Archive for June, 2012

Trends in Endodontic Therapy: Regenerative Endodontics

Monday, June 25th, 2012

By Aaron Welk, D.M.D.

One of the challenges in endodontics is the treatment and management of an immature tooth with a necrotic pulp.  Traditional treatment approaches include creation of a hard barrier which root canal filling material can be obturated against.   This root end closure procedure is called apexification.  Calcium hydroxide apexification is a procedure that allows for the induction of a hard tissue barrier apically [1].  One of the disadvantages of this approach is it can take a many months for the barrier to form.

The introduction of Mineral Trioxide Aggregate (MTA) in the 1990’s allowed for a similar approach [2] to creating apical barriers in a timelier manner [3].  With MTA apexification, an immediate barrier could be placed.   Both calcium hydroxide and mineral trioxide aggregate have been proven clinically, but with the absence of continued root development, both techniques leave the roots with thin dentin walls and short overall root length, leaving the tooth more susceptible to failure due to root fracture [4].

Regenerative endodontics is a contemporary approach to addressing this problem.  This procedure uses tissue engineering principles in facilitating the continued growth and development of the pulp-dentin complex.  In other words, when you have a case with an immature apex and necrotic pulp, regenerative endodontics allows for continued root development, thicker dentin walls, longer root length, and a closed apex, thus reducing the risk of fracture during tooth function.

Success is dependent on the activity of a newly identified population of stem cells, the so-called stem cells from apical papilla (SCAP) (Fig. 23-38) [5], a hidden treasure with enormous potential for tissue regeneration and bioroot engineering [6].

 

All immature teeth with open apices may be considered candidates for regenerative treatment, even if they have obvious pulp-space infection, a discharging sinus, or have been previously root canal treated [7].

Bioengineering has a tremendous potential in dentistry.  Researchers continue to optimize scaffolds that may encourage revascularization of the pulp space, and to explore the options of seeding cell populations into the properly sterilized pulp spaces of immature teeth [8].  Dentistry’s call for action has never been louder as we seek effective, biologically based treatments for our pediatric patients.  If you have questions about pulp regenerative procedures, I encourage you to contact your local endodontist to discuss this topic.

The pulp regeneration procedure is as follows [9]:

Case Selection

  • Tooth with necrotic pulp and an immature apex
  • Pulp space not needed for post/core, final restoration
  • Compliant patient
Informed Consent
  • Two (or more) appointments
  • Use of antimicrobial(s)
  • Possible adverse effects: staining of crown/root, lack of response to treatment, pain/infection
  • Alternatives: MTA apexification, no treatment, extraction (when deemed nonsalvageable)
  • Permission to enter information into AAE database (optional)
First Appointment
  • Local anesthesia, rubber dam isolation, access
  • Copious, gentle irrigation with 20ml NaOCl using an irrigation system that minimizes the possibility of extrusion of irrigants into the periapical space (e.g., needle with closed end and side-vents, or EndoVac). To minimize potential precipitate in the canal, use sterile water or saline between NaOCl. Lower concentrations of NaOCl are advised, to minimize cytotoxicity to stem cells in the apical tissues
  • Dry canals
  • Place antibiotic paste or calcium hydroxide. If the triple antibiotic paste is used: 1) consider sealing pulp chamber with a dentin bonding agent [to minimize risk of staining] and 2) mix 1:1:1 ciprofloxacin:metronidazole:minocycline
  • Deliver into canal system via Lentulo spiral, MAP system or Centrix syringe
  • If triple antibiotic paste is used, ensure that it remains below CEJ (minimize crown staining)
  • Seal with 3-4mm Cavit, followed by IRM, glass ionomer cement or another temporary material
  • Dismiss patient for 3-4 weeks
Second Appointment
  • Assess response to initial treatment. If there are signs/symptoms of persistent infection, consider additional treatment time with antimicrobial or alternative antimicrobial.
  • Anesthesia with 3% mepivacaine without vasoconstrictor, rubber dam, isolation
  • Copious, gentle irrigation with 20ml EDTA, followed by normal saline, using a similar closed-end needle.
  • Dry with paper points
  • Create bleeding into canal system by over-instrumenting (endo file, endo explorer)
  • Stop bleeding 3mm from CEJ
  • Place CollaPlug/Collacote at the orifice, if necessary
  • Place 3-4mm white MTA and reinforced glass ionomer and place permanent restoration
Follow-up
Clinical and Radiographic exam:
  •  No pain or soft tissue swelling (often observed between first and second appointments
  • Resolution of apical radiolucency (often observed 6-12 months after treatments
  •  Increased width of root walls (this is generally observed before apparent increase in root length and often occurs 12-24 months after treatments
  • Increased root length

Dr. Welk is a 1998 graduate of the OHSU School of Dentistry.  He received his specialty certificate in endodontics in 2002 from OHSU.  Dr. Welk is a Diplomate of the American Board of Endodontics.  He is past-president of the Oregon State Association of Endodontics, past-president of the Clackamas County Dental Society, and currently serves on the board of trustees for the Oregon Dental Association.  He maintains a private practice in West Linn, Oregon.

 

 

 

1.  Attala MN, Noujaim AA: Role of calcium hydroxide in the formation of reparative dentin. J Can Dent Assoc  1969; 35:267.

2.  Tittle KW, Farley J, Linkhardt M, Torabinejad M: Apical closure induction using bone growth factors and mineral trioxide aggregate. J Endod  1996; 22:198.(abstract #41)

3.  Pradham DP, Chawla HS, Gauba K, Goyal A: Comparative evaluation of endodontic management of teeth with unformed apices with mineral trioxide aggregate and calcium hydroxide. J Dent Child  2006; 73:79.

4.  Andreasen JO, Farik B, Munksgaard EC: Long-term calcium hydroxide as a root canal dressing may increase risk of root fracture. Dent Traumatol  2002; 18:134.

5.  Hargreaves KM, Law AS. Regenerative Endodontics. Chapter 16. Pathways of the Pulp 10th ed. Eds, Hargreaves KM, Cohen S. Mosby Elsevier, St Louis, MO, 2011: 602-19.

6.  Huang G T-J, Sonoyama W, Liu Y, Liu H, Wang S, Shi S: The hidden treasure in apical papilla: the potential role in pulp/dentin regeneration and bioroot engineering. J Endod  2008; 34:645.

7.   Iwaya S, Ikawa M, Kubota M: Revascularization of an immature permanent tooth with apical periodontitis ands inustract. Dent Traumatol  2001; 17:185.

8.  Murray PE, Garcia-Godoy F, Hargreaves KM: Regenerative endodontics: a review of current status and a call for action. J Endod  2007; 33:377.

9.  Considerations for Regenerative Procedures.  www.aae.org.  web.  11 Jun. 2012

Dental Volunteerism Abroad

Monday, June 18th, 2012

By Dr. Sean Benson

 

After the New Year holiday passes, and the cold and snow are permanent residents in Baker City, I start to focus on a warm tropical climate. Before you think I am describing some time off with relaxation at a luxurious resort I should clarify that the warm tropical climate is in Honduras, and it is hot, muggy, and malaria ridden. I start to think about if my typhoid, hepatitis, tetanus vaccinations are up date. Reminding myself to start taking my doxycline for malaria prohylaxis the few days before we hit San Pedro Sula. Double and triple checking my supply list. Do I have enough anesthetic, antibiotics, and analgesics? Do I have all my instruments, and disposable supplies. Will they all make it through customs? As you read this your first thought might be why?

I started to going to Honduras because of my good friend Jon Schott, MD. He had been going for several years and he had been providing basic medical care. He was frustrated by his lack of ability to treat emergent dental infection beyond antibiotic intervention. He believed almost all of the people he was treating needed some kind of basic dental intervention, and most had been suffering from an unchecked, and untreated dental infection for years. For several years I listened, empathized,  but was unsure if I could help. How would I provide care in the remote settings, and poor conditions that I had seen in pictures, and heard about in stories?

 

 

I enlisted the help of dentists who had done this type of thing in other countries, and came up with a plan. Dr. Weston Herringer Jr. was my mentor. He had been everywhere, and had done several trips to various countries. I borrowed, begged, and cajoled colleagues, dental supply companies, and honorary organizations. The first trip was hard, and tiring, and had its share of technical, and logistical problems…but was one of the most emotional rewarding experiences I had in long time. I was hooked.

 

 

These trips have become a part of my year. A chance to put things in perspective for myself, and take time to realize how truly fortunate I am.  I know everybody who volunteers says this, but it is true. The purity of doing volunteer dentistry is a recharge to myself professionally, and keeps me coming back for more.

I encourage everyone to volunteer for the profession in some capacity. Where, and how do not matter as much as the doing. The rewards will benefit the patient, the profession, and yourself, and provide unforgettable memories, and experiences that will make your time in practice complete.

 

Sean A Benson, DDS, graduated with his Doctorate of Dental Surgery from Ohio State University in 1998.  He currently is practices in Baker City and is an active member of the ODA, ADA and OHSU. In addition to volunteering his time abroad, Dr. Benson helps out with Northwest Medical Teams, Donated Dental Services, Give Kids a Smile Volunteer Day and is an Eastern Oregon Red Cross Advisory Board member.

 

The Clinical Record, the Ultimate Communication Tool

Monday, June 11th, 2012

By Dr. Roy Shelburne

The true success of the dental practice hinges on good communication.  The method and rate of exchange of information is one of the greatest determiners of patient satisfaction, office morale and ultimately successful outcomes in the clinical treatment of our patients.  Good communication leads to success and the better the communication the better and higher the level of success.  Bad communication leads to varying levels of frustration and confusion with a complete failure to communicate leading to a “crash and burn” scenario.  My hope is that learning how to communicate more effectively is a goal of every practice and methods of improving communication is an area of focus of the practice.   To highlight the importance of good communication, let’s look at communication as it relates to the clinical record and how excellent communication may lead to greater satisfaction, increased reimbursement, reduced stress, and better clinical outcomes for the doctor, the staff, and our patients.

Take, for example, an oral cancer screening performed during the patient examination and recorded as part of the patient’s evaluation.  In fact, the ADA’s CDT nomenclature states:  “This (D0120) includes an oral cancer evaluation and periodontal screening, where indicated, and may require interpretation of information acquired through additional diagnostic procedures.”   An oral cancer screening should be performed “as indicated” as part of the evaluation process.  What is “as indicated”?  My interpretation of “as indicated” would be for every patient that presents to the dental office who might be at risk for oral cancer…and isn’t that every patient?  With an increase in the number and severity of oral cancer cases observed in today’s environment, it’s just good for our patients.  Performing an oral cancer screening doesn’t take very long to perform and, in my opinion, the time taken is well spent.  How then, is the oral cancer screening and its result communicated?  How is it recorded?  My recommendation requires that the doctor and team member work together to perform and record the oral cancer screening.  (Working together, hum…what a concept!)  Here’s how I suggest the system be implemented.  The doctor, during the examination, explains to the patient that he/she will be performing an oral cancer screening.  The doctor then proceeds to perform the screening and verbally communicates that “Mr./Mrs. Patient, I’m taking a look at your tissues here to see if there are any suspicious areas in your mouth.  I see here on the roof of your mouth, there is a red, blistered looking area.  What can you tell me about that?”  The patient responds, “Oh, I burned that last night.  I bit into a piece of pizza that was too hot and it burned me.”  The doctor then responds, “Sorry to hear that.  Typically burns like this heal in a week or so.  Please, if it doesn’t heal by next week, give me a call and I’ll want to take another look.”  All the while this conversation proceeds, the office staff is taking note of what is said and the information is recorded in the clinical record.  This note establishes the cancer screening was done as well as records the outcome of that exam and notes any recommendations made by the doctor.  The clinical record is complete and the criterion necessary to bill for and be reimbursed for the clinical evaluation has been met.  Certainly, the standard of care has been achieved and the patient is very impressed at the thoroughness of the doctor.  The team is working together with one goal; complete, comprehensive and excellent care for the patient.  This information has been recorded by a well trained staff member and the patient’s needs have been met.

The scenario above is a single instance where a system of communication may be implemented to meet the needs of the patient and provide excellent care.  I encourage you to examine your practice for similar situations were communication can be improved for the betterment of your practice and for your patients.  It’s just good practice.

 

Dr. Shelburne is a 1977 graduate from the University of Virginia and 1981 Honor Graduate from Virginia Commonwealth University’s School of Dentistry.  After graduation, Dr. Shelburne opened his practice “back home” in his grandfather’s hardware store building and practiced there for 27 years. He has been a past president of the Southwest Virginia Dental Society and has volunteered at Virginia’s various MOM projects across the state. Dr. Shelburne specializes in record keeping and business systems that protect and defend.

Fluoride – Nature Thought of it First

Monday, June 4th, 2012

By Dr. Kurt Ferre

Fluoride is the natural cavity fighter.  It is the 13th most common element in the Earth’s crust and is found at varying concentrations in all drinking water and soil. Dr. Fredrick McKay, a young dentist, discovered the miracle of fluoride in the early 20th century.   He had recently moved to Colorado Springs and observed that although many of his patients had unsightly spots on their teeth, they had far fewer cavities than his patients back in the eastern United States where he was trained.

With the help of dentist pioneer, Dr. G. V. Black, they discovered that the decay rate was related to the naturally occurring fluoride in the water.  The problem was that in Colorado Springs the concentration was 10 parts per million, which caused the unsightly spots called fluorosis.  Dr. McKay and Dr. Black hypothesized that if the concentration were lower, then, the protective benefit of fluoride could still be achieved without the unsightly spots on the teeth.  After years of observational studies of water supplies around the country, they arrived at the concentration of 1 part per million.

In January, 1945 Grand Rapids, Michigan was the first city in theUnited Statesto add fluoride (called fluoridation) to its public water supply.  The results were dramatic.  In 10 years the cavity rate dropped 65% for 12-year old children!  It is estimated that fluoridation has saved over $40 billion and countless hours of pain and suffering for Americans.

So, how does fluoride work?  Studies have demonstrated that fluoride has both a pre-eruptive (systemic) effect and a post-eruptive (topical) effect.  Therefore, after teeth have erupted into the mouth, the primary action of the fluoride is topical for both children and adults.  When consumed in optimal amounts in water and food, and used topically in toothpastes, mouth rinses, and dental office treatments, fluoride: 1) increases tooth mineralization; 2) reduces the risk of cavities; and 3) promotes enamel remineralization throughout life for all individuals.

Sadly, Oregon is ranked 48th out of 50 states in percent of its public water supplies that have controlled amounts of fluoride added to the water.   In communities without fluoridation, the American Dental Association and American Pediatric Society recommend dietary fluoride supplements for children from the ages of 6 months through 14 years.  Parents should talk to their pediatrician or dentist about getting a prescription for their children.

With education, prevention, and access to care, cavities are a preventable disease, and fluoride will benefit everyone, not just children.

Remember, “Got teeth, get fluoride”.

 

Dr. Ferré is a 1976 graduate of Northwestern University Dental School in Chicago.  He retired in December, 2008, after a 28 ½ year career with Permanente Dental Associates in Portland. He is past-president of the Multnomah Dental Society, and he currently serves on the board of directors for the Oregon Oral Health Coalition, the Oregon Dental Association’s Government Relations Council, and the dental advisory board for Medical Teams International (MTI). In addition to his volunteer work at the Creston Children’s Dental Clinic, he is a regular volunteer on a MTI mobile dental around the Portland metropolitan area.