Southwest Endo

Patient centered care.

Below is an interesting article from the AAE’s Paper Point, May 2016 edition. It’s a great example of the importance of a multidisciplinary approach  for the treatment of our patients. At Southwest Endodontics, we work closely with all dental specialties in patient care.
As an Endodontist, When Should I Refer?
Multidisciplinary Approach to Treating Odontogenic Infection
Chase Wicker, Kimberly A. Morio and Nick Morio
University of Iowa
A 31-year-old male was referred to the Department of Endodontics resident clinic for emergency treatment. The patent’s chief complaint was, “I have been having severe pain since I had a root canal started.” The patient’s health history was significant for previous cancer therapy, asthma and an allergy to prochlorperazine. Current medications included albuterol sulfate, tramadol and amoxicillin.
Initial Endodontic Treatment
InitialEndoTreatment_Final.jpg?r=1464108662376
The patient was seen in the student clinic four days prior (02/26/16). At that time, initial exam revealed no lymphadenopathy, swelling or sinus tract. Extensive decay was noted on #19 MOB. Periapical radiograph revealed a large coronal carious lesion encroaching the pulp chamber space. Also, radiolucencies were noted in the furcation area as well as the mesial and distal roots of #19. Initial diagnosis was #19: pulp necrosis with asymptomatic apical periodontitis. Root canal therapy was initiated and working length was obtained at the first appointment. The following day (02/27/16), the patient called the clinic reporting slight swelling and discomfort associated with the left mandibular posterior quadrant. Prescriptions for tramadol and amoxicillin were phoned into the patient’s pharmacy. 
Emergency Endodontic Examination
Extraoral examination the day of the emergency visit (03/01/16) revealed submandibular space swelling associated with the patient’s left side. Induration and pain on palpation was noted. The inferior boarder of the mandible was not palpable. Intraoral examination revealed vestibular swelling buccal to #19 with purulent discharge through the sulcus of #19 upon palpation. The patient was also very symptomatic to palpation of the area. Trismus was present with a maximal incisal opening of 20 mm. #19 temporary restoration was intact and no carious lesions were noted in the left mandibular quadrant. The patient reported an alleviation of pain following the prescription of Amoxicillin and Tramadol. However, the patient did report a progressive nature of the swelling. Digital thermometer gave a reading of 98.2 °F. The patient did not report any dyspnea or dysphagia.
Diagnostic evaluation revealed:
Tooth
Palpation
Percussion
Thermal
Trans-illumination
18
+++
+
+
WNL
19
+++
+++
WNL
20
+++
+
+
WNL
Emergency Endodontic Diagnosis and Treatment
Emergency_Final.jpg?r=1464108884611
Diagnosis #19: previously initiated therapy with acute apical abscess. Local anesthesia of 3.4 cc 2% Lidocaine with 1:100k epi via IANB and 3.4 cc 4% Articaine with 1:100k epi buccal infiltration. Rubber dam isolation. Upon access, three orifices were located and a white material consistent with Ca(OH)2 was found. Working lengths were established and the canals prepared up to a 40/.04 instrument. Copious irrigation with 3% NaOCl was done throughout the procedure and a final rinse following 17% EDTA. Canals dried with paper points. Ca(OH)2 dressing was placed and #19 temporized with cotton pellet and IRM. An incision was made in the buccal vestibule adjacent to #19 and irrigation was performed with copious saline. The patient was advised to continue antibiotic regimen.
The patient was contacted 24 hours after the procedure and reported no resolution of symptoms. In addition, the patient stated the swelling had progressed over the past 12 hours: “the swelling is getting worse and I am starting to feel it in my throat.” A referral was made to the Oral Surgery Clinic at the local hospital for evaluation and treatment.  
Oral Surgery Referral and Hospital Course 
CTScans_Small.jpg?r=1464109447203
Upon presentation to the hospital, a maxillofacial CT scan with contrast was done. Fluid collection was noted in the L submandibular region that appeared to have originated from tooth #19. Blood work done on presentation revealed a slightly elevated WBC count of 12,500 and the patient was afebrile. The patient was taken to the operating room that evening for removal of tooth #19 and an extraoral incision and drainage of the L submandibular space. The patient was placed under general anesthesia. The skin was prepped and a 10 cc syringe with an 18 Ga. needle was utilized to attempt aspiration of the fluid collection for aerobic and anaerobic cultures. Due to the relatively small fluid collection, a sample was not obtained. A 1 cm skin incision was made 2 cm below the inferior boarder of the mandible on the L over the peak of the swelling to enter, drain and irrigate the submandibular space. A one-fourth inch penrose drain was placed (lingual to #19 through the sublingual and submandibular spaces exiting the skin) to allow for dependent drainage. He was admitted post-operatively for observation and IV antibiotics (3 g IV q6hr). On post-operative day #3 his WBC count had normalized and the facial swelling and associated trismus had resolved to the point he could be discharged to home on PO Augmentin. Prior to discharge, the penrose drain was removed bedside. He was placed on a 10-day course of Augmentin (3 g IV q6hr) 875 mg PO BID. He was followed as an outpatient and his post-operative course was uncomplicated. The patient was contacted one week following admission to the hospital by the treating endodontist and reported complete resolution of infection and symptoms.
Patient-centered care is crucial for patient success. This case highlights the importance of multidisciplinary care from the perspective of not only understanding but recognizing endodontic clinical limits and when to refer for surgical management. Sometimes as endodontists we may become focused on the anatomy of teeth, but continual review of the anatomy of fascial spaces, the pathways infections may take and clinical presentations of these infections will create confidence in your abilities as a clinician.
Endodontics is amazing! We have numerous tools in our tool box to manage tooth-related infections, but, as in this case, true submandibular infections cannot be managed endodontically. These infections require extraoral incision and drainage and, most often, removal of the source of the infection, which was tooth #19 in this case. If not treated in a timely fashion, these fascial space infections can escalate quickly into airway compromise, tracheostomy and ICU admission. The extraoral incision and drainage of the submandibular space infection allows for dependent drainage and disrupts the environment the bacteria need to survive. Removal of the source of infection (the tooth) helps to ensure this infection does not progress or recur. In cases like these, reaching out to experts outside of endodontics allows us to provide the best care for our patients.

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Patient centered care.

Below is an interesting article from the AAE’s Paper Point, May 2016 edition. It’s a great example of the importance of a multidisciplinary approach  for the treatment of our patients. At Southwest Endodontics, we work closely with all dental specialties in patient care.
As an Endodontist, When Should I Refer?
Multidisciplinary Approach to Treating Odontogenic Infection
Chase Wicker, Kimberly A. Morio and Nick Morio
University of Iowa
A 31-year-old male was referred to the Department of Endodontics resident clinic for emergency treatment. The patent’s chief complaint was, “I have been having severe pain since I had a root canal started.” The patient’s health history was significant for previous cancer therapy, asthma and an allergy to prochlorperazine. Current medications included albuterol sulfate, tramadol and amoxicillin.
Initial Endodontic Treatment
InitialEndoTreatment_Final.jpg?r=1464108662376
The patient was seen in the student clinic four days prior (02/26/16). At that time, initial exam revealed no lymphadenopathy, swelling or sinus tract. Extensive decay was noted on #19 MOB. Periapical radiograph revealed a large coronal carious lesion encroaching the pulp chamber space. Also, radiolucencies were noted in the furcation area as well as the mesial and distal roots of #19. Initial diagnosis was #19: pulp necrosis with asymptomatic apical periodontitis. Root canal therapy was initiated and working length was obtained at the first appointment. The following day (02/27/16), the patient called the clinic reporting slight swelling and discomfort associated with the left mandibular posterior quadrant. Prescriptions for tramadol and amoxicillin were phoned into the patient’s pharmacy. 
Emergency Endodontic Examination
Extraoral examination the day of the emergency visit (03/01/16) revealed submandibular space swelling associated with the patient’s left side. Induration and pain on palpation was noted. The inferior boarder of the mandible was not palpable. Intraoral examination revealed vestibular swelling buccal to #19 with purulent discharge through the sulcus of #19 upon palpation. The patient was also very symptomatic to palpation of the area. Trismus was present with a maximal incisal opening of 20 mm. #19 temporary restoration was intact and no carious lesions were noted in the left mandibular quadrant. The patient reported an alleviation of pain following the prescription of Amoxicillin and Tramadol. However, the patient did report a progressive nature of the swelling. Digital thermometer gave a reading of 98.2 °F. The patient did not report any dyspnea or dysphagia.
Diagnostic evaluation revealed:
Tooth
Palpation
Percussion
Thermal
Trans-illumination
18
+++
+
+
WNL
19
+++
+++
WNL
20
+++
+
+
WNL
Emergency Endodontic Diagnosis and Treatment
Emergency_Final.jpg?r=1464108884611
Diagnosis #19: previously initiated therapy with acute apical abscess. Local anesthesia of 3.4 cc 2% Lidocaine with 1:100k epi via IANB and 3.4 cc 4% Articaine with 1:100k epi buccal infiltration. Rubber dam isolation. Upon access, three orifices were located and a white material consistent with Ca(OH)2 was found. Working lengths were established and the canals prepared up to a 40/.04 instrument. Copious irrigation with 3% NaOCl was done throughout the procedure and a final rinse following 17% EDTA. Canals dried with paper points. Ca(OH)2 dressing was placed and #19 temporized with cotton pellet and IRM. An incision was made in the buccal vestibule adjacent to #19 and irrigation was performed with copious saline. The patient was advised to continue antibiotic regimen.
The patient was contacted 24 hours after the procedure and reported no resolution of symptoms. In addition, the patient stated the swelling had progressed over the past 12 hours: “the swelling is getting worse and I am starting to feel it in my throat.” A referral was made to the Oral Surgery Clinic at the local hospital for evaluation and treatment.  
Oral Surgery Referral and Hospital Course 
CTScans_Small.jpg?r=1464109447203
Upon presentation to the hospital, a maxillofacial CT scan with contrast was done. Fluid collection was noted in the L submandibular region that appeared to have originated from tooth #19. Blood work done on presentation revealed a slightly elevated WBC count of 12,500 and the patient was afebrile. The patient was taken to the operating room that evening for removal of tooth #19 and an extraoral incision and drainage of the L submandibular space. The patient was placed under general anesthesia. The skin was prepped and a 10 cc syringe with an 18 Ga. needle was utilized to attempt aspiration of the fluid collection for aerobic and anaerobic cultures. Due to the relatively small fluid collection, a sample was not obtained. A 1 cm skin incision was made 2 cm below the inferior boarder of the mandible on the L over the peak of the swelling to enter, drain and irrigate the submandibular space. A one-fourth inch penrose drain was placed (lingual to #19 through the sublingual and submandibular spaces exiting the skin) to allow for dependent drainage. He was admitted post-operatively for observation and IV antibiotics (3 g IV q6hr). On post-operative day #3 his WBC count had normalized and the facial swelling and associated trismus had resolved to the point he could be discharged to home on PO Augmentin. Prior to discharge, the penrose drain was removed bedside. He was placed on a 10-day course of Augmentin (3 g IV q6hr) 875 mg PO BID. He was followed as an outpatient and his post-operative course was uncomplicated. The patient was contacted one week following admission to the hospital by the treating endodontist and reported complete resolution of infection and symptoms.
Patient-centered care is crucial for patient success. This case highlights the importance of multidisciplinary care from the perspective of not only understanding but recognizing endodontic clinical limits and when to refer for surgical management. Sometimes as endodontists we may become focused on the anatomy of teeth, but continual review of the anatomy of fascial spaces, the pathways infections may take and clinical presentations of these infections will create confidence in your abilities as a clinician.
Endodontics is amazing! We have numerous tools in our tool box to manage tooth-related infections, but, as in this case, true submandibular infections cannot be managed endodontically. These infections require extraoral incision and drainage and, most often, removal of the source of the infection, which was tooth #19 in this case. If not treated in a timely fashion, these fascial space infections can escalate quickly into airway compromise, tracheostomy and ICU admission. The extraoral incision and drainage of the submandibular space infection allows for dependent drainage and disrupts the environment the bacteria need to survive. Removal of the source of infection (the tooth) helps to ensure this infection does not progress or recur. In cases like these, reaching out to experts outside of endodontics allows us to provide the best care for our patients.

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Saving a Tooth V Extraction

Sometimes bad things happen to good teeth!  Despite dental treatment, and even root canal therapy, some teeth can still have pain.  What next???  Sometimes, teeth need to be extracted.  There is just no alternative.  There may have been a fracture, severe loss of tooth structure due to decay, or loss of the bone and tissue that supports the tooth.

Other times, a dentist may think a tooth needs to be extracted, when there may be other options for treatment.  Tooth extraction should not be considered until all other options are examined.  Although implants are a great way to replace a missing tooth, they are costly and take 4-18 months to complete the process.  An implant and crown average about twice the cost of maintaining the tooth, and despite what you may read, an implant is not better than the natural tooth it is replacing (nothing we replace it with is better, just a good substitute).    If there is persistent infection or pain after root canal procedure, it does not necessarily mean the tooth needs to be removed.  There are several reasons that a tooth may continue to be painful after a root canal:

– An untreated root or nerve canal (tooth anatomy is complex stuff)

–  The tooth was not properly disinfected

– An aggressive type of bacteria may remain in the tooth

An endodontist, or dental root canal specialist, can accurately diagnose the issue and offer treatment options.   We are specialists in saving teeth.  In fact, that is the tag line for the American Association of Endodontists (www.aae.org).  An endodontist may have multiple options for attempting to save the tooth, all of which are less expensive and can be accomplished in one or two visits.   If an endodontist suggests that the tooth needs to be removed, then it is a good bet that there is no other option, as most endodontist do not remove teeth or place dental implants, and would not recommend this as the best option unless it is.  Although most people are referred to an endodontist, you don’t have to be referred.  You can easily look one up online and call to schedule an appointment, even if it is just for a second opinion.  Although your general dentist is knowledgeable and well-trained, it is impossible for them to know every aspect of dentistry, and there is nothing wrong with seeking someone else’s opinion.  Feel free to call Southwest Endodontics, or go to our website, www.southwestendo.com, for more information.  We are born with a finite amount of teeth, so do everything you can to make them last!

 

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Dispelling Myths of Root Canals Through Education

Dispelling Myths of Root Canals Through Education

RCAW 2016 MainCHICAGO – Despite state-of-the-art advancements in endodontic treatment that make root canal procedures often as straightforward as fillings, Americans still express fear of the procedure. According to a recent survey by the American Association of Endodontists, 67 percent of Americans say fear of pain most concerns them about having root canal treatment.

The AAE hopes to dispel these fears during its tenth anniversary celebration of Root Canal Awareness Week, March 27 – April 2. Root Canal Awareness Week is a nationwide effort to encourage patients who need a root canal to see an endodontist to save their natural teeth. Endodontists have at least two years of additional training beyond dental school and are highly skilled specialists in performing root canals and diagnosing and treating tooth pain. Their mix of advanced training, techniques and equipment improve patient comfort, ease anxiety and alleviate pain.

Endodontists, the root canal specialists, devote their practice to root canal treatment and related procedures,” said AAE President Dr. Terryl A. Propper, a private practicing endodontist in Nashville, Tenn. “We use technologies like microscopes, digital and 3-D imaging and ultrasonics to diagnose and treat our patients quickly, comfortably and successfully.”

AAE research shows that dentists refer an average of 43 percent of root canal patients to an endodontist, yet almost all general dentists surveyed, 94 percent, say they have a positive or very positive perception of endodontists and the care they provide.

“Even if your dentist does not recommend a root canal specialist, ask about the benefits of consulting one,” said Dr. Propper. “Americans are taking more control of their health care, and that should include oral health. Patients who need root canal treatment should consider seeing an endodontist.”

Tips for Selecting an Endodontist

Cover the basics. Look for an endodontist who is both convenient and accessible. Inquire about specialists near your home or workplace, and find out if the endodontist’s office is open during alternative hours, such as evenings or weekends. Ask whether specific endodontists accept your insurance plan or offer financing options. You may utilize the Find an Endodontist tool to aid in the search.

Look for a solid track record. Ask how long the endodontist has been performing root canals and how frequently he or she does the procedure. If your general dentist is suggesting a root canal, find out as much as possible about why you need it; then choose an experienced endodontist who has dealt with issues similar to yours. AAE members receive ongoing news and education on the latest research and technologies to help them stay at the forefront of the specialty. Some endodontists are also Board certified, which means they have successfully passed a number of rigorous exams beyond their specialty training. Use the Find an Endodontist tool at www.aae.org to find an AAE member.

Ask about equipment. The most up-to-date endodontic equipment includes operating microscopes and rotary instrumentation that make getting to the “root” of a dental problem easier and faster. Endodontists are more likely than general dentists to have the most advanced equipment, but find out specifically how the endodontist’s equipment will help during the procedure. Find out more about what you can expect during your visit with the specialist. Your endodontist will collaborate with your dentist on a treatment plan, and after a root canal, both should continue to monitor the success of the procedure.

For more information about the AAE and Root Canal Awareness Week, follow the AAE on Twitter at @savingyourteeth or search #rootcanal. To find an endodontist in your area, ask your general dentist for a referral, or use the Find an Endodontist search feature.

Myth #1 – Root canal treatment is painful.

Myth #1—Root canal treatment is painful.

Truth—Root canal treatment doesn’t cause pain, it relieves it.

The perception of root canals being painful began decades ago but with modern technologies and anesthetics, root canal treatment today is no more uncomfortable than having a filling placed. In fact, a recent survey showed that patients who have experienced root canal treatment are six times more likely to describe it as “painless” than patients who have not had root canal treatment.

Most patients see their dentist or endodontist when they have a severe toothache. The toothache can be caused by damaged tissues in the tooth.  Root canal treatment removes this damaged tissue from the tooth, thereby relieving the pain you feel.

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Endodontic Treatment Statistics – AAE

Endodontic Treatment Statistics

The most recent information available on the frequency of endodontic procedures comes from the American Dental Association Survey of Dental Services Rendered, conducted in late 2005-early 2006 and published in August of 2007. The survey is available from the ADA’s Health Policy Resources Center. A previous version of the survey was published in 1999, and the survey has not been repeated since 2005-2006. Information for the survey was collected using printed survey questionnaires and patient care logs, which documented the actual number of patients seen and the specific procedures completed. Data collected was used to compile national estimates for each dental procedure and specialty.

Relevant statistics from the 2005-2006 survey:

It is estimated that 22.3 million endodontic procedures were performed annually:

15.2 million/68% were performed by general dentists
5.7 million/26% were performed by endodontists
The remainder were performed by other dental specialists
It is estimated that 15.1 million root canal treatments were performed annually:

10.9 million/72% were performed by general dentists
4.2 million/28% were performed by endodontists
It is difficult to compare the 2005-2006 data to the previous Survey of Dental Services Rendered (1999) because the ADA changed the way it collected and reported data. For example, retreatments, root canal obstructions, incomplete endodontic therapy and apexification were not part of the 1999 survey but were included in 2005-2006.

The estimated total of all endodontic procedures went up about 10% from 1999 to 2006 (from 20.3 million to 22.3 million).
The estimated total number of root canal treatments went down 5% from 1999 to 2006 (from 15.8 million to 15.1 million).
Endodontists performed about 100,000 more root canal treatments in 2006 than in 1999 (an increase of about 3%) and general dentists performed about 830,000 fewer root canal treatments in 2006 than in 1999 (a decrease of about 6%).

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Endodontic Treatment Statistics – AAE

Endodontic Treatment Statistics

The most recent information available on the frequency of endodontic procedures comes from the American Dental Association Survey of Dental Services Rendered, conducted in late 2005-early 2006 and published in August of 2007. The survey is available from the ADA’s Health Policy Resources Center. A previous version of the survey was published in 1999, and the survey has not been repeated since 2005-2006. Information for the survey was collected using printed survey questionnaires and patient care logs, which documented the actual number of patients seen and the specific procedures completed. Data collected was used to compile national estimates for each dental procedure and specialty.

Relevant statistics from the 2005-2006 survey:

It is estimated that 22.3 million endodontic procedures were performed annually:

15.2 million/68% were performed by general dentists
5.7 million/26% were performed by endodontists
The remainder were performed by other dental specialists
It is estimated that 15.1 million root canal treatments were performed annually:

10.9 million/72% were performed by general dentists
4.2 million/28% were performed by endodontists
It is difficult to compare the 2005-2006 data to the previous Survey of Dental Services Rendered (1999) because the ADA changed the way it collected and reported data. For example, retreatments, root canal obstructions, incomplete endodontic therapy and apexification were not part of the 1999 survey but were included in 2005-2006.

The estimated total of all endodontic procedures went up about 10% from 1999 to 2006 (from 20.3 million to 22.3 million).
The estimated total number of root canal treatments went down 5% from 1999 to 2006 (from 15.8 million to 15.1 million).
Endodontists performed about 100,000 more root canal treatments in 2006 than in 1999 (an increase of about 3%) and general dentists performed about 830,000 fewer root canal treatments in 2006 than in 1999 (a decrease of about 6%).

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Retreatments Explained

With proper care, even teeth that have had root canal treatment can last a lifetime. But sometimes, a tooth that has been treated doesn’t heal properly and can become painful or diseased months or even years after treatment. If your tooth failed to heal or develops new problems, you have a second chance. An additional procedure may be able to support healing and save your tooth. If you are experiencing dental pain or discomfort in a previously treated tooth, talk to an endodontist about retreatment.

As occasionally happens with any dental or medical procedure, a tooth may not heal as expected after initial treatment for a variety of reasons:

  • Narrow or curved canals were not treated during the initial procedure.
  • Complicated canal anatomy went undetected in the first procedure.
  • The placement of the crown or other restoration was delayed following the endodontic treatment.
  • The restoration did not prevent salivary contamination to the inside of the tooth.

In other cases, a new problem can jeopardize a tooth that was successfully treated. For example:

  • New decay can expose the root canal filling material to bacteria, causing a new infection in the tooth.
  • A loose, cracked or broken crown or filling can expose the tooth to new infection.
  • A tooth sustains a fracture.

During retreatment, the endodontist will reopen your tooth and remove the filling materials that were placed in the root canals during the first procedure. The endodontist then carefully examines the tooth, looking for additional canals or new infection. The endodontist then removes any infection, cleans and shapes the canals, and places new filling materials. The opening is then sealed with a temporary filling. Once the tooth heals, a new crown or other restoration is placed on the tooth to protect it.

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