Sharing Passion for Fixing Teeth With Endo
Patient Centered Endodontics: The Rehabilitation of Compromised Teeth
Seeing as how this case was both apically perf’d and had a large lesion, I would toss it into the problem case type bucket. But we gave it our best, and it looks like that was enough. I’m not sure I ever found the true path. Sometimes it’s worth taking a shot. Looks like things resolved completely in both 2D and 3D.
This patient was in for another tooth so we grabbed a followup of this case we performed 6.5 years ago. Pretty extensive distal caries under the crown. The wide platform lended itself to a truss access. Root-form appropriate instrumentation was completed. We used some bent ultrasonics for chamber cleanup and some bent pluggers to manage the amalgam utilizing a custom resin matrix. We can see the results of deep margin management over time.
Same patient-both teeth probed more than 9mm in the furcation area. In both cases we placed the tooth in medication for a few months during which time the probings decreased to 3mm or less. In both cases, the prognosis is excellent. At two years the first case shows radiographic clearing. Perio of endodontic origin works out well. Primary perio- not so much.
This is the same patient as the prior post but contralateral side. She had extensive decay under the existing crown which didn’t leave much to work with. It was a pretty tough case to band and I couldn’t get it to stay on so I created a custom resin matrix out of Opaldam. Things still look good for this beat up tooth for almost a decade.
Terminal teeth are tough to band and keep rubber dam isolation. So we came up with an alternative- the custom resin matrix. Using green opaldam we make a custom matrix to pack amalgam with or place a controlled field resin. Often we use the technique subgingivaly on bone. For first iterations we used white Opaldam but found it hard to discern on bone. The green is easier to see and thus remove. Waiting 5 minutes or so for the amalgam to harden makes the green matrix easier to remove
Lower canines seem to exhibit a higher degree of prevalence of external resorption than other teeth. Perhaps it’s the higher forces as they guide the occlusion. Perhaps it’s their position as the corner of the arch which. Perhaps its the periodontal treatments that these teeth undergo. Or maybe it’s something else. 3D imaging helps determine the restorability of these teeth. When the resorption passes two line angles most times I’ll throw in the towel. This was the case with the contralateral tooth. By way of clinical classfication this one was external moderate scooping resorption. As is always the case there is osseous in-growth. It’s important to remember that there is hard tissue replacement when reading the scan or the extent of the resorption may be underestimated. It’s important to remove the osseous ingrowth and resect it back until healthy periodontal ligament can be observed under the microscope. As is typical of these cases, the soft tissue looks good at 48 hours during the suture removal appointment.
Kind of an interesting case. Not a lot of tooth to start; we went with a fiber post initially. It broke off at a year. We redid it with a stainless post. Looking good 4 years out. If there’s a failure, I have little doubt that it will be catastrophic- as in the tooth will break.
This is one of those pesky problem case types- the “dreaded disto-palatal” rooted tooth. There is furcal bone loss present, and further, the bone loss proceeds around all the roots and heads distal quite a bit. After six months in calcium hydroxide I thought things were improving and root-filled the tooth. At two years, not much healing could be observed and the swelling returned. We decided surgery was the best option to retain the tooth. Some of these I’ve been doing with resection, retro-preparation, and retro-fillings like this one. Some I’ve just removed the soft tissue. Both approaches seem to be working when I was the one performing the original endodontics.
We used imaging to determine the restorability of this tooth. Based on the resorption classification for clinicians, this is a case of external crestal resorption of the scooping variety. For the deep margin management we chose DME. The patient said she would be happy with 5 years, now we hope for more.
Precision endodontics was a concept John and I were planning to explore in more depth in the text Advanced CBCT for Endodontics: Technical Considerations, Perception, and Decision-Making (Khademi). Like many other noble concepts John wanted to bring to light in that work, the topic was edited bringing the focus back to CBCT by the editor. Still I think the topic is well worth exploring especially in terms of treatment planning and prognostication in endodontics. Wikipedia defines precision medicine as “a medical model that proposes the customization of healthcare with medical decisions, treatments, practices, or products being tailored to the individual patient.” It follows that precision endodontics is a dental model that proposes the customization of healthcare with endodontic decisions, treatments, practices, or products being tailored to the individual patient. In this model, diagnostic testing is often employed for selecting appropriate and optimal therapies based on the context of a patient’s endodontic condition.
The context of precision endodontics is wide ranging as are the management strategies clinicians chose to prescribe and execute. Generally speaking in endodontic management, decisions are based on which teeth or roots of teeth are to be managed, and how they are to be managed.
In this case, precision endodontics refers to both which, and how the patient was managed. This patient presented with pain and swelling associated with this anterior bridge abutment. CBCT imaging suggested an apical finding limited to the mesial root only. Early in my career, I would retreat the entire tooth. In some instances we would see radiographic clearing of the problematic root only to see radiographic findings and develop on another root that previously presented without findings leading to symptoms. Sort of along the lines of if it ain’t broke, you can’t fix it. CBCT appears to give us better indications of what is “broke” and what isn’t. In this case, in determining whether to retreat the distal root we appreciated the screw post and the bridge that the core supported and realized there were significant associated risks with retreatment and little potential benefit. In this way, imaging diagnostics helped us tailor which tooth and which roots were to be managed. To this extent, we were able to address precision endodontics and further explored the idea as it pertains to interim CBCT’s and management of maxillary molars.
The concept of how to tailor care for patients based on similar case types has been around for a long time with it’s inception stemming from the observations about outcome failure. Humans are pattern generating machines by nature and as such clinicians categorize patients and their conditions and then assign probabilities of the success of their management strategies based on followups. Say for example a clinician has a patient who has significant swelling or drainage from a tooth. Perhaps the clinician, with experience, notes that if endodontic management of that patient type is performed in a single visit there may be an increase in complications, failure to resolve the condition, or subsequent failure to meet patient disease centered or patient centered outcomes. Alternative strategies including management with an interim medication such as calcium hydroxide with temporization is employed and perhaps an increased predictability is observed. Both the duration of time during which the medication is utilized and the frequency with which it is applied can be customized to the perceived needs of the patient. The idea of providing as little or as much therapy as deemed necessary has been referred to as a “titrated treatment”. Managing the case with as many or as few appointments as necessary has been referred to as an “N step” treatment. Both concepts are related to customizing treatment based on the need for varying degrees of time and or type medicament to achieve a favorable outcome.
Many cases are straightforward such as a tooth with caries to the pulp and can be predictably managed in a single visit. For many clinicians, resolution of symptoms offers a degress of predictability, and many teeth are amenable to 2 visit endodontics. However, there are degrees of case types that present as a problem in that they aren’t as predictable with single or even two visit endodontic management. These are loosely referred to as problem case types. For those problem case types in addition to resolution of symptoms we may value clinical features such as resolution of sinus tracts, resolution of deep probing depths, resolution of intraradicular drainage, decreased mobility, and radiographic clearing. Certainly the number of problem cases one may encounter is a function of both the spectrum of patients that are referred, as well as the inclination to evaluate outcomes at different time intervals. The conclusions are no doubt subject to confirmation bias among other cognitive problems that murky the waters of outcomes and thus endodontic decision making.
In this case, we employed calcium hydroxide medication over the course of 3-4 months. We waited for resolution of symptoms as well as the cessation of intraradicular drainage. Additionally, signs of radiographic clearing are evident at the obturation apppointment.
The concept of precision endodontics is important in both navigating a more current retreatment algorithm as well a comprehensive approach to endodontic treatment planning.
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