiety and considered it to be more unpleasant than oral surgery (Wong 1991)
67% of patients reported moderate anxiety associated with endodontic treatment, while 17% experienced intense anxiety (Dou 2018)
For patients with moderate levels of dental anxiety, providing more information about endodontic treatment and what they will experience can reduce dental anxiety and fear of pain (Newton 2012; van Himel2006)
Anxiety Assessment and treatment Flowchart
The triangle in the middle represents CBT's tenet that all humans' core beliefs can be summed up in three categories: self, others, future.
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Cognitive behavioral therapy
Cognitive behavioral therapy is a psycho-social intervention that aims to improve mental health. CBT focuses on challenging and changing cognitive distortions and behaviors, improving emotional regulation, and the development of personal coping strategies that target solving current problems. Originally, it was designed to treat depression, but its uses have been expanded to include treatment of a number of mental health conditions, including anxiety. CBT includes a number of cognitive or behavior psychotherapies that treat defined psychopathologies using evidence-based techniques and strategies……………………………Blah Blah Blah…
General Anesthesia
IV Sedation
Inhalation Sedation
Psychological Techniques Good Pain Control Communication
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…Frank Sinatra and RCT’s
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Yummmm…Can you smell them??
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Ethics
• Informed consent • Discussion of risks, benefits and alternatives • Best interest of the patient • Best evidence
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• Informed consent • Discussion of risks, benefits and alternatives • Best interest of the patient • Best evidence
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CAUSES OF FAILURE
2. Lack of AMBITION to move past mediocrity “C.I.B.” Endo Mother Litmus Test
Nothing like Mommy!
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NOTHING LIKE MOMMY!
Don’t talk about my Mama!
Treat every patient like your Mommy!
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A root canal is just like: Baking cookies at grandma’s !
Yummmm…Can you smell them??
A root canal is just like: Baking cookies at grandma’s !
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But…stuff does happen…
Mishaps: Bleach Injury
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Irrigant
NaOCL ERRORS AND TX
• MAKE SURE CHAMBER NOT “LEAKING” • GOOD RUBBER DAM ISOLATION • DO NOT WEDGE NEEDLE • USE SIDE RELEASING NEEDLES • MOVE NEEDLE UP AND DOWN WHEN IRRIGATING
TX OF NaOCL ERRORS • DILUTE- REANESTHETIZE • NSAIDS
• TOPICAL CORTICOSTEROID OR CONSIDER MEDROL DOSE PACK • CALL OFTEN, CLOSE FOLLOW • WARN OF SEQUELA • SWELLING, SLOUGHING, DISCOLORATION, LONG TERM DISCOMFORT •TLC
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This Photo by Unknown Author is licensed under CC BY-SA
This Photo by Unknown Author is licensed under CC BY-SA
This Photo by Unknown Author is licensed under CC BY-ND
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Things go wrong!!
• Too small • Missed canals • Visibility • Instrument access • Fatigue • Breakage of instrument • Inadequate Cleaning and shaping
Things go wrong!!
• Off center • Perforations • Restorability • Missed canals • Reduced prognosis • Inadequate cleaning
Access in special conditions
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Things go wrong!!
• Too shallow or too deep
Law Regarding Perforation
• Let patient know an accident occurred and was promptly repaired. (MTA, RRM Putty, matrix/geristore) • Prognosis better if repaired ASAP • Smaller is better • No communication with sulcus • Above bone better • SOM …Magnification + Illumination
Mommy LOVE
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CAUSES OF FAILURE
3. A NEGATIVE mental attitude
This Photo by Unknown Author is licensed under CC BY-SA
This Photo by Unknown Author is licensed under CC BY-SA
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This Photo by Unknown Author is licensed under CC BY-SA
This Photo by Unknown Author is licensed under CC BY-SA-NC
This Photo by Unknown Author is licensed under CC BY-SA
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Don’t POUT!
DON’T BE A GRUMPY OLD MAN!
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THERE IS ALWAYS SOMEONE WORSE OFF !
CAUSES OF FAILURE
3. A NEGATIVE mental attitude Worst Day: Cancer Cancer Cancer
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TOP 15 NONLEOS
• Actinomycosis • Fibro-osseous • OKC • Ameloblastoma • Carcinoma • CGCG • Lymphoma • Benign Cementoblast. • Traumatic Bone Cyst • Cent. Odontog.Fibr. • Histiocytosis X • Nasopalatine duct “ • Leukemia • Residual Cyst • Osteomyelitis
Non LEO’s
All Friends Own Cars Like The Nascar Racing Association Controls But Can He Like Osteomyelitis –
Importance of Radiography
Two dimensional shadow of a three dimensional object
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Actinomycosis
Mahdi Angaji, DMD, MDent, MPhil; Jaswinder Brar, BDS, MDent. J Can Dent Assoc 2011;77:
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External Sinus Tracts…Plastic Surgery!!
Necrotic pulp/Chronic Apical Abscess
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Actinomycosis: Radiographic
Case report by Dr. Khalid Al- Hezaimi, BDS, MSc ● 24 y/o female ● Root canal therapy completed two years prior. History of draining sinus tract. ● Patient presented with severe pain on the lower left side with a localized swelling. ● As emergency treatment, I &D was completed and Amoxicillin was prescribed. ● Ultimately, Apicoectomy was
J Can Dent Assoc 2010;76: completed and lesion was biopsied and diagnosed as Actinomycosis.
Actinomycosis: CBCT
Courtesy of Dr. Shibasak et al 2013
Paget’s Disease
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Paget’s Disease Etiology: Idiopathic disorder of abnormal resorption/deposition of bone (abnormal remodeli) Clinical: Common after age 40; M>F. Usually polyostotic (multiple bone affected), rarely monostotic (single bone) - Dentures don’t fit (“getting smaller!”) as jaws enlarge - spacing of teeth and “dental appliances that no longer fit the mouth. - - Bowing of legs, fracture, bone and joint pain, pressure neuropathy. - Deafness or blindness can result from sclerotic bone around cranial nerves. - Can cause enlargement producing a lion-like faces (“leontiasis ossea”) Location: Maxilla Histology: Alternating resorption and formation of bone produces a characteristic “mosaic”pattern and marrow replaced by highly vascular fibrous connective tissue. Addtnl DX: Elevation of serum alkaline phosphatase treated if elevated by more than 25-50%; elevated urinary hydroxyproline levels. Treatment: with calcitonin & biophosphonate; plicamycin for refractory cases no longer used Difftl DX: Fibrous dysplasia: young pts. Florid cemento-osseous dysplasia: No enlargement of bone. Osteopetrosis:Younger patients, Pattern of bone change different Literature Review: Nevile B. Oral and Maxillofacial Pathology. 2nd Edition 2002.
Radiographic Characteristics of Pagets - Location: Pelvis, femur, skull, vertebrae, jaws (usually bilateral maxilla) - Stages: 1. Early Stage: Radiolucent Resorptive Phase 2. Second Stage: Granular/Ground-Glass appearance 3. Late Stage: Radiopaque Apposition Phase - Trabeculae - Altered number and shape of trabeculae - Pattern is horizontal, granular, cotton wool - Effects on surrounding structures - Enlargement of affected bone - Intact outer cortex - Lamina dura less evident - Hypercementosis
Hypercementosis caused by Paget’s Disease
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Periapical Cemento-Osseous Dysplasia
• most common fibro-osseous lesions • Etiology: Localized change in normal bone metabolism that results in replacement of the component of normal cancellous bone with fibrous tissue and cementum like material • Clinical: asymptomatic; no pain or enlargement. Most common b/t 30-50's: rare before 20; F (x10), African-Americans (70%). Lesions can still develop after extraction (--> cemental dysplasia) • Difft DX: Periapical granuloma/cyst. (Pulp test is mandatory) • Histology: Fibrous CT supporting numerous fibroblasts. Cementum and/or bone interspersed – stage I: almost all fibrous tissue – stage II: more cementum/bone, – stage III: cementum/bone predominate Literature Review: Su and Waldron. OOOOE 1997. A pathologic specimen of cement-osseus dysplasia and cement-ossifying fibromas Summerlin. OOO 1994. Clinicopathologic study of 221 cases.
Radiographic Features of PCOD
- Location - Epicenter at tooth apex (usually) - Predilection for mandibular anterior teeth - Usually multiple and bilateral (rarely solitary) - Periphery - Well defined RL/RO lesions of varying width surrounded by a band of sclerotic bone of varying width - Stages - Early stage: Radiolucency around apex and loss of lamina dura - Mixed stage: Radiopacity appears within the radiolucent area - Mature stage: Totally radiopaque (commonly with a radiolucent margin at periphery - Effects on surrounding structures - Loss of normal lamina dura - Tooth structure typically unaffected - Sclerotic bone reaction from surrounding tissues - Large lesions can cause jaw expansion with intact outer cortex
Ossifying Fibroma
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Radiographic Features of Ossifying Fibroma - Location - Mandible most common, between mandibular posteriors and IAC - If in maxilla → Canine fossa or zygomatic arch most likely - Periphery - Well defined radiolucency with sclerotic border - Internal structure - Mixed (cotton, flocculent, wispy) - Effects on surrounding structures - Usually concentric with outward expansion that is equal in all directions - Displacement of teeth or IAC - Root resorption - Expansion of bone with intact outer cortex - Missing lamina dura
Odontogenic Keratocyst
Clinical Feat: Asymptomatic, swelling on occasion; Pain from secondary infection Solitary cysts—common (5% to 15% of all odontogenic cysts); recurrence rate 10% to 30%. Multiple cysts—5% of OKC patients; recurrence greater than with solitary cysts Aggressive; recurrence risk; association with nevoid basal cell carcinoma syndrome Location: Mand posterior region 49%
Histology: Refractile, parakeratotic lining; Thin epithelium (6 to 10 cell layers); Palisaded, polarized nuclei of basal cell layer Literature Review: §Brannon (1977) Courtesy of Pace et al International Endodontic Journal, 41, 800–806, 2008 §Kim (2002) §Pringle et al OOOOE 1998. A potential endodontic misdiagnosis. §Kramer and Pindborg. Histologic typing of Odontogenic tumors. (1992)
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Courtesy of Pace et al International Endodontic Journal, 41, 800–806, 2008
Odontogenic Keratocyst: CBCT
Courtesy of Dr. Borghesi et al.
OKC
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????
Tom Daley, DDS, MSc, FRCD(C); Mark R. Darling, BChD, MSc (Dent), MSc (Path), MCh. J Can Dent Assoc 2011;77:
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Carcinoma: CBCT
Bunn et al. S. Afr. dent. j. vol.71 n.3 Johannesburg Apr. 2016
Lymphoma
NON HODGKIN’S LYMPHOMA
•Etiology: Complex group of malignancies of lymphoreticular histogenesis
•Clinical: Soft tissue lesions appear as non-tender, diffuse swellings most commonly affecting buccal vestibule, gingiva, or posterior hard palate
•Location: Maxilla > mandible
•Radiograph: Lymphoma of bone may present with vague discomfort, radiographs reveal ill-defined or ragged radiolucency •Histology: N/A Jessri et al. Australian Dental Journal 2013; 58: 250–255
•Literature: Eisendbud L et al. OOO 1983. Oral Pesentations of Non Hodgkins Lymphoma
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Lymphoma
Jessri et al. Australian Dental Journal 2013; 58: 250–255
Lymphoma: CBCT
Jessri et al. Australian Dental Journal 2013; 58: 250–255
Lymphoma
HODGKIN’S LYMPHOMA Burkitt Lymphoma •Etiology: malignant lymphoproliferative disorder •Etiology: malignancy of B lymphocytes. •Clinical: is persistently enlarging, non-tender, AKA undifferentiated lymphoma discrete mass(es) in one lymph node region. Early •Clinical: MC in children (African form, stages movable to non movable. Systemic signs and EBV+) and adolescents (American form, symptoms may include weight loss, fever, night EBV -). sweats, and generalized pruritus (itching). •Facial swelling and proptosis; pain, tenderness, •Location: Maxilla > mandible; posterior region and paresthesia are usually minimal. Premature •Radiograph: Poorly defined RL with irregular loss of primary, enlarged gingiva and alveolar borders. Lamina dura resorption, “floating process. Tooth mobility. teeth”, roots development halted. •Location: Maxilla > mandible; posterior •Difftl Dx: Ewing Sarcoma, Leukemia region •Histology Lymph node reveals complete or partial •Radiograph: Poorly defined RL with lymph node architecture by scattered large malignant irregular borders. Lamina dura resorption, cells known as Reed-Sternberg cells admixed within a “floating teeth”, roots development halted. reactive cell infiltrate composed of variable •Difftl Dx: Ewing Sarcoma, Leukemia proportions of lymphocytes, histiocytes, eosinophils, •Histology: Tiny white dots: Lipid droplets, and plasma cells. white “stars” macrophages, produce dark •Literature: stained undifferentiated B lymphocytes Robbins K et al – Head Neck Surg 1986. Primary “starry sky” pattern. lymphoma of the mandible.
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Traumatic Bone Cyst
•AKA Simple bone cyst, hemorrhagic bone cyst, solitary bone cyst & idiopathic bone cavity •Etiology: Developmental condition with replacement of normal bone by with fibrous connective tissue intermixed with irregular bone trabeculae. •Clinical: painless swelling •Radiograph: well demarcated radiolucency; usually in premolar-molar region, often scalloped upward between the roots of teeth. Lamina dura intact. •Pulp test teeth; can be associated with cemento-osseous dysplasia •Location: MD Premolar region •Difftl Dx: Periapical cyst/granuloma (Teeth are non-vital) Central giant cell granuloma (anterior location) Central hemangioma (arterio-venous malformation) Aneurysmal bone cyst (pain and expansion; aspirates blood) Odontogenic keratocyst •Histology: Titsinides S, Kalyvas D (2016) Traumatic Bone Cyst of the Jaw: A Case Report and Review of Previous Studies. J Dent Health Oral Disord Ther 5(5): 00167. A benign, empty or fluid-filled cavity within bone lined with granulation tissue/ No epithelium. Abundant in giant cells. •Literature: Cohen- (1984) Can occur after extractions Ruiz (JOE 1987)
Traumatic Bone Cyst: CBCT
Findik et al. International Journal of Experimental Dental Science. Jan-Jun 2014
Nasopalatine Duct Cyst •MC non odontogenic cyst of the oral cavity (73%) •Etiology: forms from oral nasal ducts present within incisive canals •Clinical: swelling of the anterior palate. Pain and purulent drainage. > 6mm from incisive foramen. Teeth displacement. •Radiographically: well demarcated round, ovoid, or heart shaped RL between the midline of the maxilla. Root resorption and teeth displacement. PDL intact. •Difftl Dx: PA cyst/granuloma •Literature Review: Daley TD, et al. Relative incidence of odontogenic tumors and oral and jaw cysts in a Canadian population. Oral Surg Oral Med Oral Pathol 1994;77:276- 280. Gnanasekhar, JD, et al. Misdiagnosis and mismanagement of a nasopalatine duct cyst and its corrective therapy: A case report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995;80:465-470. Patil et al. International Journal of Dental Sciences and Research, 2015, Vol. 3, No. 3, 52-55
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Nasopalatine Duct Cyst
Patil et al. International Journal of Dental Sciences and Research, 2015, Vol. 3, No. 3, 52-55
Nasopalatine Duct Cyst
Patil et al. International Journal of Dental Sciences and Research, 2015, Vol. 3, No. 3, 52-55
Nasopalatine Duct Cyst
Patil et al. International Journal of Dental Sciences and Research, 2015, Vol. 3, No. 3, 52-55
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Nasopalatine Duct Cyst: CBCT
Courtesy of Dr, Modhi AlQahtani
Residual Bone Cyst
•Etiology: A residual cyst is a inflammatory odontogenic cyst that remains after incomplete removal of the original cyst •Clinical: MC after extraction of a tooth. growth can cause significant bone resorption and weakening of the mandible or maxilla. •Location at the site of previous tooth extraction •Radiograph: Complete bone repair is usually seen in adequately treated periapical and residual cysts. Histology:stratified squamous epithelium which may demonstrate exocytosis, spongiosis, or hyperplasia Morrison A. Odontogenic cysts: residual cyst. PathologyOutlines.com website. •Literature: Weine (JADA 1983)
Residual Bone Cyst
Morrison A. Odontogenic cysts: residual cyst. PathologyOutlines.com website.
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Ameloblastoma
Most common clinically significant (not the most common) odontogenic tumor. Etiology: develop from cell rests of the enamel organ; enamel organ & the lining of odontogenic cysts or from the basal cells of the oral mucosa. Clinical: equal age and sex. typically slow-growing, locally invasive and runs a benign course: 80% MD and 70% Posterior region. 3 Types: •Conventional Solid/Multicystic (86 % of all cases) •Unicystic (13 % of all cases) a mean of 30 years. •Peripheral or Extraosseous (1 % of all cases) •Radiographic: Radiolucent lesion that is well-circumscribed; it may be unilocular or multilocular (soap-bubble, honeycomb); occasionally an ameloblastoma will be ill-defined with a ragged border. Unicystic: A RL around the crown of an unerupted tooth (most commonly a mandibular third molar). Literature: Reichart et al. Oral Oncol 1995. 3677 cases Biological profile Gortzak et al. Int J OMFS 2006. Review of 5 cases for Growth characteristics
Kumar et al. Int. J. Odontostomat., 6(1):97-103, 2012.
Ameloblastoma
Kumar et al. Int. J. Odontostomat., 6(1):97-103, 2012.
Ameloblastoma: CBCT
Kumar et al. Int. J. Odontostomat., 6(1):97-103, 2012.
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Central Giant Cell Granuloma
Difft Dx: hyperparathyroidism, cherubism and aneurysmal bone cyst.
Etiology: non-neoplastic lesion of the jaws. Females before 30.
Clinical: - Non-aggressive lesions are most common, few symptoms and slow growing. Aggressive lesions: pain, rapid growth, cortical perforation and root resorption.
Radiograph: resorb lamina dura and tooth roots--displace teeth, can displace mandibular canal . - Cortical expansion and resorption very common; often an uneven or undulating pattern - Perforation of cortex rare except aggressive lesions Location: 70% in mandible anterior two-thirds Treatment: curettage; recurrence rate 15-20%; resection for larger lesions. Histology: A multinucleated giant cells in a stroma of spindle-shaped mesenchymal cells usually with numerous vessel and red blood cells Literature: •Natkin – JOE 1994) Neoplastic in young patients. 67% mand, swelling and displaced teeth. Noleto et al. Radiol Bras vol.40 no.3. June 2007 •Kruse-Losler OOOOE 2006 – CGCG of jaws a clinical, radiologic and histopathological study. •Eisenbud and Stern. J Oral Surg 1988.
Central Giant Cell Granuloma
A. Butel et al.J Oral Med Oral Surg 2018;24:24-28
Central Giant Cell Granuloma: CBCT
A. Butel et al.J Oral Med Oral Surg 2018;24:24-28
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Central Giant Cell Granuloma
A. Butel et al.J Oral Med Oral Surg 2018;24:24-28
Benign Cementoblastoma
•<1% of odontogenic tumor. •Etiology: Rare neoplasm •Clinical: Pain reported by 2/3 75% in mandible; 90% molar or premolar with 50% involving first molar. Children and young adults; 50% Huber & Folk. Head and Neck Pathology. June 2009 Benign Cementoblastoma: Panoramic- #1 Da Silva et al. Oral and Maxillofacial Surgery Cases. Volume 5, Issue 1, March 2019 69 4/2021 Benign Cementoblastoma: CBCT Da Silva et al. Oral and Maxillofacial Surgery Cases Volume 5, Issue 1, March 2019 Central Odontogenic Fibroma •Etiology: tumors of odontogenic ectomesenchyme •Clinical: Mean age 40. Female predilection. Loosening of adjacent teeth. •Location: 60% Maxilla anterior to 1st molar. When in MD 50% posterior jaw. •Radiograph: well-defined, unilocular radiolucency. w/ schlerotic borders. It is often associated with the apical area of an erupted tooth. Root resorption. •Histology: 2 Types: Simple odontogenic fibroma is composed of stellate fibroblasts arranged in a whorled pattern with fine collagen fibrils and a lot of ground substance. +/ - foci of dystrophic calcification may be present. WHO type odontogenic fibroma appears as a fairly cellular fibrous connective tissue with collagen fibers arranged in interlacing bundles. Calcifications composed of cementoid and/or dentinoid may be present Soolari & Khan. The Open Dentistry Journal, 2014, 8, 280-288 70 4/2021 Central Odontogenic Fibroma: PA Soolari & Khan. The Open Dentistry Journal, 2014, 8, 280-288 Central Odontogenic Fibroma: CBCT Soolari & Khan. The Open Dentistry Journal, 2014, 8, 280-288 HISTIOCYTOSIS X/ LANGERHANS DISEASE Etiology: Neoplastic. Atypical proliferation of Langerhans cells affecting skin, soft tissues and bones Acute disseminated form: - Affects infants aka Letter Siwe –Widespread lesions in multiple organs, skin, jaws and skull, Hepatosplenomegaly, fever, lymphadenopathy –Painful swelling and teeth loosened when jaws affected Chronic disseminated form: - Affects young children aka Hand-Christian-Schuller –Triad of lytic bone lesions, exophthalmos and diabetes insipidus (rare to have all three) –Painful swelling and teeth loosened when jaws affected Radiograph: Teeth “floating in space” with excessive bone destruction and loss of lamina dura. - Unilocular lesions do not displace teeth; rarely resorbs roots - Can destroy cortex, extend into soft tissue - Can induce periosteal proliferation (Onion skin) Difft DX: Severe periodontitis: Starts at alveolar crest, proceeds down root surface; LCD epicenter at midroot Periapical cyst/granuloma: Teeth non-vital: in LCD teeth are vital Primary or metastatic malignancy: LCD may have periosteal proliferation, unlike malignant lesion Histology: •Sheets of Langerhans cells resembling histiocytes: large, pale cells with indistinct borders •Birbeck granules identified in Langerhans cells with electron microscopy •Varying numbers of eosinophils interspersed with Langerhans cells Literature Review Pringle, Daley and Wysocki – OOO 1992 – Langerhans cell histiocytosis in association with PA granuloma and cysts. Lee et al. Imaging Sci Dent. 2013 Jun;43(2):117-122. English. 71 4/2021 HISTIOCYTOSIS X/ LANGERHANS DISEASE Lee et al. Imaging Sci Dent. 2013 Jun;43(2):117-122. English. HISTIOCYTOSIS X/ LANGERHANS DISEASE Lee et al. Imaging Sci Dent. 2013 Jun;43(2):117-122. English. HISTIOCYTOSIS X/ LANGERHANS DISEASE: CBCT Lee et al. Imaging Sci Dent. 2013 Jun;43(2):117-122. English. 72 4/2021 Leukemia Approximately 2.5% of all cancers are leukemia Etiology: disease is characterized by overproduction of white blood cells with replacement of the normal bone marrow, circulation of abnormal cells in the blood, and infiltration of other tissues. Acute Leukemias affect children 98%: Acute lymphocytic leukemia (ALL) and acute myelogenous leukemia (AML) Chronic lymphocytic leukemia the most common type of leukemia. primarily affects elderly adults. Clinical Features: Symptoms may include: infection, fever, abnormal bleeding, bruising, anemia, fatigue (decr O2), bones or joints pain, lymphadenopathy in neck, groin, or elsewhere, and anorexia. Ulceration of the oral mucosa is deep punched-out lesions with a grayish-white necrotic base. Radiographs: multiple, well-defined, non-corticated radiolucent lesions. Severe bone loss, loss of lamina dura and loosening of teeth. Difftl Dx: Severe periodontitis Histology: Microscopic examination of leukemia-affected tissue shows diffuse infiltration and destruction of the normal host tissue by sheets of poorly differentiated cells with either myelomonocytic characteristics or lymphoid features. Literature: Neville et al. Oral Maxillofacial Pathology 2nd Ed. 2002 Wong et al. Imaging Science in Dentistry 2016; 46: 273-8 Ali R. et al. DMFR (DentMFRad) Acute lymphoblastic leukaemia: an unusual radiological presentation. 2009. Leukemia: CBCT Wong et al. Imaging Science in Dentistry 2016; 46: 273-8 OSTEOMYELITIS AKA Periostitis Ossificans or Proliferative Periostitis Etiology: dental caries MC cause. periosteal reaction to the presence of inflammation Clinical: Mean age ~ 13 Radiograph: reveal radiopaque laminations of bone that roughly parallel each other and underlying cortical surface. “Onion skin”. Location: the mandibular premolar/molar region with involvement of the lower border. Treatment: consists of the elimination of the source of infection via endo or extraction. Difftl Dx: “Onion Skin” – Ewing sarcoma, Langerhans cell disease Histology: •areas of necrotic bone are the basis for distinguishing between acute osteomyelitis and chronic osteomyelitis Literature: Neville et al. Oral Maxillofacial Pathology 2nd Ed. 2002 Gillard et al. The New York State Dental Journal NOVEMBER 2017 73 4/2021 OSTEOMYELITIS Gillard et al. The New York State Dental Journal NOVEMBER 2017 OSTEOMYELITIS Pai et al. IOSR Journal of Dental and Medical Sciences.Volume 16, Issue 1 Ver. III (January. 2017), PP 71-74 OSTEOMYELITIS: CBCT Pai et al. IOSR Journal of Dental and Medical Sciences.Volume 16, Issue 1 Ver. III (January. 2017), PP 71-74 74 4/2021 OSTEOMYELITIS: CBCT Pai et al. IOSR Journal of Dental and Medical Sciences.Volume 16, Issue 1 Ver. III (January. 2017), PP 71-74 OSTEOMYELITIS: CBCT Pai et al. IOSR Journal of Dental and Medical Sciences.Volume 16, Issue 1 Ver. III (January. 2017), PP 71-74 75 4/2021 How to determine a Normal apex vs PARL in a radiograph Normal APEX PARL Lamina Dura intact Lamina Dura not intact Normal pattern of bone around the apex Well circumscribed round area of low density around apex which is centered around the apex Consistent radiodensity More radiolucent or radiopaque than surrounding bone PDL space not widened PDL space is widened PDL space traceable PDL space not traceable How to differentiate Lesion of Endodontic Origin and Non-LEOs LEOS NON-LEOS Lamina Dura - Discontinuous Lamina Dura - Intact Associated tooth non-vital Associated tooth always vital without dental etiology Well Circumscribed lesion Lesion with indistinct borders/ill-defined fuzzy radiolucency Tear drop shaped/ unilocular Lesion may be multilocular/ unilocular Lesion is associated with the tooth on Lesion changes position with different angled radiographs and angled radiographs can separate from the tooth Slow growing Fast growing Radiolucent May be radiolucent or radiopaque Responds to Antibiotics Not likely to respond to antibiotics Swellings associated with pain Painless swelling possible Paresthesia Possible Goals of Endodontics Prevention and elimination of endodontic infection 76 4/2021 Importance of Radiography Two dimensional shadow of a three dimensional object Lesion… Healing… Healed Lesion… Healed 77 4/2021 CAUSES OF FAILURE PERIO VS ENDO ABSCESS PERIO VS. ENDO • Dull chronic ache • Sharp acute ache • WNL thermal • Thermal pain/None • Generalized pockets • Isolated pockets • Perio Abscess • Endo Abscess Case Scenario 2 Cold EPT Percussion Palpation Probings Mobility Sinus Swelling Tract WNL WNL Positive Positive 4 10 13, 3 10 Class 2 No Present 12 Periodontal Abscess 78 4/2021 ACUTE APICAL ABSCESS Oral Infections 236 Severe Odontogenic Infection • RED FLAGS • DIFFICULTY SWALLOWING • RESPIRATORY DISTRESS • IMPAIRED VISION/EYE MOVEMENT • HOARSENESS • LETHARGIC • DECREASE CONSCIOUSNESS • DEHYDRATION *ESPECIALLY CAREFUL IF CHILD* 79 4/2021 EXAM • Temp, BP, Pulse, Resp. Rate • Extra-oral • Intra-oral>>swellings, sinus tracts, caries, discolored teeth, perio, vitality tests • Danger Sign: Pharyngeal swelling and deflection of Uvula 80 4/2021 A WELL LOCALIZED ACUTE APICAL ABSCESS, WITHOUT SYSTEMIC INVOLVEMENT OR NOT MEDICALLY COMPROMISED PATIENT… DOES NOT NEED ANTIBIOTICS! Incision and Drainage - With application of Penrose Drain ANTIBIOTICS… • WHEN? • WHAT? • HOW MUCH? 81 4/2021 POST-OP I & D • FLEXIBLE Rx and LONG ACTING ANETHETIC FLARE-UPS • PRE-OP PAIN • SWELLING • NECROTIC > VITAL • WOMEN • MAND.PM AND ANTERIORS (2 CANALS) • PREVIOUSLY TREATED AND AAA • ALLERGIES • SMALL OR NO RADIOLUCENCY KNOW WHO IS MOST LIKELY TO HAVE A FLARE-UP… TO PREPARE PATIENT RX PAIN MEDS NOT PRN LONG ACTING ANESTHETIC 82 4/2021 WHEN TO ADJUST OCCLUSION • PRE-OP PAIN • VITAL PULP • PERCUSSION SENSITIVE • NO RADIOLUCENCY *THE PRESENCE OF ALL 4 IS THE STRONGEST PREDICTOR (Rosenberg et al J Endod 98) Cracked Tooth • Pain upon release of biting • Thermal pain • Usually mesio-distal, MR • Mand. 2nd Molars • May not need RCT • Cusp-reduce • Crown-Temp. 1st 83 4/2021 Cracked Tooth Cracks 84 4/2021 85 4/2021 Tooth Sleuth and Methylene blue 86 4/2021 VERTICAL ROOT FX • Endo teeth • Max 2nd pm, Mand 1st molar, Max centrals and laterals • Buccal and Lingual sinus tracts • Sinus tracts closer to marginal gingiva • J shape lesions • Pain, Swelling, Biting sensitivity • Short, screw posts 87 4/2021 Case Scenario 1 CC: “My tooth hurts when I bite on it” ● 42 year old female ● ASA I ● NKDA ● Dental History: NSRCT performed 3 years ago ● Medications: Ibuprofen 800mg every 8 hours Case Scenario 1 Cold EPT Percussion Palpation Bite test Probings Mobility Sinus Tract Negative Negative Positive Negative Positive 4 4 12, 5 4 10 Class 1 Yes Vertical Root Fracture 88 4/2021 Odontogenic vs Nonodontogenic Toothaches? REFERRED PAIN 89 4/2021 Maxillary vs Mandibular Referred Pain Anesthetic Test Ear ache—Mandibular Molars NONODONTOGENIC TOOTHACHE • Atypical Odontalgia • Cardiac Toothache • Sinus toothache-tap • Migraine • Psychogenic • Myofacial-muscles • Trigeminal Neuralgia- lancinating! Summary of Nonodontogenic Pain • Lack of Dental Pathology • Local Anesthetics not helpful usually • Pain Changes Location • Pain for Months-Years • Stimulation of the Tooth may not precipitate pain 90 4/2021 Ask Many Questions…Interview The Patient! Endodontic Diagnosis • Normal • Normal • Reversible • SAP • Irreversible (S & A) • AAP • Necrotic • AAA • Previously initiated • CAA • Previously treated • Condensing Osteitis • Non-LEO’s Normal Pulp A normal pulp is a clinical diagnostic category in which the pulp is symptom free and normally responsive to pulp testing. A “clinically” normal pulp results in a mild or transient response to thermal testing (cold or heat), lasting no more than one to two seconds after the stimulus is removed. 91 4/2021 #18 #30 #31 Cold R R R Percussion R R R Reversible Pulpitis This diagnosis is based upon subjective and objective findings indicating that the inflammation should resolve and the pulp return to normal following appropriate management of the etiology. Reversible Pulpitis • After applying a cold or sweet stimulus, the patient reports discomfort and it goes away within a couple of seconds following removal of the stimulus. • Possible etiologies include exposed dentin, caries or deep restorations. 92 4/2021 #17 #18 #19 #31 Cold R AR+* NR R Percussion R R R R * Sharp pain, lingered 2-3 seconds Symptomatic Irreversible Pulpitis After applying thermal stimulus, patient reports pain/discomfort more so than adjacent teeth and/or contralateral tooth and it lingers. Often the pain is spontaneous. Patients may not report pain or discomfort to percussion since inflammation may not have reached the periapical tissues. #2 #14 #15 #16 Cold R R AR+* R Percussion R R R R * Sharp pain, lingered >15 seconds 93 4/2021 Asymptomatic Irreversible Pulpitis These cases have no clinical symptoms and usually respond normally to thermal testing but may have had trauma or deep caries that would likely result in exposure following removal. #17 #18 #19 #31 Cold R R R R Percussion R R R R Pulp Necrosis • The pulp is non-responsive to pulp testing and is tooth is asymptomatic. • Some teeth may be non-responsive to pulp testing because of calcification (USE EPT), recent history of trauma 94 4/2021 Previously Initiated Therapy A clinical category indicating that the tooth has been previously treated by partial endodontic therapy such as pulpotomy or pulpectomy. #18 #19 #20 #30 Cold R NR R R Percussion R AR R R 95 4/2021 Previously Treated Apical Diagnoses 1. Normal 2. Symptomatic apical periodontitis 3. Asymptomatic apical periodontitis 4. Chronic apical abscess 5. Acute apical abscess 6. Condensing osteitis Apical Tests • Percussion • Axially • Laterally • Palpation • Tooth Slooth 96 4/2021 Periapical Diagnosis ● Normal apical tissues ○ Not tender to percussion or palpation ○ Lamina dura is intact ○ PDL space is uniform ● Symptomatic Apical Periodontitis ○ Inflammation of the apical periodontium ○ Painful response to biting or percussion or palpation ○ May or may not be associated with radiographic changes ● Asymptomatic Apical Periodontitis ○ Inflammation and destruction of the apical periodontium ○ Apical radiolucency is present ○ Does not present with clinical symptoms (not tender to percussion or palpation) Courtesy of The British Dental Journal Normal Apical Tissues A tooth with this diagnosis is not sensitive to percussion or palpation testing and the periodontal ligament space (PDL) is of uniform width and the lamina dura around the root(s) is intact. 97 4/2021 #18 #30 #31 Cold R R R Percussion R R R #18 #20 #21 #28 Cold R NR NR NR* Percussion R R R R Palpation R R R R * Tooth #28 has been endodontically treated 98 4/2021 Symptomatic Apical Periodontitis Symptomatic apical periodontitis represents inflammation, usually of the apical periodontium, producing clinical symptoms involving a painful response to percussion and/or biting or palpation. #19 #29 #30 Cold R R NR Percussion R R AR++ Palpation R R R Asymptomatic Apical Periodontitis Appears as an apical radiolucency and does not present with clinical symptoms (no pain to percussion or palpation) 99 4/2021 #19 #29 #30 #31 Cold R R NR R Percussion R R R R Palpation R R R R Chronic Apical Abscess An inflammatory reaction to pulpal infection and necrosis characterized by gradual onset, little or no discomfort, and an intermittent discharge of pus through an associated sinus tract. Sinus tract: Which tooth? 100 4/2021 Cracked Tooth! #19 #30 #31 Cold R R NR Percussion R R R Palpation R R AR* * Patient reports mild discomfort during palpation Acute Apical Abscess An inflammatory reaction to pulpal infection and necrosis characterized by rapid onset, spontaneous pain, extreme tenderness of the tooth to pressure, pus formation and swelling of associated tissues. 101 4/2021 Periapical Diagnosis ● Acute Apical Abscess ○ Inflammatory reaction ○ Rapid onset, spontaneous pain, tenderness to percussion ○ Intraoral swelling may or may not be present !! ○ There may or may not be signs of Courtesy of Michelle Lin, MD destruction on the radiograph and the patient may experiences malaise, fever, and lymphadenopathy ● Condensing Osteitis ○ Diffuse radiopacity ○ Localized bony reaction to a low- Courtesy of Pocket Dentistry grade inflammatory stimulus Patient Considerations…Inactivity NOT an option Condensing Osteitis Condensing osteitis is a diffuse radiopaque lesion representing a localized reaction to a low-grade inflammatory stimulus usually seen at the apex of the tooth. 102 4/2021 #19 #29 #30 #31 Cold R R R R Percussion R R R R Palpation R R R R #4 #11 #12 #13 #14 Cold R R AR* NR R PercussionOneR FinalR R CaseR R Palpation R R R AR R * Sharp pain, lingered >30 seconds Maxillary Sinusitis of Endodontic Origin 103 4/2021 What is Maxillary Sinusitis of Endodontic Origin? ● MSEO refers to sinusitis caused specifically by endodontic infections ● The inability to manage the endodontic component of the condition will result in persistence of sinus disease and failure of medical sinus therapies including antibiotic therapy and sinus surgeries. ● Caused by previously treated or necrotic teeth ● Symptoms of MSEO: ○ Congestion ○ Rhinorrhea ○ Facial Pain ○ Foul odor ● Typical endodontic pain is usually absent. ● Teeth may or may not be tender to Maxillary Sinusitis of Endodontic Origin (MSEO) ● Radiographic examination: ○ Due to anatomic noise and the inability to reveal mucosal thickening or fluid in sinuses PA radiographs are limited in aiding in the diagnosis of MSEO ○ In a 2008 study, CBCT revealed 34% more lesions than PA radiography as well as significantly more expansion of lesions into the sinus, mucosal thickening, and untreated canals. 77% of mucosal changes were observed with CBCT vs the 19% seen with PA radiographs(Low et al 2008) 104 4/2021 Treatment of Maxillary Sinusitis of Endodontic Origin ● The objective of treatment is to remove the bacteria, their by-products, and pulpal debris from the root canal system of the tooth causing the sinus infection and to prevent reinfection ● Treatment options include: NSRCT, periradicular surgery (when indicated), intentional replantation, extraction, or no treatment. ● If endodontic therapy is not completed, surgical intervention of MSEO that focuses directly on removing diseased sinus tissue and establishing a drainage will be inadequate. This has been well documented in not resolving MSEO Maxillary Sinusitis of Endodontic Origin (MSEO) ● Radiographic examination: ○ Two unique radiographic findings of MSEO include periapical osteoperiostitis and periapical mucositis (Worth & Stoneman 1972) ■ PA Osteoperiostitis- A periosteal reaction will continue to deposit a thin layer of bone on the inner periphery as it expands. Appears radiographically as a hard tissue dome with a radiopaque halo appearance on the sinus floor ■ ·PA Mucositis-Localized mucosal tissue edema that appears radiographically as a mucosal thickening or dome shaped soft tissue expansion in the floor of the sinus CAUSES OF FAILURE 4. LACK OF SELF-DISCIPLINE Chief Complaint-open ended “Anything else?”--Breached 105 4/2021 Treatment Records A complete treatment record should contain: .A thorough review of the patient’s medical and dental history .Chief complaint(s), including onset, duration, frequency, type and intensity of pain .Radiographs of diagnostic quality .Pulpal and periodontal diagnostic tests performed Treatment Records A complete treatment record should contain: .Objective clinical examination findings .Differential diagnoses and final diagnosis .The treatment plan and prognosis .Documentation of the course of treatment CAUSES OF FAILURE 5. Lack of vision and imagination sufficient to recognize favorable opportunities. New Orleans lecture/Plane MAGNIFICATION & ILLUMINATION 106 4/2021 107 4/2021 Ultrasonic Tips ProUltra® Endo Tips 108 4/2021 ProUltra® Ultrasonic Booster 3) Pulp stone (#15), Symptomatic irreversible pulpitis, symptomatic apical periodontitis 5) Post removal (#5), previously treated, Symptomatic apical periodontitis, Root perforation suspected 109 4/2021 Mandibular Molar (18/19) - SINE 5 (small football) – Stones & Soft Tissue 1 of 5 6) Re-treatment (#15), Previously treated, Chronic apical abscess, Russian red 5) Calcified canals (#4), Previously initiated, Symptomatic apical periodontitis 110 4/2021 Mandibular Molar (18/19) - SINE 2 (rounded tip) – Stones & Soft Tissue 2 of 5 Mandibular Molar (18/19) - SINE 5 (small football) – Flaring Orifice 3 of 5 Mandibular Molar (18/19) - SINE 1 (pointed tip) – Flaring Orifice 4 of 5 111 4/2021 Ways to predict your access • Instruments that help: • #2 round bur • Endo Z bur • DG16 – Endo Explorer 5 of 5 Measuring Cusp to Furcation Distance 112 4/2021 Access in special conditions • Calcified • Measure depth of pulp space on pre-op x-ray • Determine angulations and positions of canals • Aim for largest canal orifice • Periodic X-rays to determine need for modification… “I HAVE NEVER REGRETTED STOPPING TO TAKE A RADIOGRAPH!” “I HAVE REGRETTED…” “AWOP” METHOD • GOOD X-rays—Measure chamber depth • Bur into center THEN SAFE END BUR A Better Access!! • Straight line access… USE SAFE END/Orifice Opener for conservative Access 113 4/2021 A Better Access!! • No Undercuts… USE SAFE END BUR II- Access – round bur II- Access • Drop into chamber 114 4/2021 II- Access • Change to Safe-end bur Access Extend access to de-roof chamber 115 4/2021 Straight-line access?? Achieve Straight-line access Axial Wall Refinement: Endo SE SS White® Endo SE Burs • Expand the pulp chamber without damage to the floor or axial walls • Ideally suited for lateral extension of the pulp chamber, to allow access to the root entries during endodontic treatment, while preventing perforation of both the pulp chamber floor and root canal walls. 348 116 4/2021 Straight-line access Law of the CEJ The CEJ is the most consistent, repeatable landmark for locating the position of the pulp chamber Before any access is done, the CEJ should be probed 360 degrees around the tooth 117 4/2021 Periodontal probing 360 degrees around the tooth Ways to predict your access • Position of the tooth This will help create a mental picture of the perimeter of the tooth at the CEJ 118 4/2021 Probing the CEJ Proper Angle of the Tooth Must be Determined Proper Access is the Cornerstone of Successful Endodontics 119 4/2021 Loss of orientation Cause • Using occlusal surface as reference point • Failure to observe tooth orientation such as rotated or tilted tooth • Losing sight of CEJ circumference • Improper angle of initial access Remedy • Proper pre-access observation of tooth orientation • Proper mental imaging of the CEJ • Remove rubber dam during access to regain orientation • Appropriate angle of penetration of initial access bur Relationships of the Pulp Chamber to the Clinical Crown 1-The pulp chamber was always in the center of the tooth at the level of the CEJ. 2-The walls of the pulp chamber were always concentric to the external surface of the crown at the level of the CEJ. 3-The distance from the external surface of the clinical crown to the wall of the pulp chamber was the same throughout the circumference of the tooth at the level of the CEJ. Law of Concentricity 120 4/2021 Relationships on the Pulp-chamber Floor 1- The floor of pulp chamber is always a darker color than the surrounding dentinal walls Relationships on the Pulp-chamber Floor 5-The orifices lay at the terminus of developmental root fusion lines, if present Relationships on the Pulp-chamber Floor 7-Reparative dentin or calcifications are lighter than the pulp chamber floor and often obscure it and the orifices 121 4/2021 Laws of internal tooth anatomy • Law of symmetry 1: except for maxillary molars, the orifices of the canals are equidistant from a line drawn in a mesial distal direction through the pulp-chamber floor Laws of internal tooth anatomy • Law of symmetry 2: except for the maxillary molars, the orifices of the canals lie on a line perpendicular to a line drawn in a mesial-distal direction across the center of the floor of the pulp chamber Law of Color Change The color of the pulp chamber floor is always darker than the walls Image courtesy of Jorge N.R. Martins 122 4/2021 A Better Access!! • Extra canals A Better Access!! Developmental grooves Ways to predict your access • Instruments that help: • #2 round bur • Endo Z bur • DG16 – Endo Explorer 123 4/2021 Mandibular Molar (18/19) - SINE 5 (small football) – Flaring Orifice 3 of 5 5 of 5 124 4/2021 Ultrasonic Tips 125 4/2021 1 Year Post-Op 126 4/2021 Advanced Features MORA interface Foldable Tube f170/f260 (left/right inclination without horizontal inclination of eyepieces) Integrated HD camera Varioskop (adjustable focal lens/length) 1) #14 Symptomatic irreversible pulpitis, Symptomatic apical periodontitis 127 4/2021 2) #14 Symptomatic irreversible pulpitis, Symptomatic apical periodontitis 128 4/2021 Instrumentation Technique CORONAL 1/3 MID-ROOT 1/3 APICAL 1/3 Straightline Access Clinical Step by Step Instructions 1) Prepare straight line access to canal orifice. 2) Scout canal with hand file(s), to a size 6-10. 3) Establish working length and confirm patency. 4) Irrigate canal space. 5) Use ProGlider™ in one or more passes, until full working length is reached. 6) Irrigate expanded glide path. 7) Reconfirm working length before shaping canal space 129 4/2021 Irrigation Determine Working Length Apex locators 130 4/2021 Is the Apex locator lying….. Or not? Glide Path 131 4/2021 PathFile™ Study Conclusions • Superior maintenance of original canal anatomy • More forgiving of errors such as incorrect working length • Minimizes zipped apex when WL is too long • Minimizes ledging when WL is too short • Reduces the instrumentation time needed • less fatigue • Improved results by respecting anatomy Shape Canal – Crown Down • Start with a 30/.04 rotary file. Take 30/.04 to resistance or working length (whichever occurs first). • If resistance is encountered before working length is obtained, go to next smaller instrument following the same protocol until working length is achieved. • Between each rotary file recapitulate with a #10 or #15 tip hand file to maintain glide path and help irrigate (NaOCl) to the canal terminus. 132 4/2021 Usage Tip - Flexibility Usage Tip – Insert Before Rotation 133 4/2021 Irrigants into complex anatomy Types & Functions of Irrignts Removes Premixed No Fears of Initial Use w/ Non- Irrigant Disinfects Smear & Ready to Tooth 6.15% NaOCl Antibiotic Layer Use Staining OK ≤ 6.15% n/a NaOCl 17% EDTA 2% CHX BioPure® MTAD® QMix™ 2in1 Goals of Irrigation • Debride canal • Dissolve tissue • Remove smear layer • Kill microbes SEMs of smear layer partially covering instrumented sections of canal walls (Dr. Franklin Tay) 134 4/2021 QMix 2in1 removes smear layer at all levels Irrigation Options • Irrigants • Delivery / Agitation EndoActivator® System Small Medium Large 15/.02 25/.04 35/.04 135 4/2021 136 4/2021 Goals of Irrigation • Debride canal • Dissolve tissue • Remove smear layer • Kill microbes SEMs of smear layer partially covering instrumented sections of canal walls (Dr. Franklin Tay) QMix 2in1 removes smear layer at all levels “Hydrodynamic Phenomenon” • Evidence-based endodontics has shown that cavitation and acoustic streaming improve debridement and the disruption of the smear layer and biofilm. • Activated fluids promote deep cleaning and disinfection into lateral canals, fins, webs, and anastomoses. • A cleaned root canal system facilitates 3-D obturation and long-term success. 137 4/2021 Improving Outcomes F. Vertucci A Reproducible Obturation Technique for the Complexity of the RCS MICRO CT SCAN REVEALS THE TRUE COMPLEXITY OF THE ROOT CANAL SYSTEM. • Not all gutta-percha flows and fills intricate anatomy • Warm gutta-percha must be delivered to the apex • Hydraulics can move warm gutta- Real Tooth Images Courtesy of Dr. Sergio Kutler percha 3-dimensionally 138 4/2021 Gemination 139 4/2021 Pre-Op X-ray Post-Op X-ray OVER-LOOKED CANALS! • MAND. CENTRAL---30-40% 2 CANALS • MAND. LATERAL----25% • MAND. K-9------22% • MAND. 1ST PM------25% • MAND. 1ST MOLAR—28.5% 4 CANALS • MAX. 1ST MOLAR-----50-90’s 4 CANALS (VIDEO-IRIZARY, MAX PM, MAX MOLAR) 140 4/2021 Radiographic Aids in the Detection of Extra Root Canals Slowey R. OOO Vol. 37 No. 5 May 1974 Summary of Slowey’s Clues ● Multiple PDLs ● Fast Break ● Dark shadow adjacent to radiopaque file or obturation material ● Fuzzy Apex ● Off-Centered canal space a preoperative high-resolution focalized CBCT study provides detailed anatomical information • The practitioner can now design and individualize an extremely conservative approach, 141 4/2021 Maxillary Molar (3/14) - SINE 5 (small football) – MB2 2 of 3 Maxillary Molar (3/14) - SINE 3 (small ball) – Access Refinement 1 of 3 142 4/2021 Maxillary Molar (3/14) - SINE 5 (small football) – MB2 3 of 3 Distal Angle Courtesy of Dr. Jenna Gaw, DDS 143 4/2021 MIDDLE MESIAL CANAL • 5 CANALS IN MAND. MOLAR…12-40% • YOUNG TEETH • DEEP FISSURE TWIXT MB ML—EXPLORE (VIDEO) Old large shapes 144 4/2021 APICAL ROOT RESORPTION APICAL ROOT RESORPTION Old Large shapes 145 4/2021 Advantages of CBCT Transverse or Axial Coronal Sagittal CBCT CBCT 146 4/2021 Mandibular Molar (30) - SINE 3 – Access Refinement 2 of 3 Mandibular Molar (30) - SINE 3 – Access Refinement 3 of 3 Mandibular Molar (30) - SINE 3 – Access Refinement 1 of 3 147 4/2021 Referral Courtesy of Dr. Deb Knaup Endodontist Cases Courtesy Dr. Joe Bernier and David Landwehr 148 4/2021 Retreatments Root Canal Anatomy Root Canal Anatomy 149 4/2021 OOPS! C-SHAPED RC SYSTEMS • USUALLY, 2ND MAND MOLARS • 8% • USUALLY, SEPARATE ML WITH A CONTINUOUS C-SHAPED SLIT-LIKE OPENING ALONG THE BUCCAL ASPECT OF THE TOOTH Access in special conditions Anatomy VIDEO 150 4/2021 C-Shaped Anatomy Intentional Replantation Courtesy of Dr. Rob Roda 151 4/2021 Intentional Replantation Courtesy of Dr. Rob Roda Importance of Radiography Two dimensional shadow of a three dimensional object A. Diagnosis Determining root and pulpal anatomy 152 4/2021 Why not just rotaries ? •Just one simple example!!! •Two outcomes if no glide path is established: •Disarticulation •Missed canal •Both can lead to failure •Prevention: •Experience in creating a smooth GLIDE PATH that maintains the original canal shape! CBCT 153 4/2021 Missed Root Note Lateral lesion Courtesy of Dr. Joe Petrino NSRCT and Restoration Courtesy of Dr. Joe Petrino 154 4/2021 The Case Difficulty Assessment Form Case study: abnormal anatomy • Patient presents for root canal treatments in lower first and second bicuspids. • It is expected that there would be two canals in the first bicuspid, one canal in the second. Photo courtesy of Dr. Sashi Nallapati 465 155 4/2021 The Case Difficulty Assessment Form Case study: abnormal anatomy • Upon treatment, it is discovered that each bicuspid has three canals. Photo courtesy of Dr. Sashi Nallapati 466 The Case Difficulty Assessment Form Case study: abnormal anatomy Why should you refer this case? • Endodontists are exposed to the most leading-edge studies on internal anatomy and have the expertise to handle such cases. • Endodontists have enhanced surgical equipment, such as microscopes, for use in treatment to meet patients’ specialized needs. Photo courtesy of Dr. Sashi Nallapati 467 Courtesy of Victor Endodontics, PLLC 156 4/2021 Courtesy of Victor Endodontics, PLLC 3: Length-of-Tooth Film and Dark Shadows ● Additional canals are most commonly missed and seen in the mesiobuccal root of maxillary molars and the distal root of mandibular molars. ○ It is very difficult to see these canals radiographically even with angulated films. ● The best way to confirm their presence is a “length-of-tooth” film which is a radiograph with a file in place. ○ A dark radiolucent line can be seen running alongside of the file in the CORONAL ASPECT of the root. Courtesy of Yaara Berden, DDS Length-of-Tooth Film and Dark Shadows Courtesy of Yaara Berden, DDS 157 4/2021 The “Fast-Break” ● Radiographs of teeth with MULTIPLE CANALS show a change in density along the canal space known as a “fast-break”. ● An angulated film will aid in the exposure of additional canals. ● Occurs most frequently with maxillary premolars and mandibular incisors and less with multirooted teeth. Courtesy of Jenna Gaw DDS LESION vs. LAMINA DURA 158 4/2021 Lesion vs. Lamina Dura Treatment Planning Options Courtesy of Dr. Tyler Peterson 159 4/2021 DOM and Magnification 3.5x 5.1x 8.5x 13.6x DOM and Accessing Teeth Sclerosed pulp chamber in lower View of a pulp stone as seen via left first molar due to a deep the DOM. Note the rough pulp restoration and recurrent caries floor source, indicative of pulp stones. 160 4/2021 SOM and Preserving Tooth Structure DOM and Calcifications DOM and Canal Location 161 4/2021 Vision and imagination sufficient to recognize favorable opportunities. What is Regenerative Endodontics? J Endod 2004;30:196-200. General observations and trends from case studies . Young, healthy patients . Immature apex (open ≥1mm), necrotic pulp . Pulp space not needed for post/core, final restoration . Two appointments . No instrumentation performed . Irrigation with NaOCl . Use of Double antibiotic paste or Ca(OH)2 . Blood clot instigated, MTA placed . Coronal seal with GIC, composite, or amalgam . Follow-up range 7 mo. to 5 yrs. 162 4/2021 Regenerative endodontic case studies Case studies have shown: . healing of apical periodontitis . continued development of the root apex . increased thickness of the root canal wall J Endod 2008;34:876-87. Regenerative endodontic A case studies A B D E C from J Endod 2004;30:196-200. Regenerative endodontic case studies H E F G from J Endod 2004;30:196-200. 163 4/2021 Why 3-D? Introduction: ● Radiographic imaging is important in: ○ Diagnosis ○ treatment planning ○ follow-up in endodontics ● The interpretation of an image can be confounded ○ the regional anatomy Courtesy of: Taylor P. ○ superimposition of both the teeth and surrounding dentoalveolar structures. Cotton, JOE 2007 ● Periapical radiograph problems: ○ Periapical radiograph reveal limited aspects and geometric distortion of the anatomical structures because of the superimposition. (Grondahl HG et al Endod Topics 2004) ○ Two-dimensional view, of the true three-dimensional anatomy.(Patel S, Dawood A,et al. Int Endod J 2007 and Cotton TP,et al J Endod 2007) ● These problems can be overcome by utilizing small volume CBCT, which produce accurate 3-D images of the teeth and surrounding dentoalveolar structures (Patel S, Dawood A,et al. Int Endod J 2007 and Cotton TP,et al J Endod 2007 and Scarfe WC et al Int J Dent 2009) Principles of CBCT - Field of View . Large . Medium . Focused 164 4/2021 Principles of CBCT - Field of View . Large . Medium . Focused Principles of CBCT - Field of View . Large . Medium . Focused Potential Endodontic Applications of CBCT • Aiding surgical planning • Retreatments- treatment planning • Traumatic injuries - diagnosis and treatment planning • Intra-operative (i.e. finding canals) • Maxillary sinusitis of dental origin • Calcified cases • Facial pain cases to rule out odontogenic etiology 165 4/2021 •This guide is not intended to substitute for clinician’s independent judgment in light of the conditions and needs of a specific patient. •14 recommendations about use of conventional radiographs and/or CBCT. Diagnosis: Recommendation 2 Limited FOV CBCT should be considered the imaging modality of choice for diagnosis in patients who present with contradictory or nonspecific clinical signs and symptoms associated with untreated or previously endodontically treated teeth. Courtesy of: Mohamed Fayad and Bradford R. Johnson Detection of Apical Periodontitis 166 4/2021 Detection of Apical Periodontitis Detection of Apical Periodontitis Is there a lesion? 167 4/2021 Is there a lesion? Is there a missed canal? Non-Surgical Retreatment: Recommendation 8 Limited FOV CBCT should be the imaging modality of choice for non-surgical retreatment to assess endodontic treatment complications, such as overextended root canal obturation material, separated endodontic instruments, and localization of perforations Liang, Wesselink, et al 2010 concluded that treatment outcome, length and density of root fillings, out outcome predictors as determined with CBCT scans may not be the same as corresponding values determined with PA radiographs. For CBCT, density of root filling and coronal restoration quality were the top predictors of root canal success. Pictures courtesy of dentalcaseoftheday.com 168 4/2021 Non-Surgical Retreatment: Recommendation 8 Limited FOV CBCT should be the imaging modality of choice for non-surgical retreatment to assess endodontic treatment complications, such as overextended root canal obturation material, separated endodontic instruments, and localization of perforations Liang, Wesselink, et al 2010 concluded that treatment outcome, length and density of root fillings, out outcome predictors as determined with CBCT scans may not be the same as corresponding values determined with PA radiographs. For CBCT, density of root filling and coronal restoration quality were the top predictors of root canal success. Pictures courtesy of dentalcaseoftheday.com Complications Complications Strip peroration is now observed 169 4/2021 CAUSES OF FAILURE 7. Lack of belief in infinite intelligence. REFERRAL=Share Responsibility Give Pt. best chance to heal Working Together! 170 4/2021 Standard of Practice An acceptable level of performance or an expectation for professional intervention, formulated by professional organizations based upon current scientific knowledge and clinical expertise. Dental Dam ● Rubber dam use during non-surgical endodontic treatment has been mandated by the American Association of Endodontist ● Benefits: ○ Provides a barrier against any mechanical and chemical mishaps and is considered mandatory in the US ○ Protection barrier for the patient ○ Keeps patients from swallowing or aspirating instruments and irrigants ○ Enhances visibility ○ Retracts tissues ○ Protects the dentist and auxiliary members and decreases transmission of HIV, hepatitis, and tuberculosis ○ Minimizes aerosols Courtesy of Dr. Bharat Katarmal 171 4/2021 High Difficulty For wisdom is better than rubies; and all the things that may be desired are not to be compared to it. (Proverbs 8:11) CAUSES OF FAILURE 8. Ill health DISEASE: Perio (32%) Pathogenesis-Lesion/NO pain until YOU cause it! Biofilm-Smear layer-DISRUPT Disinfection below Immune Threshold 172 4/2021 Irrigants and Disinfection Irrigants accomplish: .Gross debridement .Elimination of MO’s .Digestion of organic substances .Removal of smear layer EndoActivator® System Small Medium Large 15/.02 25/.04 35/.04 173 4/2021 Methods to Minimize NaOCl Accidents CAUSES OF FAILURE 9. Lack of persistence in carrying through to finish that which you start; unwillingness to go the extra mile or render a service; the habit of running away from unpleasant circumstances instead of mastering them! 1 % STATISTICS= IT’S POSSIBLE TIMELY= Just have to do the hard work…sooner than later (delayed restoration decreases survival) Local Factors • Diagnosis • Restorability and ferrule • Strategic nature of tooth • Caries risk and oral hygiene • Periodontal assesssment • Cracks, fractures, resorption • Occlusion and parafunction 174 4/2021 CAUSES OF FAILURE 10. The desire to get something for nothing. Tx-- Diagnosis not pain—Prognosis Proper Case Selection: “Endo surgery and retreat doesn’t work!” 175 4/2021 Oral and Intravenous Bisphosphonate- Induced Osteonecrosis of the Jaws, Second Edition Robert E. Marx, D.D.S. Quintessence Publishing Company www.quintpub.com BONJ: Clinical Presentation Clinical Features of Suspected BONJ Exposed bone in maxillofacial area that occurs in association with dental surgery or occurs spontaneously with no evidence of healing* Working Diagnosis of BONJ No evidence of healing after six weeks of appropriate evaluation and dental care No evidence of metastatic disease in the jaw or osteoradionecrosis * Refer for appropriate dental evaluation and care as soon as possible. Courtesy of Dr. Martin Rogers 176 4/2021 Nonsurgical Retreatment Courtesy of Dr. Martin Rogers Goals of Endodontics Prevention and elimination of endodontic infection Goals of Endodontics Prevention and elimination of endodontic infection 177 4/2021 APICAL ROOT RESORPTION APICAL ROOT RESORPTION 178 4/2021 4 KEYS TO SUCCESS • HOMEWORK • LISTEN • SAY NO TO DRUGS • PRAY APICAL ROOT RESORPTION 179 4/2021 APICAL ROOT RESORPTION Here's To you! I THANK THE LORD FOR ALLOWING ME TO SERVE YOU TODAY! 180 4/2021 181 4/2021 May the Lord Bless and Keep you! Ready for a NAP and Massage… THANK YOU! 182