This month, I am presenting a diagnosis case that was unusual.
Patient is a 41 year old Caucasian female who presented with the Chief complaint of sudden pain on the left side of her face and dentition for the past 2 days. Her medical history is unremarkable with the only medication she is currently taking is Ibuprofen for the control of her sudden onset of pain. The patient was seen by her dentist and referred for evaluation of tooth #19 due to radiographic apical pathology.
Clinically, tooth #19 has an MOD composite restoration with good margins, normal (similar to adjacent teeth) response to cold, negative percussion tenderness, slight palpation tenderness and very mild cortical plate expansion near the distal root end, normal periodontal probing depths, no mobility noted. Radiographs reveal conservative composite restoration present, a circular RL lesion (12 x 12 mm) associated with the distal root end. The outer 2-3 mm circumference of the lesion appears more radiodense while the center appears more lucent and has an irregular trabecular pattern.
External palpation of the left Masseter and Temporalis muscles produces some mild discomfort. From the clinical and radiographic exam, I will aske the question as to whether this is a LEO(Lesion of Endodontic Origin) or non–LEO?
I present the radiographs for this case.

Since the tooth responded similarly to cold as the adjacent teeth and the restorative treatment was conservative, I initially did not think this was an endodontic issue. The pain the patient was reporting as sudden onset was actually related to nocturnal bruxism and stress as she was getting married in a few days. So, I have ruled out root canal treatment. What is the differential diagnosis? What are the potential treatment options for this case, if any?

My differential diagnosis included the following:
1. Ossifying Fibroma (early stage)
2. Focal cemento-osseous dysplasia
3. Simple bone cyst
4. Ameloblastoma
5. Keratocystic odontogenic tumor

The diagnosis is #2. Focal cemento-osseous dysplasia. Review of the patient’s pano did not reveal any other locale for additional pathosis. If so, this would be a case of Florid cemento-osseous dysplasia. Treatment is observation, unless the lesion becomes large enough to cause discomfort. In which case, enucleation of the lesion would be indicated. These lesions become problematic when they become large and communicate with the oral cavity. Also, hypovascularization can occur and these lesions can be prone to necrosis with minimal provocation. At this time, annual radiographic examination is the only treatment recommended.

Thank you for the opportunity to serve your practice and patient’s needs!

This month, I wanted to show some unusual anatomy cases that I have recently treated. Some of the anatomy is difficult to discern from the preoperative images. However, close examination does reveal that the canal anatomy is not typical. I usually try to visualize the root canal space from the top to the apex of the root. In doing so, I am not only anticipating what my final outcome will look like, but to also search for clues that the canals are atypical. Careful intraoperative imaging as well as tactile feel of what the files are doing provide clues to the root anatomy. Thanks again for your trust in our practice. If you have any questions or comments, please let me know.

Happy New Year! Thank you again for your confidence in our practice. We continually strive to provide the best endodontic care for our patients. This month I will provide some examples of a new type of endodontic file that has come to the market. This file has the same nickle-titanium properties that are present in almost all rotary files plus an additional treatment in which the file does not retain shape memory. Why is this of benefit? This allows the file to closely follow the anatomy of the canal without straighting out, reducing the risk of ledging, transportation, and perforation. It also reduces the amount of tooth structure that is removed during the instrumentation process. The particular file that I use, also has a shorter cutting area, which again will reduce the amount of root structure removal. In conjunction with the conservative access preparations I strive to attain, there is a reduction in the probability of vertical root and coronal tooth structure fracture. I will add that the apical preparation size is still significantly enlarged enough to provide for irrigation. I recommend that the final apical preparation be completed with files with a maximum of 0.04 taper to minimize the development of root microfracture. I am not implying that apical preparation sizes should be miniscule. However, the apical preparation should be gauged and appropriate for the respective canal. The introduction of larger taper (.06 and .08) tapers should be minimized in the apical third to reduce the incidence of file separation and excessive dentin removal. I provide some examples of some recent cases. Thank you and please feel free to comment.

This month’s blog addresses the topic of conservation of tooth structure. In many of today’s dental journals, one can find a myriad of debate concerning the proper way to clean and shape root canal systems. I will address one particular type of canal system that is commonly found. A ribbon shaped root canal is one in which is typically found in maxillary premolars, mandibular incisors and the distal roots of mandibular molars. The problem with this type of anatomy is that traditional preparations result in excessive removal of root structure which may lead to vertical root fractures or perforation of the root. I have modified the preparation of these types of canals to address these concerns. As noted in the following illustration, a typical canal preparation, if enlarged to encompass the periphery of the canal system, would result in excessive canal preparation and a weakened remaining root structure.

Therefore, I propose modifying the preparation to address the periphery first. This will result in a more conservative preparation. It will also better facilitate the cleaning and shaping the lateral extents of the canal system where typically a fair amount of debris is accumulated during the instrumentation process. This is an example of a mandibular incisor in which 2 canals were present.

As illustrated by the red outline in the final radiograph, one can see the results of this modification. The canal outline almost appears like a figure eight.
This is an example of a mandibular molar in which the same approach was utilized.
Thank you for supporting my practice. I am open to any questions or thoughts regarding this months post. I strive to elevate my treatments to the highest possible level.

This month I would like to address the issue of canal debris and smear layer formation. As an endodontist, I am constantly trying to render a root canal that is not loaded with residual debris, pulp remnants, and, of course bacteria. Several methods have been advocated for smear layer removal. The multitude of solutions and techniques used to produce a cleaner canal preparation are as follows:
1. Preparation design – Step-back, crown-down, double flare, balanced force, modified crown-down, passive step-back, ultrasonic, rotary instrumentation, Self-adjusting file (SAF).
2. Irrigation solutions – sodium hypochlorite in differing concentrations, hydrogen peroxide, saline, local anesthetic, ionized water
3. Chemical means – a chleator either in a cream form applied to the file(RC prep, Prolube, File Eze, Glyde) or an irrigant such as Citric acid, 17% EDTA, Smear Clear, Maleic acid as a final solution prior to obturation.
4. Irrigation solution agitation – Passive ultrasonic, Active ultrasonic (Peizoflow, and there are many others), Tsunami irrigation (Ruddle), Endovac, Continuous Irrigation (SAF).
5: Use of additional irrigants for bacterial removal and canal disinfection – Alcohol, 2% chlorhexidine, Q-mix.
6: Lasers – PIPs
The aformentioned categories are a majority of what has been attempted to produce a canal system in which the residual bacterial load is minimal and there has been a removal of the tissue and debris from lateral canals and canal isthmuses. These, of course, are not all inclusive and there are other steps and solutions that have been attempted.
In my experience, and these are my own thoughts, I think that prevention of a smear layer early on during canal preparation is essential. Playing catch-up after debris has been created and packed into the isthmuses and lateral canals is much more difficult to remove. Since I have modified my irrigation routine, I have noticed that the amount of lateral canals that are evident post-operatively, have appeared more often. I offer these examples as support for this change in canal preparation.
In addition to the modification in irrigation, I still use ultrasonic activation of sodium hypochlorite as a final step. By adjusting the thought process of haow the root canal system is approached, I believe we are able to produce cleaner canals and therefore, increased endodontic success. I am open to any questions or thoughts regarding this months post. Thanks again for supporting my practice. I strive to elevate my treatments to the highest possible level.

This month, I am presenting a retreatment case that proved to be more challenging than I imagined. The patient is a 53 y.o. male who was referred for an evaluation of tooth #30. He was asymptomatic at the time of initial examination. His medical history was non-contributory. The dental history was as follows: He had the root canal treatment performed approximately 10 years ago by his dentist at the time. He was recently seen by his dentist who noted that the root canal treatment was less than ideal and that there was an apical pathosis associated with the mesial root. Clinical exam reveals that tooth #30 has a PFM crn present, negative percussion or palpation tenderness, normal periodontal probing depths. Radiographic examination reveals that the tooth has had previous RCT, there is a threaded post present in the distal root. The obturation of the mesial and distal canals is well short of the radiographic apex. The distal root appears to have been obturated with a carrier based material, the mesial root reveals ill-fitting master cones based on their curled appearance. There is a RL lesion associated with the mesial root. The radiographs are as follows: .
The clinical diagnosis is Previously treated #30 with asymptomatic periapical periodontitis.
Retreatment of the root canal was recommended and the patient decided to proceed with the treatment. The problems that are anticipated when the case is viewed radiographically are as follows: Preservation of the crn (if possible), removal of the threaded post in the distal root, removal of the carrier-based obturation in the distal root, negotiating the meisal canals after removal of the existing gutta-percha. The mesial canals appear to have been ledged during the previous treatment and this always poses a significant challenge. Careful exploration of the canals with pre-bent small files and a gentle touch is what is needed in these situations. At the initial visit, the tooth was accessed, the threaded post was removed with an ultrasonic and copious water to prevent as much heat transfer to the root as possible. The carrier was removed (Soft-core) from the distal root and this canal was negotiated to the apex. The mesial canals presented with a more difficult challenge to negotiation. The canals were severly ledged and also joined, as evidenced by the drying of one canal led to the other canal being dried as well. I was unable to complete the case in the first appointment. Calcium hydroxide was placed and the patient was reappointed. The interim radiograph is as follows:

At the second appointment, the patient was asymptomatic, the tooth was again accessed and the process of trying to negotiate the mesial canals was ensued. I think I went through approximately 50 hand files in trying to gain patency. Being persistent paid off and I was finally able to gain access to the apex. The case was cleaned and shaped, and obturated with warm gutta-percha. The completed case is as follows:
This case demonstrated a challenge to canal negotiation. Proper technique and an understanding of my goals was essential in order to properly treat the case. Certainly, I could have initally opted for a root end resection. However, I felt fairly confident that I could manage the retreatment without having to go to an apicoectomy. I welcome any comments or feedback regarding this case. Thank you again for entrusting my office with the care of your valued patients.

I hope everyone is enjoying their summer. This month’s case is an example of a conservative approach to endodontic therapy. The patient is a 33 y.o female who presented for endodontic evaluation tooth #21. She is asymptomatic at initial presentation. Her medical history has several positive entries including Factor V leiden (excessive clotting), Chronic regional pain syndrome which is related to an injury to her left foot (Cymbalta, Lyrica are the medications she is taking to manage). Clinically, she has Class V caries on the buccal surface tooth #21. Pulp tests reveal that the tooth responds WNL to cold, negative percussion tenderness, normal perio probing depths and negative palpation tenderness. Radiographs reveal normal periradicular tissues and the extent (as limited by conventional radiographs) of the buccal caries. Treatment options were presented and the patient decided to have the caries removed and, if needed, root canal treatment should a pulp exposure occur. Pre-treatment radiographs are as follows:
A buccal gingival mini-flap was reflected to permit caries removal. After the caries was excavated, a vital pulp exposure occurred and root canal treatment was initiated. A conservative approach to access was chosen due to the ability to obtain straight line entry into the root canal and opting for conservation of the remaining tooth structure. In doing so, I wanted to maintain the structural integrity and strength of the coronal tooth structure and avoid a crown, if possible. The access preparation is shown as well as the final restoration following root canal treatment.

Final radiographs are as follows:

The patient was recalled in 1 week to evaluate her gingival healing. The tissues appeared to be healing well and within normal limits. She had no complaints of pain.

This case demonstrates that endodontic treatment can be accomplished while conserving as much tooth structure as possible. Traditional access would have dictated an occlusal approach and therefore, the need for a crn. If straight line access can be achieved as well as the remaining goals of endodontic treatment, then a non-traditional approach, such as this case represents, can be accomplished. I welcome any comments or questions. Thank you for supporting our practice. We strive to provide the best treatment for your patients.

This month I am presenting a case of an atypical root anatomy. The patient is a 37 y.o. male who presented for evaluation of tooth #30. He was experiencing spontaneous pain and cold sensitivity on the mandibular right side. Clinically, tooth #30 had gross caries, hyperreactivity to cold that lingered, slight percussion tenderness. Periodontally, the patient had detectable calculus and gingivitis associated with the tooth. He was also missing teeth #31 and 32. Radiographs revealed that the caries approximated the pulp chamber and calculus was present on the mesial root surface. A vertical line was noted across the distal root indicating the presence of additional root anatomy in both preoperative images. The periradicular tissues otherwise appeared WNL radiographically. As you can see, I have outlined the PDL/Lamina dura in the second radiograph. This type of root anatomy is known as radix entomolaris.
There are two general types of this unusual root anatomy. Radix entomolaris (RE): This supernumerary root is located distolingually in mandibular molars, mainly first molars. Radix paramolaris (RP): An additional root at the mesiobuccal side in mandibular molars. The dimensions of the RE can vary from a short conical extension to a ‘mature’ root with normal length and root canal. In most cases the pulpal extension is radiographically visible. In general, the RE is smaller than the distobuccal and mesial roots and can be separate from, or partially fused with, the other roots. Treatment of these cases involves initial relocation of the orifice to the lingual to achieve straight-line access. However, to avoid perforation or stripping in the coronal third of a severe curved root, care should be taken not to remove an excessive amount of dentin on the lingual side of the cavity and orifice of the RE. The likelihood of instrument separation, root perforation, or canal transportation is elevated in these cases due to the severity of the root curvature. The following images are taken from The Radix Entomolaris and Paramolaris: Clinical Approach in Endodontics Filip L. Calberson, DDS, MMS, Roeland J. De Moor, DDS, MMS, PhD, and Christophe A. Deroose, DDS, MMS. JOE — Volume 33, Number 1, January 2007. These are some extracted molars that demonstrate the variablilty of root anatomy
Treatment involved caries removal, GI tem restoration, and RCT. Here are the post-operative images.
I welcome any comments or questions. Thank you for your continued confidence in me and my practice.

This month’s case is entitled “If you can’t beat ’em, bypass ’em”. The patient is a 29 y.o. female who was referred for evaluation #15 for possible RCT. She was asymptomatic at the time of presentation. Exam revealed gross caries mesially. Pulp tests revealed tooth #15 had a hyperreactive response to cold, normal periodontal probings and negative percussion tenderness. Radiographs revealed normal periradicular tissues and caries that approximated the pulp chamber. Radiographs also revealed that tooth #14 had previous RCT. It was noted that there was a RL lesion associated with the DB root, a separated instrument in the DB root and the canal was instrumented well short of the radiographic apex. Tooth was asymptomatic to percussion and probing depths were WNL. Tooth #14 was treatment planned to have the crn remade by her referring dentist.
The only positive entry in her medical history was Synthroid for hypothyroid. Clinical Dx #15: Caries #15, Asymptomatic irreversible pulpitis with normal periradicular. Dx #14: Previously treated #14 with asymptomatic periradicular periodontitis.

Tooth #15 was treated first. The caries was removed and a vital pulp exposure occurred. The root canal was completed and the patient was appointed for retreatment tooth #14. I will focus on tooth #14 for the remainder of this month’s blog. Tooth was accessed and the Softcore obturation was removed, an untreated MB2 canal was located and instrumented to the apex. An attempt to remove the instrument was not done at this appointment. Calcium hydroxide was placed as an interim medicament and the patient was scheduled to return in 1 week for completion.
At the next appointment, the file was bypassed to the apex and the root canal was completed.
This case demonstrated that sometimes it is easier to bypass a separated instrument, rather than removing it and sacrificing significant tooth structure during the process. There was a higher potential to bypass the instrument than remove it because it was a hand file. Typically, a rotary file is much more difficult to bypass due to its taper. Final radiographs revealed that tooth #13 had a RL lesion present and previous RCT. The tooth will eventually be retreated. I welcome any questions or comments. Thank you for your continued confidence in my practice, Chris

Happy New Year to all of you! This month, I am presenting a case of a severely dilacerated meisal root on tooth #31. The patient presented with CC of sensitivity to cold ever since she had a crown placed on the tooth. She had cracked the tooth or exisiting restoration that was present, and therefore, required a crown on the tooth. The patient had increasing sensitivity to cold over the past 3 months. Clinical exam revealed a FGC tooth #31, hyperreactive to cold that was more pronounced and lingered significantly more than the adjacent teeth, slight percussion tenderness, normal periodontal probing depths. Radiographs revealed a S-shaped mesial root #31 with no periradicular pathosis visible. Her medical history had positive entries for ovarian cancer 10 years ago and PCN causing nausea, but otherwise unremarkable. Here are the pre-operative radiographs.
The clinical diagnosis was Irreversible pulpitis #31 with symptomatic periradicular periodontitis. The informed consent was signed and administration of local anesthetic was given. After several injections, the patient was still unable to achieve profound anesthesia. I had used 1 carpule of each anesthetic to attempt to adequately numb the area ( 2% Lidocaine with 1:100,000 epi, 3% Mepivicaine, 0.5% Marcaine with 1:200,000 epi, 4% Articaine with 1:100,000 epi). She was given an IAN block, a Gow-Gates, PDL, Buccal Nerve and Lingual Nerve, and an infiltration injection. The endodontic treatment was not attempted, due to lack of profound anesthesia. The patient was dismissed and I recommended that she take 3, 200mg Advil Liquigels 30 minutes prior to her next appointment to help with the anesthesia. There is a paper by Dr. Ken Hargreaves that discusses the use of local anesthetics and how the pH is affected by increasing amounts of epinephrine and why different anesthtic types without epi can be beneficial in these situations. Also, he talks about the need to close the TTX channels with the administration of an NSAID that are typically resistant to local anesthetics.
At the next appointment, the same types of anesthetics were given as noted previously, with two exceptions to the first appointment. First, the patient had taken the Advil as directed and second, I gave her a closed mouth injection known as the Akinosi technique of local anesthetic administration. She obtained profound anesthesia and I was able to perform the root canal treatment as planned. Post-op radiographs:

The final radiograph demonstrated two distal canals, one of which (DL), exited very short of the other. I welcome any comments or questions. Thank you for your continued confidence in my practice.