A Kase Quickie
WELCOME BACK all ye loyal readers and followers. First, I hope your New Year will be happy and healthy, and of course we can all look back with a great feeling of accomplishment and say we made it through 2011. Now on to 2012, and the start of a new cycle. There are, however, only eleven months or so till December 21st, so if you believe the Mayans, none of the informative material I present will really matter anyway. For those who think that the cycle will continue, well, here we go.
This is a quick review of a case that presented with a hopeless look and, initially, a guarded-to-poor prognosis. A patient came in with asymptomatic extensive bone loss associated with tooth #30 (Figure 1). The tooth had been endodontically treated a few years back and restored with a prefabricated post and core and PFM crown.When evaluating a case such as this for salvage, it is important that all concerns are addressed, both those that concern treatment and—just as importantly—those that concern the patient’s expectations. The clinical treatment side is obvious, but informing the patient of the risk vs. reward and all the alternatives to the treatment might not be as black-and-white. I have spoken many times in the past about the importance of obtaining informed consent—written, oral, or both—for any procedure you perform. However, when it comes to a more heroic treatment, the proverbial “Hail Mary” procedure, you’d better make sure you dot your I’s and cross your T’s.
This case radiographically in particular looked to be a knee-jerk “I take teeth out and put one in”! But there was more to it than that, thus making this a good illustration of the reason to do a good clinical exam. The tooth in question was asymptomatic, not mobile, and had no clinical pocket depth that communicated to the radiolucency. The PA radiograph showed obvious overextensions of filling material beyond the apex. Additionally, there was a suggestion of an unfilled canal on the distal root. All those were good reasons for a failure! I decided to CBCT scan the area, and the scan showed clearly that all suspicions were confirmed and, additionally, there was no loss of cervical bone—thus the tooth seemed to be periodontally intact. All in all, this was an endodontic failure for obvious reasons and perhaps it would be retreatable with the proper patient consent and expectations.
So what do you tell the patient? Everything, but for Pete’s sake let’s not be inflammatory and try to be dento-politically correct. You are obligated to tell the patient the diagnosis, prognosis, risks, and treatment alternatives. In this case, these certainly include ultimate loss of tooth; the usual aches and pains associated with disassembly and retreatment; need for a new post, core, and crown; finding a fracture; not being able to remove the old post or filling material; and separating the over-extension of material beyond the apex—among the many. So let’s get this party started!
After anesthesia and placement of the rubber dam, clamping 31 and dragging anteriorly to 29, which gives better visualization of the area for proper access orientation, I gained access. It was opened enough with new diamonds to remove the porcelain and a # 4 round to remove the underlying metal, all with copious water spray. Once I visualized the head of the post with a fine diamond I trephined around the post to the orifice of the prep. With my ultrasonic file tip, I was able to remove more of the interior composite core and free up the post. Using ultrasonics to loosen the post, I was able to rotate it out with a slightly modified Flexi-Post® wrench. Now that the post head was out of my way, I removed the remaining composite core to the pulpal floor, exposing all the canal orifices. I used a Pleezer reamer to try to remove the coronal filling material and met resistance. I found that I was hitting Thermafill carriers. With a drop of chloroform and .08 files used with reciprocation, I was able to work an instrument alongside each carrier. After expanding this guide path, I was able to engage the carrier with a 20 to 25 Hedstrom and extract the Thermafill carrier and thus—luckily—the over-extensions. I was also now able to identify the additional unfilled distal canal (Figure 2). All the canals were instrumented and filled using SafeSiders® and EZ-Fill®—I know, as we always do! The tooth looks great, and the patient feels great (Figure 3). Followup recall radiographs will be taken at three and six months. The access was temporized, and the patient was referred back for restorative.
So to conclude, yes this was heroic, but with proper diagnosis, treatment and proper informed consent consistent with the expectations of the patient the outcome may prove to be a big win.
A Kase Quickie
Updated Product Review: DentalVibe Gen II. I have been using the DentalVibe (Figures 4 and 5), since last year to reduce or eliminate the pain associated with local anesthetic injections. To refresh your memory, DentalVibe is a cordless, handheld, easy-to-use device designed to reduce the pain and fear associated with the dreaded dental injection in all areas of the mouth. As I said in my original review and follow-up, “It really works!” It is clearly not a “bells-and-whistles gadget,” but an invaluable addition to my everyday practice. When I think about how many injections I give in a day and the anxiety I see in the patients’ faces, anything that brings a smile and wipes away the fear and negative expectations is worth its weight in gold (particularly in view of gold prices these days)!
The DentalVibe works by using unique, microprocessor-controlled VibraPulse® technology to provide the most effective way to “close” the pain gate to the brain and block the discomfort of dental injections. The microsonic oscillations of DentalVibe’s comfort tips are pulsed in a controlled synchronized wave pattern. Along with enhanced amplitude, VibraPulse Technology sends a soothing percussive or tapping stimulation deep into the oral mucosa, stimulating the submucosal sensory nerve endings. The impulses that produce the sensation of touch or vibration travel very quickly along thick, myelinated, A beta nerve fibers at 75 meters per second. Pain sensation travels slowly along thin, unmyelinated, C nerve fibers at 37.5 meters per second. When the two occur at the same time, the vibrational sensation reaches the sensory area of the brain first, causing a release of inhibitory interneurons, preventing the activation of projection neurons, resulting in a closure of the gate to the sensation of pain.
So, okay, that’s the theory of how and why it works and now here is the nuts-and-bolts report on actual use. I can say that in every injection I have given using the DentalVibe there has been at the very least a great reduction if not total elimination of discomfort during the injection procedure. And since the release of the original unit it has now been upgraded to the second generation, Gen II. This version has better illumination, and it has twice the power, thus increasing the amplitude at the vibrating tip. This increase leads to greater sensory nerve stimulation, which enhances the pain-blocking effect. A new white tip increases visibility within the oral cavity. An increase in power output from the unit, coupled with the addition of many microfilaments further stimulates the oral mucosa, offering greater vibrational stimulation. So, with the release of the Gen II, I can confidently say that the DentalVibe has become my knee-jerk, go-to device when giving injections, and I would definitely feel a bit uncomfortable if I didn’t have it at my disposal. It still gets six out of five stars! Check out www.dentalvibe.com for more info and a technique video.
If any of our Endo-Mail family is interested in ordering the Dentalvibe Gen II, please use the Coupon Code “Kase” when ordering on the DentalVibe website for a $100.00 discount, which brings the price from $595.00 to $495.00.
January - March 2012