The “Ugly Truth”

On 08/28/2010, In Instrumentation, Non-surgical Root Canal, By Vladimir Tismensky, DDS

So, why do root canal files break?

1. Operator errors

- pushing rotary files, no glyde path, instrumenting dry, overusing files

2. File defect

- It is extremely unlikely that a file has a manufacturing defect, however it can have defects and/or fatigue from multiple use.

3. Root canal anatomy

- Canals are generally not round.  They can be bunch of different shapes: tear drop, figure eight, oval… There are also fins and isthmuses where a file may get caught and inevidably break.

The important thing is if a procedural error happens, and most of these occur during intra-operative stage as we saw from the last post, a prudent clinician should evaluate why the error occured to minimize such things in the future.

Had a very humbling experience yesterday…

I broke a file in a seemingly straight-forward case!

Had a patient that came in for a root canal #30. This tooth is asymptomatic, perio probings are 5mm or less, no response to cold, WNL to percussion and palpation, periradicular area radiographically. Tooth #31 is planned to be extracted due to extensive endo-perio involvement and loss of furcal bone due to a fracture.

pre-op #30

I believe that my yellow protaper got caught in a fin, but this doesn’t make me feel any better. The reason I think it was a fin is because during instrumentation, my instrument was “grabbed”  as it was rotating (so it started screwing into the canal actively) and it snapped in the ML canal before my foot was off the pedal. Now, this canal had a glyde path, patency, instrument had a lubricant on it, and a previous instrument in a Protaper series (white protaper) was to the apex with out problems.

mid-op #30, broken file ML canal

Once the file broke, I continued with instrumentation of three other canals and an x-ray was taken with master cones.  This film shows that the ML canal is fairly straight, root walls are rather thick and the access to the instrument in the apical 1/3 is possible. The file was then removed using the microscope and ultrasonic instruments in the following order: buc1, cpr#4, cpr#5 and finally cpr#6.

Instrumentation was then completed and canals were obturated using Resilon obturation material in a warm vertical fashion and a thin layer of glass ionomer resin was placed over each orifis as a barrier. This patient was then scheduled for a routine 6 months follow-up.

post-op1 #30, instrument removed

post-op#2, instrument removed

These types of cases remind us that the root canal system is a network of very complex and delicate structures and we must treat it with the utmost care and respect!

 
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Malpractice Claims in Endodontics

On 08/14/2010, In Informed Consent, Risk Management, By Vladimir Tismensky, DDS

A recent study by Givol et.al., published in the Journal of Endodontics, points out some interesting facts about malpractice claims in endodontics.

Endodontic claims are the most frequently filed malpractice claims in dentistry. It has been reported that there are twice as many endodontic malpractice claims than other specialty areas. Endodontic claims have been reported to be 14% – 17% of the total malpractice claims in dentistry.

The study by Givol et. al. was a review of malpractice claims made in Israel between 1992 – 2008. Some interesting data comes from this review. Of the 720 complaints that were analyzed, 72% were considered “justified” and 27% were considered “unjustified” complaints.

Errors found and analyzed were categorized as pre-operative, intra-operative and post-operative.

Most of the errors occurred in the intraoperative phase of treatment. These included access preparation, detection of canals, instrumentation or obturation.

Swelling & pain as the only complaint were reported in 100 cases and none of them were considered “justified” complaints. Swelling and pain are considered a side effect of treatment and not a complication. Patients should be informed of this possible side effect during informed consent. It has been reported by Tsesis et. al. that pain and swelling can occur following endodontic treatment in 1.5% – 20% of cases. Helping patients understand this possible side effect can help prevent misunderstanding and hopefully prevent unnecessary malpractice claims.

The lack of adherence to strict treatment protocols resulting in poor quality treatment was a common cause of malpractice claims.

Endodontic treatment requires exceptional technical skill and strict adherence to accepted treatment protocols. Proper case selection and appropriate referral to a specialist can also prevent unnecessary complications.

SOURCES
Givol N, Rosen E, Taicher S, Tsesis I. Risk Management in Endodontics. J Endod 2010;36:982-984.

Tsesis I, Faivishevsky V, Fuss Z, Zukerman O. Flare-ups after endodontic treatment: A meta-analysis of literature. J Endod 2008;34:1177-81.

 
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Apical Surgery – To Do or Not To Do

On 06/27/2010, In Apicoectomy, Endodontic Surgery, By Vladimir Tismensky, DDS

In this post I really wanted to simply go through some of the concepts involved in apical surgery and to share my thought process when considering such procedures.

So, why do some root canals fail?

1. Intra-radicular infection.

2. Extra-radicular infection.

3. True periapical cyst.

Root canal failure in most cases can be attributed to at least one of three reasons listed above.  When I get a patient with failing root canal, I prefer a non-surgical re-treatment when possible to save the natural tooth.  Sometimes however, this option is not possible or practical. In this case, a decision must be made whether or not endodontic surgery is a viable option.

Indications for apical surgery:

1. Conventional re-treatment is not possible or practical.

2. Re-treatment has already been done.

3. Biopsy is necessary.

So, at this point in a treatment planning algorithm, a clinician must evaluate the tooth in question and together with the patient choose the course of treatment.

Is it just better to extract the tooth and place an implant? In many cases it is.

Case selection and surgical skills!!!!!  These two are paramount when considering apical surgery!

Case selection, in my mind, simply involves patient factors (medical history etc.) and “tooth” factors.  I will concentrate on “tooth” factors.

Here are some of the things I look at during evaluation for possible apical surgery:

1. Proximity of the apical lesion to vital anatomical structures. For example, if the apex of tooth #29 is “sitting” on a mental foramen, apical surgery is contraindicated and an implant, bridge or intentional replantation (to be discussed in future posts) should be considered.

2. If there are deep pockets or fractures – implant!  I need crestal bone around the tooth to give me better prognosis.

3. How deep is the vestibule? Lets say on a lower molar, typically lower second molars, if there is a thick buccal plate and a shallow vestibule, I will typically recommend an extraction and an implant because the apical surgery will destroy lots of good bone and in a case like this, an implant will be less traumatic. Conversely, if the vestibule is deep, the surgical access is easier and I am more likely to choose apical surgery option.

4. Size of the lesion – the larger, the worse!  There is no “cut and dry” rule here. We do know however that apical surgery performed on a lesion more than 5mm in diameter tend to have a lower chance for healing.

5. Existing restoration is to be considered and also intangibles.

Surgical skills:

Besides all the obvious, like basic principles of flap design and tissue handling, the following should be done during apical surgery:

1. Periapical granuloma/cyst should be removed.

2. Must resect the root(s), best completed at a 3mm level from the apex.

3. Must place root-end filling(s) and according to research best material for that appears to be MTA.  It is desirable to make the root-end preparation and therefor a root-end filling as long as possible to prevent apical leakage.

4. If the root-end filling is not placed, failure will follow!

5. During the root-end preparation – isthmus (if present) between canals MUST be incorporated into the preparation and sealed.  Often isthmus is present on MB root of an upper molar (between MB1 and MB2), lower anteriors, upper premolars and lower molars (between buccal and lingual canals)

6. In order to achieve best possible outcomes, surgical operating microscope and ultrasonic instrumentation should be used.

CASE 1

30 year old healthy male presented with the swelling around #13.  Periapical area is present on the radiograph. Diagnosis #13 failing root canal with acute periapical abscess.

Options:  re-treatment with the post removal and a new crown, implant supported crown or apical surgery.

In this case, my patient opted for apical surgery.

Pre-op #13

Full periosteal flap was raised and the periapical lesion was curretted out. Roots were then resected. In this case, untreated palatal root was discovered.

Root end preparation using ultrasonic instruments

MTA root-end fillings in buccal and palatal roots (no isthmus here, roots are separate here)

Immediate post-op #13

Follow-up 2 years

Follow-up 2 years

Both 2 year follow-up radiographs show complete periapical healing, tooth is asymptomatic and functional.

CASE 2

50 year old woman with controlled hypertension, reported persistent discomfort in the periapical area associated with tooth #7, previous root canal was done by an endodontist. Diagnosis #7 Previously treated root canal with chronic periapical periodontitis.

Pre-op #7, large periapical area

Flap raised, lesion was curretted out

MTA root-end filling

Immediate post-op, calcium sulfate barrier was placed into the surgical crypt.

Follow-up 3 years

At the 3 year follow up, tooth is asymptomatic and functional, radiograph shows a complete healing with the classic “star burst” appearance of a periapical scar.

CASE 3

34 year old healthy male reported a “bubble” on his gum.

Diagnosis: #30 previously treated root canal with chronic periapical abscess.

Pre-op #30, sinus track traced

Separated instrument is “peeking” out of the mesial root. Large periapical lesion.

No perio probings above 3mm, new crown placed 3 weeks ago.

Immediate post-op #30

Mesial and distal roots were resected and MTA root-end fillings were placed. Isthmus was also prepared and sealed between MB and ML canals.

Follow-up 1 year

At one year, tooth #30 is asymptomatic and functional.  Radiograph shows complete periapical healing.

 
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Maxillary Molar with Two Palatal Roots

On 05/22/2010, In Non-surgical Root Canal, Root Canal Anatomy, By Vladimir Tismensky, DDS

Maxillary molar with four distinct roots is a rarity!

The overall incidence of four-rooted maxillary molars has been reported to be less than 0.4%. Nevertheless, dentists should be aware of such variation.

When examining the pre-operative periapical radiographs of maxillary molars, if the outlines of the roots are unclear, the root canals show sharp density changes, or the apices cannot be well defined, then extra roots can be suspected! Horizontally angulated radiographs can also be helpful to distinguish the multiple root morphology of maxillary molars. Most definitive means however is visualizing the “road map” on the pulp chamber floor.

The following two cases had pulp chambers shaped like a quadrangle with one orifice in each corner.

Case 1: Tooth #14 (palatal roots length: 23mm on both)

Pre-op

Post-op

Case 2: Tooth #15 (palatal roots length: 25mm MP and 24mm DP )

Pre-op

Post-op

In both cases canals were instrumented with a combination of hand files and Protaper rotary instruments and sealed with Resilon cones and sealer using warm vertical condensation.

 
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Instrumenting Curved Canals

On 04/25/2010, In Instrumentation, Non-surgical Root Canal, By Vladimir Tismensky, DDS

It is often challenging to clean and shape curved canals. Most, if not all dentists who perform root canal treatment are familiar with this ugly feeling of breaking an instrument in the canal. I get a jolt down my spine and “butterflies” in my stomach when it happens.
To avoid these types of errors, I come up with a “game plan” and think through every case from the beginning to the end before I actually do it . It takes only a minute….

When I get a curved case, these are some of the things that go through my mind:

1. Slow down!!!!!!!!!!
2. Straight line access to make those curves gentler.
3. Lots of lubricant (RC Prep, Glyde, etc.) and irrigation (NaOCl, EDTA)
4. Use hand instruments more. (I may finish the apical third by hand, pre-curving stainless steel files or using Ni-Ti hand files)
5. Check patency more often with #6, 8 or 10.
6. Instrument in a “crown down” fashion.
7. I typically use Protaper files for rotary instrumentation, but in curved cases I will use those for coronal shaping and may choose Profile instruments (since they are landed and tend to stay centered in the canal and zip less) to finish the apical third.
8. Choose  rotary files with the lesser taper as well, like .02 rather than .04 or .06.
9. Do not “push” rotary files, they will break!
10. Be more conservative with apical enlargement.

Case 1: Tooth #32

Pre-op

Post-op

Case 2: Tooth #4

Pre-op

Post-op

 
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Nice Periapical Healing

On 03/30/2010, In Non-surgical Root Canal, Root Canal Anatomy, By Vladimir Tismensky, DDS

Tooth #4
Necrotic pulp with asymptomatic periapical periodontitis.

Pre-op

Instrumentation was completed with protaper instruments and hand files in the apical third.

Post-op

Warm vertical condensation using Resilon cones and sealer.

Follow-up 6 months

 
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Palatal Root Apical Surgery

On 03/30/2010, In Apicoectomy, Endodontic Surgery, By Vladimir Tismensky, DDS

Apical microsurgery has changed drastically with the use of microscopes, ultrasonics and new root end filling materials. It is now possible to minimize the size of the osteotomies, preserve bone and have access to difficult to reach areas. There are also prospective clinical studies with long-term follow-ups using current surgical techniques and materials that show over 90% success in saving natural teeth using apical surgery option.

This is an example of palatal root surgery.

Tooth #14 was retreated 1 month prior to this film. Regretfully, I lost apical control of my obturation on the palatal root and this tooth was symptomatic (biting tenderness).

Pre-op


All roots were resected, root-end preparations were made using ultrasonic instruments and MTA root-end fillings were placed.

MTA in MB1, MB2, isthmus, and DB

MTA in the palatal root

Post-op

5 days post-op at suture removal

18 months follow-op


At 18 months follow up, although radiographically there is no complete healing observed, the tooth is asymptomatic and functional.

 
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Trigeminal Neuralgia

On 03/25/2010, In Diagnosis, Trigeminal Neuralgia, By Vladimir Tismensky, DDS

Trigeminal neuralgia (TN), also called tic douloureux, is a chronic pain condition that affects the trigeminal nerve. The disorder causes extreme, sporadic, sudden burning or shock-like face pain that lasts anywhere from a few seconds to as long as 2 minutes per episode. These attacks can occur in quick succession. The intensity of pain can be physically and mentally incapacitating.

The presumed cause of TN is a blood vessel pressing on the trigeminal nerve as it exits the brainstem. This compression causes the wearing away of the myelin sheath. TN may be part of the normal aging process or can also occur in people with multiple sclerosis, or may be caused by damage to the myelin sheath by compression from a tumor.

TN is characterized by a sudden, severe, electric shock-like, stabbing pain that is typically felt on one side of the jaw or cheek. The attacks of pain, which generally last several seconds, come and go throughout the day. These episodes can last for days, weeks, or months at a time and then disappear for months or years.

The intense flashes of pain can be triggered by vibration or contact with the cheek (such as when shaving, washing the face, or applying makeup), brushing teeth, eating, drinking, talking, or being exposed to the wind. The pain may affect a small area of the face or may spread. The bouts of pain rarely occur at night, when the patient is sleeping.

The attacks often worsen over time, with fewer and shorter pain-free periods before they recur.

TN occurs most often in people over age 50, but it can occur at any age. The disorder is more common in women than in men.

There is no single test to diagnose TN. Diagnosis is generally based on the patient’s medical history and description of symptoms, a physical exam, and a thorough neurological examination by a physician.

(Source: www.nih.gov)

For a dentist, it is imperative to recognize symptoms and make an appropriate referral to a neurologist.

CASE

58 year old healthy white female was referred for an evaluation of pain in the maxillary right area. She reported spontaneous pulsating, stabbing like pain lasting for seconds to minutes in the area of tooth #3 occurring several times a day. This pain was also brought on by brushing her teeth around tooth #3, during eating and occasionally when washing her face.

Pre-op

Previous root canal on tooth #3 was done years ago. Clinically, tooth #3 tested WNL to percussion and palpation, and no response to cold. Perio probings no more than 4mm. Radiographically, normal periapical areas, untreated DB and possibly MB2 canals.

Post-op

Endodontic retreatment was completed, DB and MB2 were located and treated as well.

This lady was happy for exactly one week (no pain at all).

She came back two weeks later reporting “electric shock” like sensations, and feeling worse: pain was more severe and more often. A neuralgia was then suspected.

This patient was diagnosed with Trigeminal Neuralgia and placed on Trileptal (form of Tegretol) 300 mg BID by her neurologist after which her symptoms went away.

 
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Root Amputation

On 03/23/2010, In Endodontic Surgery, By Vladimir Tismensky, DDS

79 years old petite indian woman was referred for an evaluation of tooth #19. Her medical history included a hypertension and type II diabetes controlled by medications. She reported no pain, occasional bad taste and discomfort when eating. Clinical examination revealed periodontal probings right to the apex of a distal root of #19, and 4mm or less around the mesial root.

Pre-op

Treatment options:
1. Extraction and tooth replacement
2. Root canal treatment and distal root amputation.

Post-op

After root canal treatment was completed on the mesial root, dual cure core resin was placed into the distal root and a root amputation was completed.
When considering a root amputation, one must evaluate the face type, the musculature (how strong are the masseters, angle of the jaw, etc.), occlusion. This procedure may not work for a 30 y/o with bradycephalic face, however in older individual with weaker muscles of mastication, it can last a lifetime.

 
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