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From: "Dr. Glenn A. van As"
Sent: Monday, January 02, 2006 1:06 PM
Subject: [roots] You Crack me up
Well folks there has been an ongoing discussion of the merits of the microscope for general practice. Here is the kind of case I deal with
ALL the time in my practice. This lady came in symptomatic with sensitivity to chewing and she swore it was the gold crown well it wasnt.
The first step was to show her that the tooth that was problematic was not the previously endodontically treated tooth which looked nice but
the 2nd molar distal to the gold crown. The next step was to identify the extent of the crack and to document it because the dental plan
cannot see it radiographically nor will they ever support the provision of a full coverage restoration on a tooth such as this when there is
only a pre-existing occlusal restoration.
I see this each day in my practice, middle aged clenching ,bruxing , grinding , parafunctional nightmare cases that are habitually cracking ,
breaking , pulpally damaging teeth. Now this one is not a pulpal problem yet (they most often arent if temperature is not a lingering and
highly sensitive and if its only uncomfortable to chewing).
Now the scope helped me identify the problem , localize the cracks with the aid of the methylene blue , and as you can see from the photos shot
at 2.1X mag (read loupes), compared to the visual information presented at 12-19X power, you can quickly see how a scope can not only help you
identify the problem , but communicate the problem to the patient and then help you document the problem so that the patient will be able to
receive reimbursement for a full coverage restoration from their dental plan.
Could you diagnose a crack without a scope.........YUP..........
Could you document the crack with an Intra Oral camera.....Perhaps (it was small)
Would you feel comfortable with your treatment plan knowing that infact the cracks were on the MB and ML cusps. THe mesial decay most likely
caused the problem , compounded by the heavy wear facet in that location, the clenching, the pre existing amalgam and the fact that the
opposing tooth has both an endo and a full coveage restoration (guess what she broke that tooth and wont wear her Nightguard despite me
In any event , this is just to show you the kind of visual information that the scope can present to you, and that when you buy a scope the
first two things you notice are
1. Decay in alot more places than you first noticed (embarrasingly so).
2. Cracks everywhere, some under restorations and some that you create like lightening when you drop a carbided crosscut fissure bur into the
enamel........Oh ya, you can watch these occur......frightens the heck out of you using fissure burs the first time you do it!
Thought I would put the photos at 1024 by 768 as the cracks would be easier for the old guys to see.....Glenn
G., Your rad in ddx mode suggests there is no lingual cusp contact in co. There probably was because you demonstrated the wear facet on
the inner incline of the ml cusp. That being said you didn't mention how you solved that problem. You probably slightly shortened the
opposing lingual cusp and built up the central fossa of 31 and polished off the ml inner incline defect. I know the scope is a great tool,
but frankly I would have seen all the significant cracks with the IO cam. More on this later... got to go to work !! -mhenley
My rads were all preop so I am guessing that you are looking at the problem as existing and not at the final result. In any event as
mentioned this is a core buildup.......Crown to resolve the cracks is still to come once approved by the dental
plan. I actually took ALL the contacts out to try and minimize the occlusion on this tooth until the crown is done.- Glenn
I know the scope is a great tool, but frankly I would have seen all the significant cracks with the IO cam.
NOPE!!!!!!!..........your IO cam would have just given you glimpses of what was going on. It would take an exceptional practitioner to
assimilate those "glimpses" in to recognizable decisions. But that same practitioner that possessed that talent would have had the where
abouts to skip all of the BS and go right to a scope..."C Barrington"
Now, why in the hell did you have to say that. Here I sit thinking that the microscope is the only way to find these cracks when
I've been doing it since you were a suckling babe. I rode the road with my father, who was a country vet. We've driven up to a horse pen
and I've heard him tell a farmer, "she's going to die. Take her where you want to bury her". "How do you know". Because her ears are
laid back and she's got tetanus. He missed very little. You don't have to get out of the car to diagnose some things.
Cracks are a pain in the ass but you don't need a microscope to diagnose them. Sometimes having crap for brains and a bit of experience
helps. If you don't have the knowledge, you can look at it all day with a microscope and see a BIG tooth. Guy
Guy , I really shake my head here. Microscopes are for several reasons.
1. They are superior for evaluating the extent of the cracks and for finding them prior to opening the prep and for finding them
during the prep.
2. They are fantastic at documenting them for the dental plan.
3. They are great at communicating them to the patient.
I can see we are not going to change your mind........your ears are already laid back on this one.
The mind is like a parachute , it only works when it is open.
PS My dad was a dentist until this year as well, I road to work with him lots, I saw his belt driven Ritters,
I heard him talk about the good old days.
Guess what he said to me this year, - " the scope made you a much better dentist". He practiced for 44 years , hes got you beat! - Glenn
Well, now that I have the scope what pray tell am I going to do differently?
Let me help you with the answer..... absolutely nothing... absolutely !!!! - mhenley
Well, you have to have your eyes open when you are looking through the oculars..... :-) "C"
Yup, I am dead serious.
If you educate them too much, sooner or later they are going to start asking about your finish lines, why your crown margins are open
and why their crowns wont stay on.....
Get it done as quickly as possible, get their money and then get them out the door ..............geographic success is what I am all about.....
:-)!!!!! - C Barrington
I have spent the last thirty years educating patients who think that we
should just pull it out and put in a plate. Don't go there son. Guy
Mac, Question: do you use the IOC during treatment? - Arturo
Glenn, thanks to your postings, i knew how to deal this same kind of problem i had today.
One question though - is the methylen blue die the only stuff to use, or i can use, for instance, caries marker as a substitute?
Does it matter if it is aqueous solution or spirit? - Dmitri