From: Marga Ree
To: ROOTS
Sent: Saturday, June 25, 2011 12:53 AM
Subject: [roots] retreatment of a 3 canaled premolar

I was concerned that this tooth was perforated, given the fat post in the mesiobucccal canal. Furthermore,
the crown had a poor fit, so I wasn't too confident on the restorative prognosis. I removed the crown to
assess restorability, which appeared to be pretty decent, there was sufficient remaining sound tooth
substance to justify preservation.

I removed the post, and couldn't find any signs of perforation, except that the mesiobuccal canal was
hogged out. Pre-endo build-up of composite, canal projectors as space maintainers, and Ca(OH)2 for some time.

Today we finished treatment, because of the weakening of the mesiobuccal root 2 fiber posts were placed,
one in the palatal canal, and one in the mesiobuccal canal.

It doesn't look as nice as an initial treatment, but I am pretty confident that it will heal.
Patient is scheduled for a new crown. - Marga





State of the art endodontic and restorative effort and thanks for sharing your expertise. The only   Concern
I have  is with cbct use although the 3d pictures are marvelous. Normally in such cases I wouldn't  ct scan
the patient. Seeing these wonderful pictures makes me wanna get a CBCT for my practice as well,
but I am still resisting! - Antonis Chaniotis

How exactly is cbct a concern to you?  too much information?  Dosage issues?  Cost? - gary

Dosage and cost related issues Gary! Too much information never harmed anybody! - Antonis

Thanks for your comments Antonis.

Regarding using a CBCT scan, yes, there is dosage and cost involved.

One of the reasons I choose a Kodak 9000 is the fact that the effective dose is pretty favourable compared
to other machines, see paper attached.

Depending on the area to be scanned, it's between 19 - 40 microSievert. To compare this with a pano: 14-24
microSievert, and an intra-oral radiograph: 3-6 microSievert. So in the most favourable scenario, a Kodak 9000
scan is comparable with 3 rads, in the worst case scenario: 13 rads.

Regarding cost, yes, of course, I will usually charge the patient for a scan, but it is not uncommon that
I can actually save a patient cost, by establishing an more accurate diagnosis, identifying cases with a
poor prognosis before starting treatment and e.g. recommending extraction, identifying missed anatomy during
treatment and therefore searching more goal-oriented. Just to give you some examples.

I don't scan all my patients, far from that, and I always try to balance pros and cons. The CBCT has
influenced my way of practicing, and I still learn from every single scan.

Finally, too much information, as Gary suggestested, can be an issue, because you are supposed to identify
pathosis and abnormalcies in the whole scan, even it is outside your purview. If you use large field of view
scans, you are responsible for reading and interpreting areas that are beyond your comfort zone. Another
important reason to use small field of view machines.

Just out of curiosity, what are your indications to run a scan on a patient?  - Marga

Effective dose range for dental conebeam computed tomography scanners

Thank you for sharing your experience of cbct use in endodontic practice. I use mostly cbct prior to surgery for
Planning my approach and sometimes for diagnosis of suspected  missed anatomy. I have used it for healing confirmation
but I am not sure I did the right thing! I would like to get one in for my practice but I am concerned about the cost
and ending up performing free of charge ct scans. Nowadays in Greece people hardly pay for the treatment itself not
to mention the ct scan.

Your work is inspiring for a lot of people on roots and I think sometimes you are setting the gold standards
for people to raise their bars.  -  Antonis

Beautiful case Marga!
The key point here is the restoration!all this effort would have been doomed with a proper restoration!
Maybe it is time that post graduate endo programs start teaching preendodontic buildup and restoration
(as they do in Italy) And not implants, or maybe even that! It is clear that nowadays the skills you need to have
as an endodontist are far beyond doing just nsrcts! Well done and thanks for the inspiration! - Konstantinos

Thanks Konstantinos. I couldn't agree more, the person that finishes the endo should be in charge of the coronal seal
as well. Endodontists should take courses in restorative dentistry, to know hat they are supposed to do. And I agree
again, post graduate endo programs should teach restorative aspects.

If an endodontist is in charge of the build-up, he or she should be damned good at it, at least as good or better
than the restorative dentist. And we have some very useful tools to do this better, e.g. the microscope in the first
place. How can you check whether canal walls are clean for a subsequent bonding procedure without using a microscope?
How can you properly execute an adhesive procedure without using rubber dam?

We have the tools, now we need to increase our knowledge and improve our skills on restorative dentistry. You get cases
referred because you can do a better endo than the referral, same should apply to the coronal seal!!

An endodontist shouldn't be a one trick pony.....:-)  - Marga