• December 2018 •

From the Endodontic Offices of Musikant, Kase, Dukoff, Kim, Matt & Goswami

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THIS WAS THE YEAR THAT WASN'T

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Doug Kase, D.D.S.

As 2018 draws to a close,
There’s one thing to look forward to everyone knows!
The year went so quickly as to blur the time line,
It’s that moment again for my holiday rhyme.

It’s hard to believe in only 365 days,
So much has happened it truly does amaze!
Looking back at what transpired it really is a blur,
With what comes out of Washington the truth it does obscure.
(Continued)

New Internal Bleaching Solution Making Endo Easier

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Amy Dukoff, D.M.D.

Dr Amy Dukoff with be presenting at our office on the proper Application of E-Rinse White for Internal Bleaching at our office on October 4th - 6:30PM It removes the dirt & debri & organic material from within the dentin;

- Aids in removing pulpal tissue trapped in the pulpal calcifications.

- Aids in removing the trapped dirt and stains and dead tissue from under the pulpal calcifications

- Facilitates locating the pulpal orifices by removing the unwanted pulpal debri, dirt, stains, tissue in order to improve the illumination - the way light passes through the dentinal tubules- improving visibility inside the tooth.

This Course is FREE and good for 2 ADA CE Credits!!

-- As always light food and refreshments will be served.

RSVP:

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Endodontic Failures

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Doug Kase, D.D.S.

In review of the endodontic failures that come through the office, a great many of them are due to vertical root fractures rather then actual failure of the RCT. This particularly seems to be associated with treatment that uses the aging standard of greater taper. Greater tapered canal preparation of .06 and.04 result in more tooth structure removal hence weakening the root which makes the tooth more susceptible to vertical fracture. As the standard of care is changing to thinner and thinner canal preparation to conserve root structure, the expectation is to see less of an occurrence of fracture over time. The use of rotary or interrupted rotary NiTi is inconsistent with minimal root preparation since it it indiscriminate in both the buccal-lingual and medial-distal dimensions. The use of .02 stainless instruments in a reciprocating hand piece allows targeted instrumentation by internal routing of the canal walls in the buccal-lingual direction while conserving tooth structure in the thinner mesial-distal dimension. Additionally this easily accomplished with NO FEAR of instrument separation.

(Continued)

ENDO Tip of the Week - Using an Apex Locator

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Doug Kase, D.D.S.

Using an apex locator! First and foremost, use of an apex locator is the standard of care. It’s a common question and complaint in every malpractice issue I have defended, particularly those involved with overfills and nerve damage to the mandibular canal. So if you have one, please use it. If you don’t have one, please buy one!

It is important to realize that the mechanism by which the apex locator works is the completion of an electrical circuit, lip ground to canal. If one of those contact points is not able to conduct, then there will be a faulty measurement which can lead to over instrumentation or under instrumentation. Thus it is imperative that proper contact is made on the lip ground. A dry lip and lip ground will not conduct well, so wet the lip ground before placement and continually check that the lip is moist under the rubber dam during the procedure. Additionally and equally important, a completely dry canal will be a poor conductor. So it is important to make sure the canal is damp. Using a little RC Prep on the instrument will solve this. A wet pulp chamber, particularly in contact with a metal restoration or tissue will throw the reading off. Don’t use a loose fitting instrument. Use one that has some contact with the canal walls for a more accurate reading. With a little snugness you won’t disturb the position of the instrument as you slide your stop into position. If you are getting close to a measurement of 22 to 25 mm you may want to use a 31 mm instrument so tooth structure or the rubber stop prevent you from getting the instrument clip on firmly. You can also attach the instrument clip to the end of a college plier thus making the plier an extended clip. If you clip it to one end of an explorer it makes a wonderful probe to check for perforations.

A confirmation radiograph can be taken if you feel more comfortable doing so, but I would definitely suggest it if the apicies are in close proximity to the mandibular nerve or any other risky anatomy. Additionally if your locator is not responding in the normal fashion that you are used to, take a confirm radiograph. Calcified apices and debris blocked apicies will also throw off the reading. Hope this is of help. More tips to come!

(Continued)

Evolutionary Endodontics: Two Pathways, Different Outcomes - CE Credit

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Barry L. Musikant, D.M.D., F.A.C.D.
Evolution applies to both life and innovation. In endodontics, productive innovation leads to a better quality of life, at least orally speaking. Evolution is all about competition, with the winners being those that best adapt to a changing environment. In the practice of endodontics, we have competing systems that at times cross paths, but start from different premises.(Continued)

Kase of the Month - Root Amputation Procedure

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Dr. Manisha Goswami

What would you do if a patient presented with a failing root canal retreatment or a failing apicoectomy?

( ) Continue watching the Super Bowl
( ) Retreat the retreatment
( ) Extract the tooth
(X) Dental root amputation

Dental Root Amputation Procedure

Dental root amputation is described as the surgical removal of one of the roots of a multi-rooted tooth. This procedure is carried out to remove disease, to prevent further bone loss and/or to remove part of the tooth that has a tooth fracture. This procedure is indicated in patients that present with a failing root canal retreatment (RCT) or a failing apicoectomy. This option is worth exploring if a patient wants to save their tooth. Dental root amputation may prolong the viability of a tooth for a few years. Case selection is of utmost importance prior to performing this procedure. Long-term survival rate of a resected tooth is 83% at five years and 68% at ten years. Lower molars usually fail due to root fracture while the upper molars usually fail due to periodontal breakdown progression.

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Kase of the Month - Never Assume

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Doug Kase, D.D.S.

There are time when assumptions just don't hold water. We all sometimes assume that the anatomy of many roots are written in stone. Maxillary anterior teeth should have only one canal and any irregularities seen on a radiograph are attributed to invaginations in root morphology or artifact, because how could a central, lateral or canine have 2 canals or for that matter 2 roots. We all know that the appearance of an MB2 canal in a maxillary first molar happens 65% of the time. This is not "fake news"! Lower first premolars can easily present with 2 canals. Maxillary second molars can have an MB2 as well. Thus it becomes imperative that we don't accept root or canal morphology as "knee jerk or boiler plate." Angled PA radiographs from both the distal and mesial are helpful. A CBCT scan would be imperative if in doubt. Wouldn't it be nice to know the actual number of canals in a tooth before needless excavation is started and tooth structure is undermined rendering the root more susceptible to fracture. If it is present, then using a scope and conservative excavation is indicated. Don't take it for granted!

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Kase of the Month - Irrigation is King

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Doug Kase, D.D.S.

In endodontics as with many other things in life there are no shortcuts. Everything that leads to a successful outcome when doing root canal is dependent upon the preceding steps when initiating treatment. Obviously proper diagnosis Is first. To avoid the dentolegal stuff; communication, alternatives, documentation and consent are paramount as well! Cutting to the nitty gritty, when doing root canal if you don't have proper irrigation, the treatment will probably not fall into the success rate of standard endodontics. Debridement is dependent on irrigation, thus If there is not enough irrigation solution in your canal contacting tissue and canal walls the you aren't debriding properly. Whether it's 5.25% sodium hypochlorite, 18% EDTA, or your final irrigation solution of 2% chlorhexidine, all must ultimately get close enough to the apex to do their job. Using 30 gauge needles bent to follow the canal with no wedging and light pressure is key. Delivering solution to the apex is also done with negative pressure irrigation systems where the irrigant is drawn from the pulp chamber to the apex under suction. Most importantly establishing a proper glide path and shape to a patent apex is the key to getting solution to the apical 1/3. Once you start creating your shape and approach a your expected taper the irrigation needle can be placed in a more apical direction. You can't get a 30 gauge needle down a canal that's been instrumented to a 25 with no taper in the proper dimension. That's just math!

(Continued)

Risk Management and Endodontics

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Doug Kase, D.D.S.

Doug Kase will be presenting on risk management issues in Endodontics.

THERE ARE TWO SIDES to every story, two peas in a pod, and it still takes two to tango. So with the word two in mind, our office has two philosophies when it comes to endodontics.

First, we have always thought that one of the best ways to help our referrers is to TEACH them to do ENDONONTIC TREATMENT as we do it.

Now to our philosophy number two: to teach you WHEN to REFER. Providing the best care possible for the patient is intimately tied to doing good acceptable endodontics. Thus case selection is paramount.

I have had the opportunity over the past years of doing professional review to defend colleagues of mine. In all cases there is one common line in the bill of particulars that plays the same tune: failure to refer to a specialist. Now of course there are plenty of clinical circumstances in which bad things happen to practitioners with good intentions. But when an endodontic case fails because a dentist missed a canal or because a calcification made a canal unobtainable and a specialist retreats successfully, failure to refer becomes a more pertinent issue and more difficult to defend. It goes back to that raised bar I talked about earlier. Your standard of care has to be the same as that of the specialist you might eventually refer to. Please understand that I am clearly not telling my loyal readers to refer every case to your friendly neighborhood endodontist, although that would a home run, but use your best judgment.

When:

Thursday, May 17th: 6:30 PM

Where:

119 West 57th Street, Suite 700 New York, NY 10019

RSVP:

https://www.meetup.com/manhattan-dentists-club/events/250370867/

2 CE ADA Credits!!

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Kase of the Month - Persistence is Key!!

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Doug Kase, D.D.S.

Every once in a while it's good to be the hero. After all go ask Ironman and Superman their opinion and I'm sure they will agree. Failure of a prior root canal just happens. It can happen for many reasons as I pointed out in a prior case. So let me repeat for a brief moment. There are obvious reasons we may see either clinically or radiographically. Caries contamination for starters. A failed, well obturated with all canals identified RCT that has had long standing decay in the chamber is a good reason for failure and re-treatment. Pretty obvious!! Short fills, missed canals, lateral canals and under instrumented canals are all reasons for potential failure with the ability to retreat and resolve. Sometimes there separated instruments and sometimes there are post removals involved which require dismantling of the restorative. Obviously the key is diagnostics. Some are apparent and some not so much!  For me a CBCT IS THE MOST DIAGNOSTIC TOOL WE HAVE AT OUR DISPOSAL. It gives us the blueprint for re-treatment direction. Using a microscope allows us to more precisely locate the cause once we have our game plan in mind. 

(Continued)

Mandibular Incisors

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Sara Kim, D.M.D.
In the past, I have spoken about the anatomy of posterior teeth but I want now to talk about mandibular incisors. A patient walks into your office and you determine that he or she needs root canal treatment on a mandibular incisor. You may think “Piece of cake!” after looking at the radiograph, which appears to have a single narrow canal. Yes, you are correct that mandibular incisors usually (97-98%) have a single canal but these single canals tend to be wide labiolingually.(Continued)