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.
This was a retreatment case where we had to negotiate towards the apical 1/3 before finding the canal. 3D imaging shows resolution of the distal apical finding. In deciding whether to retreat the tooth we followed the retreatment algorithm. The tooth was symptomatic, and while there was some significant tooth removal during the prior treatment and crown, the tooth still has enough tooth structure to meet the patients expectation.
The distal invagination of maxillary molars can create a bit of a challenge when adapting a matrix band. There are lots of matrix options, but if your normal armamentariam is a toffle-meyer and band, then an application of a little Dycal can help out. Just a dab applied with a perio probe to fill the space. Then smooth carbide to clean up the flash. This can be removed an interproximal carver at the time of amalgam carving or later with a scaler. Having this tip in the bag helps one practice Restoratively Driven Endodontics.
We got a two year followup on this patient when looking at the premolar. There were three mesio-buccals on this case. The patient requested we keep the crown so we salvaged the mesial margin with amalgam.
Simply put, parfocus in endodontics is where the object of interest is in focus for the endodontist, the scopeside assistant, and the camera. The lack of parfocus can lead to team incohesiveness, lack of efficiency, headaches, and poor documentation. I’ve seen a number of methods for parfocaling. This is mine; it’s worked for me when many other methods haven’t. There are two distinct parts of parfocaling the scope: parfocaling the rig and parfocaling the case.
Parfocaling the Rig
Step 1. Make sure all the components of the microscope are tight . With a fully loaded rig, there are many parts including spacers, beamsplitters, dual iris, and binoculars. You want to make sure each of these are completely aligned, seated, and tight. You may need an allen wrench or screwdriver depending on your setup.
Step 2. Using either your dental chair, desk, or sliding backwall worksurface create a horizontal worksurface and place some fine print on it. Bring the scope around so that you can comfortably look into the scope and view the fine print under the microscope. Adjust the binocular inclination and interpupillary distance so that your comfortable and you see one circular image surrounded by a singular clear black ring. Set both of the oculars to zero (+/-). Bring the image into decent focus at first second to highest mag, then highest mag. It does not need to be in perfect focus at this point. Now, lock down all 6 knobs on the rig such that it can’t move at all in any plane.
Step 3. If you have a dual iris, open it all the way. If your camera adaptor has an iris, make sure it’s open all the way. Take a picture of a single letter of the fine print. Pull the captured image up to full size on your best monitor in the operatory. Then adjust the fine focus. And take another picture. It will be either better or worse just like at the optometrist. If it’s better, keep going in that direction. Worse, reverse it. Keep playing better or worse using the images on the monitor until you get perfect images. The body of the microscope and your camera are now parfocaled. Trouble at this stage means there is likely something not set up correctly in the microscope setup downstream of the beamsplitter.
Once in focus, all lower mags will be in focus. Due to the open iris they will be overexposed.
Step 4. You have a decision to make here. Glasses or no glasses. I wear flat faced glasses for eye protection. But to each their own. If you typically wear glasses, put em on. Using just the right eye adjust the ocular as you look into the scope. Slowly adjust in the plus direction. Like before, if + is better keep going. If not reverse it. Keep going until things start to get worse. If After you finished dialing in the right eye, repeat with the left. Now go to the lowest setting and double check each on their own. If an adjustment needs to be made use the ocular adjustments at the lowest setting. Make note of your new ocular settings. Do it either mentally, or with a wax pencil. You don’t want anything permanent, because as we age things will change.
Step 5. With the rig still locked down, have your scopeside assistant adjust his/her ocular in the same way you just did. Your rig should now be parfocaled.
Parfocaling the Case
After adjusting the scope for comfort for both the endodontist and scopeside assistant, using the patient chair bring the cavosurface of the tooth into focus at first low, then medium, and finally high magnification. With the iris wide open, take a picture. The picture should be clear and in focus albeit over exposed. The case is now parfocaled. Depending on the depth of the chamber, the focus may need to be adjusted, but most of the case should be in focus throughout the rest of the procedure. Before taking pictures, bump the mag to high and fine-focus using your legs underneath the chair.
We are really passionate about rehabilitating teeth with restorative endodontics. The vision is to share our idea of quality endodontics through our lens with a pile of cases. So, if you want your fix, sign up!
You must be logged in to post a comment.