From: Rob Kaufmann
To: ROOTS
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 definitive diagnosis.

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 seen before.

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