Cuspid palpation sensitivity - Courtesy ROOTS
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From: Rob Kaufmann
Sent: Sunday, June 27, 2010 9:10 AM
Subject: [roots] Max Cuspid palpation sensitivity
Patient referred to me for persistent localized, discreet, reproducible
buccal palpation sensitivity over the cuspid apex. The endo had been
previously done (recently) by a local endodontist ( good clinician).
The patient was not satisfied with teh post op symptoms and the previous
endodontist's "wait and see/perhaps surgery" attitude and wanted a more
Periapical radiography did not show any frank pathology and the fill
appeared to be at the radiographic terminus. Percussion was negative
and perio findings were WL. The tooth had been virgin prior to treatment
and had been treated due to discoloration after adult ortho.
I did find a very localized specific area of palpation sensitivity.
I decided to do a cbCT. What do you think it showed? End - Part 1
- Rob Kaufmann
cbCT cross section of tooth showed overextension of the filling material
into the periapex resulting in the palpation sensitivity. I call this a
"buccal root prominence" problem and the solution actually is quite simple
- surgical removal of the excess gutta percha and resection of the root
apex to a level even with the adjacent buccal cortical bone.
Problem easily solved. She's booked for surgery in a week or two. But my
2D endo competitor would have never seen it.
While I may have suspected that this problem was occurring ( I have seen
this many times before and have experience in treating this) , the cbCT
and its proximal view allowed me to confirm my suspicions. Without this
imaging, some less experienced clinicians may have considered an endo
retreat that would have accomplished nothing other than subjecting the
patient to another procedure and additional cost. The cbCT allows for
NOVEL, UNIQUE and DIFFERENT visualizations that have never been routinely
The more I use the Kodak 9000, the more it is becoming apparent to me that
this imaging modality will NOT be the endodontic exception. It is simply
becoming an normal part of the armamentarium that allows us to see, further
appreciate and recognize the 3 dimensionality of the problems and teeth that
we are attempting to treat. It is clear that old fashioned 2 D x ray imaging
is at BEST ... a guess of what the tooth looks like and at WORST ...
pretty inadequate. . And while we USED to regard the cbCT image as "mainly
for those exceptional cases" .. .not for routine use....I am starting to
understand that my older 2D images really are pretty poor ( by themselves)
for assessing a case and a situation.
If anything, the whole field is screaming out for someone to take the
initiative and teach us how to read these images properly. (Endo and Path -wise).
My learning has mainly been through playing with the slices - using the
"Oblique View" sectioning method that adds a WHOEL NEW dimension to reading
these images. Dale Miles wrote a great text and there have been some generalized
":here what cbCTs can do" lectures , such as those at the Summit. But what is
needed is a hands on tutorial with Endo/Path case examples ( of the Kodak 9000)
and specific instructions on how to manipulate and get the view that you want....
NOT but just stumbling on it in your viewer.
Note to Endo Grad students: DO you want a fantastic job that will make you a
great living and allow you to sit on the beach every day rather than treat
patients? Go into cbCT Endo Radiology. I predict that most clinicians will NOT
have the time or patience to read these cbCT scans. ( Unless YOU are doing an
implant - It takes time to go through the volume of slices) - I send burnt CDs
of patient cbCTs to my referrals and I a SURE they end up in the trash - None of
them have the time inclination or patience to load the CD, assemble the volume and
wade through the Kodak software - something they have NEVER seen before and
that takes a while to learn to use. Dentists will eventually pay YOU to do this
for them -they don't have the time..
If I was 25 years younger, I'd seriously investigate the Endo/cbCT/Radiology
thing. There would be no better way to "go to work" than by sitting in the veranda
of my St John USVI villa, reading scans all day and collecting VISA numbers.
You can do that ANY WHERE! Now THAT would be the life!!!
One other feature I'd like to see Kodak insert is a "movie" feature. Instead of
sending the whole volume to my Referring Dentist, I'd like to be able to send
them a 30 sec movie of just the area of interest that I manipulate in real time
for them. I try to send the clip in .avi format in rough (poorer quality for smaller
file size - 7 MB) format - in the next message. I tried doing it properly in high
quality but the file size was massive (170 Meg) .
Comments welcome. ( BTW, I'm at my cottage - and it is POURING! - not missing much -
which is why I'm online on Saturday night!)
I can see Kendo turning green with envy for not having one of these 9000 units
in his office - Rob Kaufmann