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Practice Profile

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Dr. Fleur A. Blethen

Dr. Fleur A. Blethen

Empathy, tenacity, and perseverance are keys to this clinician’s flourishing practice  What can you tell us about your background? I was born and raised in Seattle, Washington, and lived there until I was 13 years old. My family relocated...

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Dr. Ernest Reeh, Practice Profile

Dr. Ernest Reeh, Practice Profile

Focus on patients, family, academics, and endodontics What can you tell us about your background? I have a bachelor’s degree in chemistry with a minor in business. I was accepted off of the alternate list for dental school and then attained...

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Practice Profile - Dr. Anthony Horalek

Practice Profile - Dr. Anthony Horalek

Practice Profile | Dr. Anthony Horalek: The art and science of endodontics.

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Clinical Articles

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GuttaCore® system: a step forward in the evolution of endodontics

GuttaCore® system: a step forward in the evolution of endodontics

Dr. Andrei Zoryan dispels some of the common myths surrounding carrier-based obturation Carrier-based gutta percha Carrier-based obturation (such as Thermafil®, GT® obturator, ProTaper® obturator [Dentsply Tulsa Dental Specialties]) is one...

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Endodontic retreatment of a lower right first molar with WaveOne®

Endodontic retreatment of a lower right first molar with WaveOne®

Dr. David C. Baker uses a technique that facilitates quick and predictable results Patient history The patient is a 34-year-old female who was referred by a local colleague. She had broken her lower right first molar and complained of some general...

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The Laschal FXP set incorporates transferred oscillation technology

Background There are other ultrasonic devices on the market that depend upon direct contact with a separated file to loosen and remove. However, it is absolutely impossible to restrict the contact of the tip to the file remnant itself. The vibrations...

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Practice Management

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Superior customer service

Superior customer service

Dr. Roger Levin presents the 10 top ways to help create a perfect dental team With the changes brought on by the economy, top companies are bringing in the best resources they can find to evaluate where their organizations stand. They want to know...

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Office Matters: Hard-piped filtered water system vs. self-contained bottled water system

John Bednar helps avert problems coming down the pipe If your office currently has a hard-piped filtered water system, now is a good time to consider if and when you should change to a self-contained bottled water system. A hard-piped filtered water...

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Secrets to financial and personal freedom for endodontists

Secrets to financial and personal freedom for endodontists

In part 1 of his series, Dr. Ace Goerig offers the first steps to becoming debt-free I was presenting at a recent AAE national meeting with over 200 endodontists in the room, and I asked the question, “How many of you are completely debt-free?” ...

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Orsteen_1_copy

Dr. Nicolai Orsteen describes a complicated RCT treatment



A 24-year-old white Northern European man presented with the chief complaint of pain from the maxillary left lateral front tooth, with periodic swelling of the left anterior palatal.

The patient’s dental history indicated previous problems in this region, documenting an emergency appointment in March 2007 due to pain and swelling from tooth No. 22. He was prescribed a 7-day course of penicillin V tablets (660 mg qds*4) for acute apical periodontitis in tooth No. 22. Following this appointment, the patient was referred for examination and treatment of tooth No. 22.

Diagnosis
The extra-oral examination was within normal limits, visible in Figures 2 and 3. Screen_shot_2012-01-06_at_1.55.34_PM
However, as is indicated in Table 1, the intra-oral examination revealed gingival bleeding on probing, no sinus tract, and fluctuant swelling of the palate mucosa in the area of teeth Nos. 21, 22, and 23. The periodontal pockets, however, were within normal limits.

Further radiographic investigation in April 2008 revealed that the patient was suffering from a discontinuation of the lamina dura on tooth No. 22, as well as a large circumscribed apical radiolucency (Ø 15 mm). The radiographic findings in the coronal part of the root were diagnosed as dens in dente (Figure 4).

Following the investigations, the diagnosis showed that a periradicular abscess was related to non-vital tooth No. 22. The problems associated with the diagnosis were a wide root canal and an open apex with large apical lesion.
The structured treatment plan involved conventional root canal treatment (RCT), and an assessment for surgery after 6 months.

Treatment
Treatment commenced in April 2008. Following an initial clinical examination, the tooth was diagnosed with an apical abscess (no sinus present). Access was gained under a rubber dam, and the canal was filled with exudate.The root canal length was determined both by apex locator (RootZX®, J. Morita) and a periapical radiograph. The root canal disinfection was completed mechanically using Hedstroms files (size 90/20 mm/incisal edge).

Screen_shot_2012-01-06_at_1.58.17_PM

Particular care was taken during irrigation due to the open apex, and ultrasonics was used for the further cleaning of the canal. A formula of 1% NaOCl,  2% chlorhexidine, and 17% EDTA was used for chemical root canal disinfection. The canal was dressed with Ca(OH)2, and an intermediate restorative material (IRM) was applied as a temporary filling.

Five days after the completion of the treatment, the patient sought an emergency consultation because of severe pain and swelling from tooth No. 22. He was prescribed an 8-day course of clindamycin (500 mg x 3*3) to ease the discomfort.

Following the surgery, in May, tooth No. 22 was asymptomatic and sensitive to percussion. The temporary filling was removed, and the root canal disinfected again with Irrisafe® (Satelec), as well as a formula of 1% NaOCl, 2% chlorhexidine, and 17% EDTA. A long-term intra-canal dressing with Ca(OH)2 was placed, and an IRM was applied as a temporary filling.

The patient missed the following three appointments, but returned in October. On this date, the tooth was still sensitive to percussion and palpation. As there were no real signs of improvement, it was decided that the tooth should be root filled, and an appointment for apical surgery was made. To ease discomfort, the root canal was filled with an 8-mm length of white mineral trioxide aggregate (MTA), and a wet cotton pellet was placed over the MTA. A temporary filling with IRM was placed on top of the cotton pellet.

The re-operative procedure was carried out in November. A marginal incision from the mesial aspect of tooth No. 21 and to the distal aspect of tooth No. 23 was made, followed by 5-mm vertical releasing incisions at the mesial aspect of tooth No. 21, and a length of 10 mm at the distal aspect of tooth No. 23. The mucoperiosteal flap was elevated (Figure 10), and a pathological fenestration of the cortical buccal bone was evident, approximately 3 mm from the marginal bone crest between teeth Nos. 22 and 23. An osteotomy was performed, after which the lesion was treated by curettage. A biopsy of the lesion was taken. The palatal cortical bone also had a pathological perforation, a root-end resection of about 3 mm of the root. The root end was inspected through the operating microscope, and no fracture was found. The adaptation of the white MTA to the root canal was judged as good, and the operation site was inspected and rinsed with sterile saline, before being sutured with five 6-0 silk sutures.
The patient was informed about the prognosis of the tooth and given postoperative instructions. Six 400 mg ibuprofen tablets were dispensed, and the patient was instructed to take 1 every 4 hours on the first day after surgery. A prescription of penicillin V tablets (qds 660 mg *4) for 7 days was also given. The sutures were removed seven days later, and there was evidence of good soft-tissue healing. The patient experienced no discomfort from the surgical site.

Result
The temporary filling and cotton pellet were removed during the post-treatment restoration procedure, and replaced by a composite restoration (35% phosphoric acid, 3M ESPE Adper™ Scotchbond™, Filtek™ Flow [A3] in the apical part, and Filtek™ Supreme [A3D and A2B] in the coronal part). Teeth Nos. 21 and 23 maintained vitality. The histological report of the lesion showed a partial epithelium-lined cystic with a radicular cyst.

Screen_shot_2012-01-06_at_1.59.03_PM

Prognosis
The patient’s long-term prognosis is uncertain, due to the thin root canal walls and risk of fracture.

Follow-up
At a 12-month post-surgery appointment, the patient was still asymptomatic. Teeth Nos. 21 and 23 were sensitive to an ice-test, and there were no periodontal probing depths over 4 mm around tooth No. 22.

Screen_shot_2012-01-06_at_1.59.44_PM

Bio
Nicolai Orsteen, BDS, DMD, DFO, is a specialist in endodontics practicing at EndoCare in London. Dr. Orsteen graduated from the University of Oslo in 2002, completing his specialist training in endodontics in 2009. He worked in general practice in Oslo from 2002 and was also a secretary on the regional dental board in Norway 2004-2006. Starting in August 2008, Dr. Orsteen worked at a specialist practice in Oslo before joining the specialist team at EndoCare. For more information please email This email address is being protected from spambots. You need JavaScript enabled to view it. or visit www.endocare.co.uk

References
1. Christensen G. Current paradigm shifts in dentistry. Dent Today 2007;26(2):90-94.

2. Wu MK, Shemesh H, Wesselink PR. Limitations of previously published systematic reviews evaluating the outcome of endodontic treatment. Int Endod J 2009;42(8):656-666.

3. Gutierrez JH, Aguayo P. Apical foraminal openings in human teeth. Number and location. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995;79(6):769-777.

4. Haga CS. Microscopic measurements of root canal preparations following instrumentation. J Br Endod Soc 1968;2(3):41-46.

5. Yu DC, Tam A, Schilder H. Root canal anatomy illustrated by microcomputed tomography and clinical cases. Gen Dent 2006;54(5):331-335.

6. Wu MK, R’oris A, Barkis D, Wesselink PR. Prevalence and extent of long oval canals in the apical third. Oral Sur, Oral Med Oral Pathol Oral Radiol Endod 2000;89(6):739-743.

7. Mauger MJ, Schindler WG, Walker WA 3rd. An evaluation of canal morphology at different levels of root resection in mandibular incisors. J Endod, 1998:24(9):607-609.

8. Tan BT, Messer HH. The quality of apical canal preparation using hand and rotary instruments with specific criteria for enlargement based on initial apical file size. J Endod 2002;28(9):658-664.

9. Allen FW. In vivo study of apical cleaning. Gen Dent 2007;55(5):449-454.

10. Ash MM (1993). Wheeler’s Dental Anatomy, Physiology and Occlusion 6th ed. W.B. Saunders, Philadelphia: 232.

11. Versumer J, Hulsmann M, Schafers F. A comparative study of root canal preparation using Profile .04 and Lightspeed rotary Ni-Ti instruments. Int Endod J 2002;35(1):37-46.

12. Prashanth VS. Evaluation of new system for root canal irrigation to conventional: an ex vivo study. Discus Dental, Culver City, CA: The EndoFiles Newsletter, Summer 2008.

13. Kerekes K, Tronstad L. Morphometric observations on root canals of human anterior teeth. J Endod 1977;3(1):24-29.

14. Kerekes K, Tronstad L. Morphometric observations on root canals of human premolars. J Endod 1977;3(2):74-79.

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There remains a growing belief among clinicians that obturation is to blame for endodontic failures. This notion has more recently fallen under scrutiny as researchers have discovered that the most thorough obturation can only reflect the quality of the cleaning and shaping of the canal. In fact, a number of researchers point to the thorough use of irrigants — making sure that the debris and irrigant itself are lifted completely out of the canal, not forced out the apex — as the most important determinant in the long-term success of an endodontic procedure.

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