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  Underneath the alloy
The opinions and photographs within this web page are not ours. Authors have been credited for the individual posts where they are. - Photos courtesy of Ahmad
From: ahmad tehrani
Sent: Friday, February 24, 2006 8:27 AM
Subject: [roots] Endo?

#31....LR second molar. this is what I found underneath the alloy.
what should I do? - ahmad

underneath the alloy

Pulp tests? perio probings? Symptoms? - Randy Ahmad what are the symptoms? What is the periodontal status? If none and the tooth tested normal just do a full coverage restoration and the patient will be fine. chief complaint? symptoms? signs? ;-) ? - Marcos No complaints! Just a fractured alloy that has transient cold sensitivity. EPT respond within the range of other teeth in the same quadrant. - ahmad I would suggest after explaining to the pt the prognosis for a fracture like this to open the pulp chamber and see if the fracture runs across the floor. and if it stoppes in the proximal and can be prep out or does it continue down into the root. If it can be prep out placing a bonded onturation material and getting it in a temp crown may be the way to go. allow it to sit before placement of a perm crown but I am of the opinion that the prognosis needs to be explained to the pt and a tx choice of attempted endo or implant should be offered. - Gregory Kurtzman good logic, but wrong answer...)) don't you want to know more information before accessing the pulp??? - ahmad Ahhhhhh probing mobility percussion isolated to either the buccal or lingual? grin so whats the right answer?- Gregory tooth slooth? percussion test? transillumination? furcal involvement? perio probing depths? - Marcos we're getting somewhere... Tooth slooth....slight pain when asked to bite as hard as he could. Percussion: negative. Lateral percussion: reported slight sensation/ Tansillumination: well it was a crack!...and showed a crack. No furcal catch with Nabors probe. No periodontal involvement...>4mm pockets There is at least one important piece of the puzzle left - ahmad occlusal intereferences, my dear Tehrani....Marcos NO! He has had his bite equilibrated and wears a night guard. keep digging! - ahmad why did you not remove the red stuff [kuraray caries detector, I assume] from the bottom of the cavity? or did you, and that is the missing piece..........? - Marcos It is Sable-SEEK from UDP. I was out of methylene blue which is excellent for pointing out cracks and lights up well for photography. The sole purpose of this post was to point out that endodontic discovery/diagnosis is like an onion ( Dovgan's Quote ) that needs to be peeled back one layer at a time. A picture of a crack is not diagnostic without other pieces of jigsaw put together. You gather as much information as you can from medical, dental, social, individual history of your patient and come up with a diagnosis. The missing piece was patient's age.... he is 92 years old! So let see what we have...92 year old patient who is in no pain. I pulp tested all the teeth in that quadrant and compared it to his contra-lateral side. No unusual findings. At least nothing that jumps out as extraordinary. You remove the alloy and find this fracture line on pulpal floor. now, what would you do? - ahmad Ahmad - this thread is exactly the reason why I encourage my endo sales specialists to monitor Roots, as well as why I encourage our customers to do the same. This is a great teaching technique which is rarely seen - informative and motivating. Thank you! - Kim I'd place a temp direct resin bonded crown to see if all the symptoms resolve. I've been doing this for years. Guy yes, he is 92, but for how long he will still live, noone knows...... I would... ...1/ explain the situation, your findings and the diagnosis, showing x-ray and photograph, and what it altogether means in terms of prognosis (survability of the tooth and risk of pain/infecftion in the future), then ...2/ list and detail his alternatives (including prognosis for survability of the tooth and risk of pain and infecdtion with each option), ...3/ encourage him to ask questions about the case, and how to solve it ...4/ let and ask him to make a decision by himself; you cannot go wrong with this approach...........................what did you do? - Marcos Your decision tree is acceptable to me...very generic for all situations. I liked the part of presenting pros and cons and letting the pt decide. 92 simply means that this tooth has been around for along time. No? So implants without giving the tooth the benefit of the doubt is out of question. Plus he has arthritis with chronic back pain to sit still more than 20 minutes! OK lets talk we have compelling evidence this tooth is endodontically involved? Yes, no , maybe. Yes: but unfortunately( -:)) irreversible pulpitis... today. No: Diagnostic testing is least TODAY. Maybe: whatever we do to restore, may tip the scale and push it over the edge. Distal pulp horn seems obliterated or sclerosed. There is probably a huge pulp stone in pulp chamber. The distal canal is calcified. So do we still access the pulp, knowing we could end up compromising the situation? The problem with endo is that if it is not done to the highest level, it carries the stigma of guarded prognosis. A fracture line through pulpal floor running inside a canal is doom as well. A fracture from M<--->D specially with an isolated deep eriodontal component is also doomed. So. What we have & I saw was a fracture or perhaps a craze line. As much as I wanted to drill a hole and get the pulp out, I opted to prepare the tooth for a full gold crown after a bonded buildup. So did the patient! I have a hard time convincing myself in to doing endo, without an iron clad diagnosis. I decided against an onlay, because of internal preparation creating a wedging effect upon an already existing fracture line. I sacrificed the mesial enamel for predictibility and simplifying the results. Fabricated a custom made provisional and will evaluate it for 4 weeks before impressing for permanent restorations. If the need for endo arises before final cementation so be it. The core can be isolated and pulp accessed. In the future, it can always be accessed through the Au crown, bulk buildup and close with a gold foil. so what would you have done? - ahmad ps..I'll post the full case with pictures, in a few minutes.. I would have done what the patient had asked me to ;-) if it were my tooth, I'd want 1/ SE Bond and a composite resin to bond & fill the cavity, 2/ an overlay to prevent the tooth from splitting in two, and 3/ every-six-months follow-up-exam-&-xray hmmmm: in a couple of hours or so it is gonna be about time to go to bed over here................ but in case I fall asleep right after I click "Send", Ahmad, I want to say I enjoyed this Quiz (even though it seems as if it has been a one on one.... where are the Rooters when you need them to solve an Indiana-Jones-type enigma............? [or is it only on my end that ROOTS was quiet these hours ?]) - Marcos I also thought this was very enjoyable and thought provoking. Maybe time for a quiz du jour? Get people thinking instead of spoon feeding the cases? - Bill Fred used to do this on regular basis....but the politics of full time teaching drains all your juices. lets do it..but first lets get rid of all spoons...)) - ahmad Hi Ahmad, I posted this earlier in the German group, case done in June 2004. I've treated a couple cases like this. They were sensitive to chewing - pain upon release of pressure - which ceased immediately after treatment, reaction to cold has been normal ever since. I'll try to get an X-ray next time. The trick is that the ribbond increases the tensile strength of the composite. Maybe this would have been an option for your pt. as well - Winfried

Hi Winnie: I am convinced no one does composite like guys are amazing. Ribbond gave me nothing but grief...It bends and crushes when condensed, I end up with voids....etc...((( But, I got your instruction about the use of ribbond. I will definitely try it next week and post a case! - ahmad One trick to Ribbond is I wet it with a flowable composite pushing the resin into the fibers (I think this works better then applying an adhesive as the flowable is a filled resin) I then place some hybrid comp down on a peice of plastic lay the ribbond ontop fold the plastic over and compress the Ribbond into the comp, open the plastic fold the comp over the ribbond and cover and compress again. then take a scalpel and cut off the extra comp so you have just the width of he Ribbond then its easy to place and shape. - Gregori Fabricated a custom made provisional and will evaluate it for 4 weeks before impressing for permanent restorations. If the need for endo arises before final cementation so be it. The core can be isolated and pulp accessed. In the future, it can always be accessed through the Au crown, bulk buildup and close with a gold foil. so what would you have done? - ahmad This is exactly what I would have done, Ahmad. Anyone as old as me notice that we seem to be seeing more cracked teeth than we did thirty years ago. Could have something to do with diagnosis but I think not. I think lifestyle changes in the last fifty years have induced more clinching and bruxing. I've been in dentistry for forty years in one form or another. Just seems like we are seeing more cracked teeth. I believe amalgam fractures them. Others disagree. I'll hang on to that belief. Guy