The Apex-Endodontic Blog for General Dentists

Where are the updated Prophylaxis Recommendations?

Mon, 13 Mar 2023 20:59:43 GMT

2TheApex: AAE Guide RIGHT HERE! ADA Guides here! Key points to note: Antibiotic inadvertently NOT administered pre-operatively can be given up to two hours following treatment.If the patient is already taking an antibiotic, a different class antibiotic should be given for prophylaxis. (Example: Patient already taking Penicillin for days is not good enough and should be given another class of antibiotic acceptable for prophylaxis, i.e. Clindamycin 600mg)In general, NOT recommended for prosthetic joint implants unless specifically prescribed by the patient's orthopedic surgeon. Their surgeon should recommend the specific regimen and ideally write the RX for the patient when possible.(image: Staph. Aureus)

Are Pulpotomies still a thing?

Fri, 17 Sep 2021 18:09:39 GMT

2TheApex: Yes.

Pulpotomies are a good way to get a patient with irreversible pulpitis some relief until root canal therapy can be fully completed. Profound anesthesia is key. After popping into the pulp camber change your bur to a non-endcutting bur like the Endo-Z bur . Run the bur around the chamber and remove any tissue above the canals. Do not be temped to use any files in the canals. Staying out of the canals is key to a pulpotomy. Pressure with a hypochlorite soaked pellet usually stops any bleeding. Rinse the chamber with hypochlorite, dry and restore with a cotton pellet and temporary restoration. The insurance code for the procedure is D3220

Endo Emergency procedures reference

What is the best way to do a direct pulp cap?

Tue, 09 Feb 2021 19:16:46 GMT

2TheApex: Asymptomatic vital tooth, isolation, coronal seal, and a bio compatible material are the keys to a direct pulp cap.

Tooth status: Asymptomatic carious exposure or recent trauma, no history of symptoms suggesting irreversible pulpits, and an an incompletely formed apex.

Pulp testing should be done prior to anesthesia. Prognosis of a direct pulp cap from a carious exposure in a mature tooth is very poor and often leads to more problems in the future.

Isolation: Rubber dam isolation is very important, saliva contamination will cause bacteria to be introduced to the site. NaOCl soaked cotton pellet should placed gently but firmly on the exposed pulp to decontaminate the area and control bleeding. Persistent and excessive bleeding is a sign of inflammation and likely irreversible pulpitits. A pulp cap should not be attempted in this situation.

Bio compatible material: MTA or other bioceramic material is the preferred. Traditionally CaOH has been used, however this is less biocompatible and will eventually break down.

Seal: The seal is the deal! Coronal leakage will invariably lead to pulpal pathosis. We recommend placing thin layer of Vitrebond directly over the pulp cap material, then proceed with a bonded final restoration immediately.

Manage expectations: Inform patient of the possibility that root canal treatment may still be necessary.

Uni- or Bilateral Mental nerve block for Mandibular Incisors with Irreversible Pulpitis??

Mon, 25 Jan 2021 19:22:39 GMT

2TheApex: Bilateral Nerve blocks were more successful (38% Uni- vs. 64% for Bilateral)

Mandibular teeth with Irreversible Pulpitis are the most challenging to gain profound anesthesia. Due to some cross-innervations depositing anesthetic at BOTH mental foramina was found to be more successful that just one. Of course a Mental Nerve block may be preferred by patients since the tongue is not numb and it has a faster onset of action than an inferior alveolar nerve block.

Reference Click Here

What’s our current source of information for COVID19?

Sun, 15 Mar 2020 19:04:19 GMT

All of this is so rapidly changing our thoughts may change tomorrow. Dated 3/15/20

DETAILED ARTICLE IN NATURE

The above article has detailed screening questions.

ADA INFO

Our door sign

More info will be posted once we get our protocol together.

Please share what you and your office is doing.

Thank you,

Derek

Thanks Dr. Clara Ping for tip on Nature article

Cracked teeth: Save or Extract?

Mon, 24 Feb 2020 07:22:51 GMT

2TheApex: There is no cut and dry answer for cracked teeth. The decision to extract or save a tooth should be based on a through clinical evaluation and a discussion with the patient about prognosis, risks, benefits, and alternative treatment options.

Cracked teeth (not to be confused with split teeth or vertical root fractures) are a challenging topic to discuss with patients. Below is a small checklist that we use to run through decision making with the patient when deciding to save or extract a tooth.

1) What does the patient want? Are they willing to take the risk of the tooth having a short life span even with root canal treatment and crown placement?

2) Systemic factors: history of bisphosphonate treatment, poor options for replacement, upcoming joint replacement surgery etc…

3)Probing depths. [Better prognosis] < 6 mm < [worse prognosis]. Deep narrow defects are a bad sign, however remember that not all teeth with fractures will present with detectable periodontal defects.

4) Radiographic findings. Is there a vertical defect or bone loss in the furcation?

5) Is the tooth vital or necrotic? There is some research to suggest that teeth that undergo necrosis from a fracture may have a poor prognosis.

6) How far apically does the crack extend internally? Good: crack stops coronal to CEJ. Questionable: Crack extends to CEJ or pulpal floor but not beyond. Poor: Crack extends into canal or onto pulpal floor. Hopeless: Crack extends entire length of tooth across pulpal floor and both margins.

How do we explain tooth resorption to patients?

Fri, 14 Feb 2020 20:43:06 GMT

resorption

2TheApex: "The cells that usually remove bone so it can be replaced started to eat away at your tooth. This can be due to the anatomy of the tooth, a history of trauma, or other unknown reasons. We usually call it idiopathic tooth resorption because idiopathic means "We don't know why.""I find that if you explain to patients that it's not from lack of brushing or flossing they find some solace that it's not their fault if the tooth has to be removed.Another way to explain it might be:"The cells in your body that naturally turn bone over begin to take away tooth structure. We aren't really sure why this happens, but it can be associated with a defect in the tooth structure, trauma, as well as a few other things. Resorptive defects can be very small and stop spontaneously or they can be extremely aggressive and completely destroy the tooth. There is really no way of knowing which is going to happen.""It can happen from inside - out, or from the outside - in, and this dictates what treatment is necessary"How do you explain resorption??Thank you!

Can I use my driver's license to fly domestically?

Tue, 26 Nov 2019 20:59:39 GMT

2TheApex: Yes, BUT! as of Oct. 2020 it must be a REAL ID.WI, IA, and MN are REAL ID compliant states. But, your driver's license must have a gold or black star on the front to be compliant. If you don't see a punched out looking star in gold or black then time to renew or replace your license. The lines at the DMV will only get longer as the deadline approaches. You will need to bring additional documents to get the REAL ID version. It looks like a Social Security card and birth certificate or passport should be adequate for most people. Please follow links below to be sure. Mine doesn't have a star, so see you at the DMV. WI Residents IA Residents MN Residents

Any new help out there for selling or finding a practice to buy/join?

Mon, 23 Sep 2019 20:07:40 GMT

ToTheApex: YES!The ADA has launched a new program for finding the right person to sell your practice to OR for buying a practice. Wisconsin is one of the first states to offer it. Think of it as eHarmony for dental practices. Both owners and prospects fill out questionnaires. A real person reviews all questionnaires and matches potential practices and doctors. This is not free but I think it's really cheap considering what they are offering and other options out there.Check it out here: ADA Practice Transitions

Use Topical Anesthestic prior to injections?

Wed, 11 Sep 2019 20:18:14 GMT

2TheApex:Yes! Our goal is to make dental visits as painless as possible. "Your comfort is our priority" can be heard daily in my operatory several times a day. Topical anesthetic is most effective for infiltration injections in areas of unattached tissue. Research does not support it's effectiveness for palatal (highly keratinized tissue) injections. But, we feel it comes down to empathy and possible placebo effect for most injection sites. The 30-60 seconds it takes to apply the topical is a trust builder with a patient we likely just met minutes earlier.How to apply it: Dry the area with a 2 x 2 gauze, place a cotton-tipped applicator with the topical at the site of future injection, cover it with the gauze and have patient close their mouth for 30-60 seconds. Then remove applicator and wipe out remaining topical with the gauze. Inject.For some injection sites it comes down to: Why Not? For the palatal injections I do skip it in favor of pressure anesthesia using the back end of my mouth mirror. Of course for some patients you may need to skip it due to allergies or medical reasons.Other tips for successful local anesthesia click here

How do you access through procelain?

Mon, 01 Oct 2018 20:29:00 GMT

industry metal fire radio

2TheApex: Diamonds are a dentists' best friend.We always explain to the patient that we plan to try and keep the current crown unless we already know it's best to replace it or find a reason to replace it during the treatment. "One risk of the procedure is that the porcelain could crack and you may need a new crown. Of course, we take every precaution to avoid that." The diamonds we use currently are Darby Dental product #959-4599 and the other is the Dura-cut diamond thru Brasseler product #5011987U0. Both are about a #4 size round.Always use a lot of water and light pressure to "paint" away the porcelain. Depending on the type of material it sometimes takes more than one bur to get the job done. As soon as the cutting becomes inefficient it's time to replace it.

New website Domain

Wed, 19 Sep 2018 20:53:23 GMT

We have changed the Blog website to www.totheapex.com You can also get here directly using 2theapex.wordpress.com Sorry for any confusion. Thanks for bookmarking us and following the Blog. Look for new posts soon!Reply with suggestions for new topics. Ask us anything!!Thank you,Drs. Nordeen and Jespersen

Is this the future of brushing?

Fri, 21 Jul 2017 20:56:29 GMT

2TheApex: Time will tell.I don't an ADA seal on this yet but only 10 seconds to brush ALL of your teeth is appealing. Patients might use it. Click HERE for more info on the Amabrush. They plan to ship in December. Good Holiday gift??

What is your "MacGuffin?"

Fri, 30 Dec 2016 00:03:00 GMT

alfred-hitchcock-226x300

2TheApex: Huh?? This is a post I found interesting from Summit Practice Solutions. Enjoy and have a Safe and Happy New Year!! -Derek

The Great MacGuffin

After all the great movies that are out now, I thought I would use a film term to illustrate a huge barrier to growth. "MacGuffin" was coined in 1939 by famed filmmaker Alfred Hitchcock. McGuffin is defined as: A plot device that motivates the characters and advances the story. This plot device is often in the form of some goal, desired object, or other motivator that the protagonist pursues, often with little or no narrative explanation. The most common MacGuffin is an object, place, or person. Other more abstract types include money, victory, glory, survival, power, love, or some unexplained driving force. I know that you're asking yourself: "How is this pertinent to Dentistry or my practice?" It has everything to do with it. In the movies, the MacGuffin is made up. In real life, this motivator is what will define our successes and failures. We are all driven to succeed, and you can define success any way you want. For me, it has always been centered on a balance of faith, family, and serving my patients at work. It is that balance that I struggle with, but it is the MacGuffin that drives me to keep striving.

So what are you chasing in your story? What motivates you or could motivate you to take your practice to another level of excellence?

Money: The default, low level, knee-jerk goal that catches all of us. It starts with a huge school debt, accelerates when we buy our first practice (we call it investing in our future at that point), and is perpetuated by an entitlement mentality that creates a life built on debt and the hope that someday your ship will arrive. In the book, The Fulfillment Curve, there is a justified amount of money that we need to set as a benchmark. It allows us to service our debts, provide food and shelter while educating and supplying the needs of our growing families. It is what comes after this base amount that creates a life of diminished rewards and a lifestyle that jeopardizes our future. Money is not the root of all evil; it is the love of money. Leadership and success demands that each of us get a handle on how we save, spend, give, and invest the money and time that we have here.
Peer pressure: Sometimes in just keeping up with the community we live in, or the dentist down the street, we allow other peoples opinions to define our self-worth. Not a very good goal in life because you are setting yourself up for failure. You can't control what others do or how they live, you can only decide and execute your life plan.
Clinical excellence: Great standard to move towards. The mistake is thinking that you will ever arrive. If you're like me, the more I learn the more I find out that I have more to learn. A lifetime of learning is a great ambition, just make sure that you understand that every doctor should strive for more competence every year. But clinical excellence will not grow a practice or compensate for a lack of systems, people skills, great patient relationships, and an incredible staff.
To get out: Maybe the most desperate reason to push yourself. With over 50% of dentists wishing they had not entered the field, we can assume that the profession (or the path to it) is fraught with numerous potholes that many of us find ourselves in. I run into at least one doctor each month with a sad story of being trapped in a profession that they feel they are ill equipped for and facing the realization that they were never really suited for.

For me, the driving force behind my career always seemed to morph and evolve as the years progressed. Now four decades later, as I look back, I still find that my deepest MacGuffin was my desire to serve in an excellent way: clinically, relationship wise, and business success wise from production and profitability. I guess I could leave it at that, but just under the surface in a place I don't like to go, I was also driven by the desire to "not die broke". I have no idea where this came from, but even today I tend to worry about the clients that just can't seem to grasp a path toward financial independence.

This time each year I like to do my Ten Year Plan in which I set up goals for the next 10 years. It has gotten a little scarier each year as I approach my "use before date". As a New Year's goal this year, explore where you are and where you want to go by taking the Ten Year Plan challenge. Just click on this link to get your copy and call me if you have any questions.

http://summitpracticesolutions.com/files/2014/02/Ten-Year-Plan-1.pdf

THIS IS HOW YOU SUMMIT!

Mike Abernathy, DDS

972-523-4660 cell

abernathy2004@yahoo.com

P.S. Have a friend that would like to get our newsletter? Share it to them by clicking here

Where's a good reference for local anesthesia techniques that work??

Thu, 29 Dec 2016 22:23:23 GMT

painful-needle

2TheApex: Right Here!! This is a great summary of techniques that can help with that "Hot Tooth." And a good source for what does NOT add to successful anesthesia. CLICK HERE Enjoy

Nasal Spray alternative to Needle?

Thu, 29 Sep 2016 23:19:32 GMT

2TheApex: Yes! Last June the FDA approved an anesthetic nasal spray (Kovanaze) for use in restorative procedures on teeth #4 through #13. It takes two squirts 5 minutes apart (a third squirt may be needed sometimes). One big advantage, in addition to calming patients with a needle phobia, could be pulpal anesthesia without lip numbness for esthetic cases. Use for root canal treatment or biopsy has not been studied yet. Kovanaze is reported to be available sometime this fall. Recent Study Manufacturer Press Release Explanation with diagrams from Spear Education

What percentage of crown-prepped teeth become necrotic?

Mon, 05 Sep 2016 15:51:41 GMT

2TheApex: Roughly 10% One statistic you may want to share with patients is that 1 in 10 teeth with crowns end up requiring root canal therapy. Here is the Study . Not a bad statistic for patients to know prior to a crown prep. There is always a risk. The more highly the tooth is restored increases the chances.http://endolit.com/betaadmin/uploads/A_Prospective_Study_of_the_Incidence_of_Asymptomatic_Pulp_Necrosis_Following_Crown_Preparation.pdf

Where to go for Dental Trauma guidelines?

Sat, 25 Jun 2016 19:26:06 GMT

2TheApex: The Guide(click) (update July 2017-they changed this to a paid service of $25/year)Just a reminder post since it's the trauma season. This is a great reference. It gives both patients and parents proper expectations following treatment that you can print out.

What are the most recent guidelines regarding bisphosphonates?

Fri, 05 Feb 2016 20:34:36 GMT

2TheApex: Guidelines for patients taking antiresorptive medications can be found here .

The AAOMS recently released a position paper about medication-related osteonecrosis of the jaw (MRONJ). Bisphosphonates are the most common class of medication associated with MRONJ. The definition has been expanded, however, and now includes medications taken by more than 5.1 million people over the age of 55. Dental procedures which expose and/or damage bone have the potential to cause osteonecrosis for these patients. The highest risk category is IV cancer therapy , which is about 100 times higher than patients being treated for osteoporosis. Patients taking oral bisphosphonates for greater than 4 years are at an increased risk and should consult with their physician regarding a 2 month drug holiday prior to invasive treatment such as extraction. Patients should be treated aggressively prior to, and direct osseous injury should be avoided during, IV therapy. This could mean root canal treatment in lieu of extraction, if they are high risk. I highly encourage you to review the paper itself, as there much more information provided there.

What's the best way to avoid post-operative muscle pain for your patients?

Mon, 23 Nov 2015 07:17:15 GMT

2TheApex: Use a bite block

Whenever a patient can tolerate a bite block/mouth prop, aka "tooth pillow", we use one. Since using them routinely, I perceive a decrease in post-op myofascial pain complaints. And it also makes the access easier and the treatment more smooth when the patient doesn't need to be constantly reminded to open their mouth. We explain to the patient that, "We plan to use a mouth pillow for your comfort. This way you can relax your jaw and you don't need to hold your mouth open for the entire procedure. If you don't like it just let us know and we can always take it out." We tie a piece of floss to it so it can be removed quickly if needed.

Good idea to mix Chlorhexidine and Sodium Hypochlorite in the canals??

Mon, 12 Oct 2015 07:12:50 GMT

2TheApex: No.

Mixing chlorhexidine and sodium hypochlorite forms a precipitate called parachloroaniline (PCA). It is orange-brown in color and, in theory, could compromise the treatment. The compound has also been shown to be toxic and classified as a carcinogen.Can you irrigate with both of these solutions in one tooth? Sure, just don't mix them directly. You can irrigate with EDTA or alcohol after the sodium hypochlorite and prior to the chlorhexidine.The point is to avoid chlorhexidine and hypochlorite from coming in direct contact.More info here .Thank you for Dr. McCormick in Mauston for posing the question. We felt it was worth sharing. If you have a particular topic or question don't hesitate to ask. Thanks Mick!

How many canals are in that tooth?

Wed, 12 Aug 2015 07:08:22 GMT

2TheApex: Expect multiple canals until proven otherwise.Except for maxillary anteriors, all teeth should be expected to have more than one canal . Some commonly missed canals are MB2, the lingual canal in mandibular anterior teeth, second (or third!) canals in premolars, and a second distal canal in mandibular molars. Recently I had a very interesting case that was a new one for me: a second palatal canal in a maxillary molar.Preop:

Cone fit: Note palatal cone offset to the distal of the root.

Final: 4 canals, with 2 canals in the palatal root.

The palatal canals shared a common orifice, and the additional canal was not evident on initial access. The canals bifurcated apical to the orifice, and the second canal was located with the aid of the dental microscope to the mesial. A very interesting case, and a good reminder to always expect the unexpected.

When to use the CBCT?

Mon, 13 Jul 2015 07:01:51 GMT

2TheApex: When a conventional periapical radiograph is inadequate. (the uber simplified answer)

The AAE has published a revised position paper on the use of CBCT. You can find it HERE (click). This is the complete answer of when CBCT is indicated. It's a quick and easy 7 pages.Example CaseCBCT Vs. Conventional Periapical radiograph. (recent case from Dr. Nordeen)Pre-op periapical Image of Maxillary right

Obvious Findings: Radiolucent lesion tooth #4. Possible lesion tooth #2???CBCT (mid-retreatment of tooth #4) of the same area using a custom curve. Note apex of tooth #7 caught in the field.

Video while scrolling through CBCT. (from cervical to apices and back) Video is slightly zoomed in, so the detail we view images is better than this normally.[wpvideo idbaZgBn]Obvious findings with Cone Beam: Radiolucent lesions on teeth #2, #4 and #7. Almost complete furcal bone loss on tooth #2.In our practice we use it routinely for surgery, retreatment, resorptive defects, inconclusive diagnosis and trauma. This technology has become as important in our practice as the microscope in providing the best care possible for our patients. We have gone from using it only several times a month to almost daily. This has been the next "game changer" in endodontics.

One poke or two??

Fri, 29 May 2015 06:54:04 GMT

2TheApex: Two inferior alveolar nerve blocks (IANB) are more effective than one in both symptomatic and asymptomatic patients.A recent article published in the Journal of Endodontics showed that administering 2 carpules of local anesthetic was significantly more effective at achieving profound lip anesthesia. 3169 people participated in the study with failure rates of 7.7% with one carpule, and 2.3% with two carpules of 2% Lido with 1:100,000 epi. Although this may seem like common sense, it is the first article to show that increasing volume will increase IANB success rates. This study only examined anesthetic success in terms of lip numbness, not as a pain free procedure. As we all know, pain can still be present during the procedure even with profound lip numbness. However, adequate anesthesia will almost never be achieved without first achieving lip numbness as a sign of a successful IANB first.

Typical blood loss during root end surgery?

Sun, 10 May 2015 06:52:01 GMT

2TheApex: Similar to an extraction

The average blood lost during root end surgery is 9.5ml according to Messer. This is similar to a single tooth extraction. Time is the biggest factor. Buckley reported that by using 1:50,000 epi. (vs. 1:100,000) blood loss is cut in half during periodontal surgical procedures.

Which irrigating solution is the best?

Sun, 22 Mar 2015 06:49:08 GMT

2TheApex: Sodium hypochlorite

An ideal endodontic irrigant disinfects the canal, act as a lubricant, removes debris, dissolves tissue, removes the smear layer, and is safe for the patient. Although there is no perfect irrigating solution, one does stand head and shoulders above the rest: sodium hypchlorite (NaOCl). In a review article of irrigating solutions, Haapasallo stated "It is difficult to imagine successful irrigation of the root canal without hypochlorite." Sodium hypochlorite cannot fill all the criteria by itself, and so a chelating such as EDTA is used to help facilitate smear layer removal, but no other irrigant fits the criteria of an ideal irrigating solution better. There are risks to using sodium hypchlorite, and it must be used with caution to avoid extrusion into periapical tissues. Other irrigating solutions have been shown to be potentially beneficial in some circumstances, but if possible they should be used as an adjunct and not as the only irrigant. At this point in time, the research is clear that NaOCl is the best endodontic irrigating solution available.

What is that purple stuff in my access?

Tue, 03 Feb 2015 05:44:05 GMT

2TheApex: It's PermaFlo Purple , a colored flowable composite.

Coronal seal has been shown to be critical in the long-term success of endodontic treatment. (click on "Coronal Seal" for flagship research on this subject) PermaFlo Purple is a flowable composite that will provide an excellent seal and is easily identifiable for when the Cavit is removed after treatment for the final restoration or if retreatment should needed in the future. It is useful in teeth that have deep caries or small crack making a coronal seal with Cavit questionable, or in patients that may have difficulty returning for a final restoration within the 30 days recommended following root canal treatment. It is bonded and placed as a thin layer, so does not need to be removed and can be bonded to just like any other composite restoration.

lesion was squamous cell carcinoma. It was removed in total by an oral surgeon and the patient needed no further care.April is Oral Cancer Awareness month. Click here for info on how to promote it within your practice.

What is Gutta-Percha made of?

Sun, 04 Jan 2015 05:40:53 GMT

2TheApex: 65% Zinc Oxide; 20% Gutta-Percha; 10% metal sulfites; 5% waxes and resins (Friedman) It's mostly Zinc Oxide. We call it Gutta-Percha since that is what gives it unique properties we enjoy, like plasticity. The material was used as an obturation material over 100 years ago. It comes from the sap of a tree that grows in Malaysia. It is also safe to use in patients that are allergic to latex. ( American Latex Allergy Association ) Gutta-percha has stood the test of time and it still the standard by which all obturation materials are judged.

How do I do an oral cancer screening?

Fri, 07 Nov 2014 05:36:11 GMT

2TheApex: Very Easily Oral cancer still has a poor 5 year survival rate although it has improved in the last 10 years to 57 percent. Early detection is key! Taking the time to do a screening could save someone's life. Here is a video on how to perform a comprehensive screening. It's worth the 11 minutes for a refresher.http://www.youtube.com/watch?v=TrquHxrOF7EEarly in my practice this patient was referred for treatment of tooth #15. I found this tongue lesion upon exam.

Can you call in a RX containing Hydrocodone?

Mon, 06 Oct 2014 05:18:06 GMT

2TheApex: Not any more (as of today) Effective today any medication containing Hydrocodone is Reclassified as Schedule II. Yes, Hydrocodone combined with Tylenol is now Schedule II. (Click here for the DEA ruling on this) This means you CANNOT give an oral order for Hydrocodone. The pharmacy will need a physical prescription brought in to the pharmacy. Back to writing (or printing) and signing paper again. No more phoning it in unless it's an "emergency." Click below for the rules in our area. Wisconsin , Minnesota , Iowa . Weekend pain control after October 6, 2014. First determine the patients pain level and how they are currently trying to control it. Sometimes patients are inadvertently doing things to make the pain worse. (Like placing ice on an swelling caused by infection) Be sure they are taking OTC pain medications properly. Taking 800 mg Ibuprofen every six hours with an Extra Strength Tylenol (500 mg) staggered between the Ibuprofen can manage most pain we encounter. Other options: Call in for Schedule III (Tylenol III) or call Hydrocodone in as an "emergency" and most states will allow you 7 days to get them a physical prescription. Another medication that works well for dental pain is Ultram ( Tramadol ) Schedule IV. If you think the pain source is primarily inflammatory a Medrol dose pack can be very effective. When prescribing, the patient's heath history is paramount as well as current medications and allergies. A proper diagnosis is always critical to managing a patient's pain. What do you plan to prescribe for a patient, if needed, after hours?

Is diagnosis more challenging with a patient taking Ibuprofen?

Sun, 14 Sep 2014 05:13:15 GMT

2TheApex: Yes!If a patient has been taking Ibuprofen symptoms can be masked. Read found palpation to be masked up to 40% of the time. Cold response was masked 25% of the time. Be sure and ask patients if they have been taking any NSAIDs and at what dosage prior to pulpal testing. The bite stick test is one test that seems to be least affected by taking NSAIDs. We encourage patients to cease taking any pain medication at least 6 hours prior to the appointment if it sounds like the diagnosis might be challenging.

Can you take a tax deduction if you are producing crowns (CEREC or similar) in your office?

Tue, 24 Jun 2014 15:32:19 GMT

2TheApex : YES ! Disclaimer: We are not a source for tax advice nor are we accounting professionals. Please consult a CPA to be sure this applies to your office and makes financial sense .Domestic Production Activity Deduction (DPAD) is the production or manufacturing of tangible property within the United States. Milling crowns in the office is considered by the IRS to be a manufacturing process. The deduction is 9% of the net income from the CAD/CAM process. This may be worth contacting your accountant if you think it could apply to your practice. Is the deduction enough to justify the additional paperwork your accountant will need to claim the deduction?

What is successful root canal treatment?

Mon, 09 Jun 2014 15:29:13 GMT

2TheApex: A functional, asymptomatic tooth with no clinical signs of pathosis can be considered successful even without complete healing of the ligament . Endodontic success has traditionally been defined as the prevention or elimination of periapical disease following root canal treatment, meaning both complete healing of the PDL radiographically and absence of symptoms clinically. However, utilizing CBCT to evaluate PDL healing Patel showed a 25% reduction in "success" compared to periapical radiographs. Many of these teeth are still in function, asymptomatic, free of active disease, and esthetic; yet fail to meet the above, very stringent, definition of endodontic success. Has treatment been unsuccessful in these cases? How do we measure success clinically? Does it really even matter what definition we use for “success”? Having a clear definition of success is important because treatment plans are be based largely on the prognosis of treatment options. Endodontic treatment and implant placement will frequently be compared, however most implant studies define success as simply survival of the implant. ( Iqbal ) Helping patients maintain their natural dentition is a primary goal of endodontics, and a definition of success that emphasizes survival more closely aligns with both patient goals and allows for the most accurate comparison of treatment options. Doyle addressed this discrepancy directly by analyzing both the success and survival of implant and endodontic treatment, which resulted in almost identical success and survival rates. A financial evaluation, however, shows that in most circumstances endodontic treatment is the most cost effective option. ( Pennington )

Antibiotics for Endodontic infections

Sun, 27 Apr 2014 15:23:00 GMT

2TheApex: Penicillin VK 500mg, Disp. 30 Tabs Take 2 stat then 1 QID until gonePenicillin allergic Patient: Clindamycin 300mg, Disp. 30 Tabs Take 2 stat then 1 QID until gone If the patient taking Pen VK does not have a decrease in symptoms within 48 hours we add Metronidazole 500mg Disp. 30 tabs taken QID until gone.The reason for choosing Pen VK as the first line antibiotic lies in the fact that it will kill most bacteria in endodontic infections. It is also a very narrow spectrum antibiotic thus it has very low side effects. Baumgartner recommended Pen VK after his research published in 2003. A medication that is well tolerated is more likely to be taken by the patient and the prescription completed. It is also cheap. Patient compliance should be considered.Ideally, antibiotics should be limited to patients with malaise, fever, lymph node involvement, a suppressed or compromised immune system, cellulitis or a spreading infection, or a rapid onset of severe infection. This supported by Matthews review of the literature.Removal of the infection by complete debridement of the root canal system is a priority. Incision for drainage is also considered for all moderate to severe infections with localized involvement.When prescribing any medications the medical history is considered. With a complicated medical history other antibiotics can always be considered.-Pic is of Alexander Fleming, who is credited with discovering penicillin in 1928.

Restoration of teeth following endodontic treatment.

Tue, 04 Mar 2014 15:19:38 GMT

2TheApex: Endodontically treated teeth not restored with a crown are 6 times more likely to be lost.A good restoration is just as important to the success of root canal treatment treatment as the quality of obturation. (1) While it has been shown that the dentin of endodontically treated teeth is not more brittle than their vital counterparts, they often experience a reduction in overall strength from loss of tooth structure. (2) Loss of even one marginal ridge, such as in an MO or DO preparation, can reduce the strength of a posterior tooth by 46%, loss of both marginal ridges results in a 63% reduction, while a conservative endodontic access will only reduce the strength of the tooth by about 5%. (3) A crown may not be indicated for every tooth following root canal treatment, however Aquilino showed that teeth not restored with a crown were lost 6 times more frequently than those restored with a crown. (4)1: Ray, H. A., and M. Trope. "Periapical status of endodontically treated teeth in relation to the technical quality of the root filling and the coronal restoration." International Endodontic Journal 28.1 (1995): 12-18.2: Sedgley, Christine M., and Harold H. Messer. "Are endodontically treated teeth more brittle?." Journal of Endodontics 18.7 (1992): 332-335.3: Reeh, Ernest S., Harold H. Messer, and William H. Douglas. "Reduction in tooth stiffness as a result of endodontic and restorative procedures." Journal of Endodontics 15.11 (1989): 512-516.4: Aquilino, Steven A., and Daniel J. Caplan. "Relationship between crown placement and the survival of endodontically treated teeth." The Journal of prosthetic dentistry 87.3 (2002): 256-263.

Isolation during Restoration

Tue, 04 Mar 2014 15:16:51 GMT

2TheApex: Use of rubber dam isolation during post placement significantly increases success of root canal therapy.

Recent research published in the Journal of Endodontics (Dec. 2013) by Goldfein found 73.6% of teeth in non-RD group considered successful at follow-up. The RD group increased success rate to 93.3%. This demonstrates how critical it is to avoid coronal contamination. Regardless of how well the root canal therapy was done the treatment will fail if it's not sealed. Careful RD clamp placement along with topical anesthetic is usually enough for patient comfort during a simple restoration appointment.

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Thu, 02 Jan 2014 15:10:17 GMT

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Length Determination

Wed, 18 Dec 2013 15:02:06 GMT

2TheApex: Electronic apex locators the most accurate method of determining canal length.

Accurate length determination is essential for adequate root canal treatment. Root canal space that has not been adequately cleaned is a potential nidus of bacteria which may lead to future periapical pathosis. On the other hand, over extended obturation material will create an inflammatory reaction that can cause pain and impede healing. (1) The two most common methods of length determination are radiographs and electronic apex locators (EALs). Radiographs are an indispensable tool that will yield much more anatomical and diagnostic information than just the length of the canal, however, in vivo studies directly comparing the accuracy of the two techniques have shown that EALs are more accurate in locating the apical foramen . (2) This is due to the apical foramen being located an unknown distance from the radiographic apex, a difference which will not always be evident on a periapical radiograph. A recent meta-analysis by Schaeffer showed that the best prognosis is obtained when the canal is adequately obturated between 0 and 2 mm from the radiographic apex, highlighting the need for accurate length determination for successful outcomes. (3) In addition to length measurement, EALs will aid in the diagnosis of perforations and resorption. (4, 5) Modern apex locators operate on a principal of relative ratios of impedance which allows them work in the presence of any common irrigating solution, and are accurate in both vital and necrotic teeth. (6,7) EALs are technique sensitive, but when used in conjunction with necessary radiographs will yield the most reliable and accurate results.

1: Ricucci, D., and K. Langeland. "Apical limit of root-canal instrumentation and obturation, part 2. A histological study." International Endodontic Journa l 31 (1998): 394-409.2: Williams, Clayton B., Anthony P. Joyce, and Steven Roberts. "A comparison between in vivo radiographic working length determination and measurement after extraction." Journal of endodontics 32.7 (2006): 624-627.3: Schaeffer, Michelle A., Robert R. White, and Richard E. Walton. "Determining the optimal obturation length: a meta-analysis of literature." Journal of endodontics 31.4 (2005): 271-274.4: Kaufman, A. Y., et al. "Reliability of different electronic apex locators to detect root perforations in vitro." International endodontic journal 30.6 (1997): 403-407.5: Goldberg, Fernando, et al. "In vitro measurement accuracy of an electronic apex locator in teeth with simulated apical root resorption." Journal of endodontics 28.6 (2002): 461-463.6: Shabahang, Shahrokh, William WY Goon, and Alan H. Gluskin. "An in vivo evaluation of Root ZX electronic apex locator." Journal of Endodontics 22.11 (1996): 616-618.7: Dunlap, Craig A., et al. "An in vivo evaluation of an electronic apex locator that uses the ratio method in vital and necrotic canals." Journal of Endodontics 24.1 (1998): 48-50.

Does pulp canal obliteration= root canal treatment???

Mon, 25 Nov 2013 14:37:27 GMT

2TheApex: Most of the time a tooth with pulp canal obliteration does not need root canal therapy. Signs and symptoms determine treatment. Just because a tooth has calcified does not mean it is or will become necrotic. Quite the contrary. According to Andeasen, 22% of traumatized undergo calcific metamorphosis. Holcomb and Gregory found that only 7% become necrotic. They recommended treatment only if a periapical lesion developed. Walton found that a pulp space is always present histologically even if it is not visible radiographically. Negotiating a "histologically present" canal does not make for a fun afternoon. (unless you are an endodontist working on keeping your finger calluses)Pulpal testing should not be trusted with calcified teeth. Most of the time a tooth with pulp canal obliteration will be nonresponsive to cold testing. Electric pulp testing cannot be trusted. Jacobsen found that only 50% of the time a vital calcified tooth would have a positive response to electric pulp testing.Many times poor aesthetics of a calcified tooth is the chief complaint. The darker shade of the tooth is due to the increase of dentin thickness and not necessarily an indication of necrosis. Elective treatment with internal bleaching can be completed to correct this in many cases. To get an exact shade match a veneer may be best.

Cold testing.

Fri, 08 Nov 2013 13:23:15 GMT

2TheApex : Cold testing is 90% accurate in determining pulp vitality.Diagnosis can be one of the most challenging aspects of endodontic treatment. The most commonly used test to determine pulpal status is the cold test. There are several different methods to perform a cold test including: refrigerant spray (Endo Ice), ice, cold water, and CO2 sticks. Here are some general tips for cold testing:

Always dry and isolate the teeth to be tested.
Don't trust that the patient knows what tooth hurts, studies show only 37%-73% accuracy in patients correctly identifying teeth with pulpitis.
Start with a normal adjacent or contralateral tooth as a control. This gives the patient a reference for the test, allows you to judge their reaction with a normal pulp, and aids in correctly identifying the source of the patient’s discomfort.
When possible, testing on the facial surface of the tooth allows for the most accurate results.
When using refrigerant spray, use a large, loose, cotton pellet held in a cotton pliers to maximize temperature change. Avoid using cotton tip applicators because the tightly bound fibers do not transfer temperature change adequately.
If using ice, always start with the most posterior tooth, as cold water will run back and may illicit a response from a tooth other than that being tested.
Teeth with crowns and large restorations will most often still respond accurately to a cold test.

Remember that pulp testing is not a direct measure of the histological condition of the pulp, but rather a test based on the patients response to an external stimulus. Approximately 10% of cold tests will yield incorrect results, and should not be relied upon as the sole indicator of pulpal status. The patient’s medical history, reported symptoms, previous dental history, clinical findings, and radiographic examination must all be utilized to arrive at an accurate diagnosis. Cold testing, while an indispensable tool, is just one part of our diagnostic tool kit.

What's an easy way to remove a temporary restoration and the cotton pellets?

Sun, 03 Nov 2013 13:17:01 GMT

2TheApex : Use an Endo Z bur or another non-endcutting bur A non-endcutting bur can still cut through Cavit or IRM easily. The bur smooths the walls of the access and is a safe way to remove the restoration and any cotton pellets. Here's short video of it being done. It's not recommended to run the handpiece for very long with the cotton pellet wrapped around it. The Endo Z bur is from Tulsa Dentsply. I use it on most cases for access once I know I have entered the pulp chamber.http://www.youtube.com/watch?v=E2cUM2lHGZY

Latest Trauma Guidelines from the AAE

Mon, 28 Oct 2013 13:11:08 GMT

Where do I find the latest Free e-book on Trauma guidelines from the AAE? 2TheApex : http://www.nxtbook.com/nxtbooks/aae/traumaguidelines/

Dental Trauma!!! What do I do?

Mon, 14 Oct 2013 13:04:29 GMT

2TheApex : Head to www.dentaltraumaguide.orgDental trauma isn't encountered every day in the office. When the patient does show up it's usually upsetting to everyone involved. Since it's infrequent, knowing the specific treatment for each case can be challenging. The DentalTraumaGuide.org website is excellent for determining appropriate treatment for each case. It has all the updated information on how to handle almost every trauma situation we will encounter in our office. The prognosis guide is specific to each case and is wonderful to be able to share with the patient and parents.

Welcome!

Mon, 26 Aug 2013 13:00:19 GMT

We are in the process of starting this blog to help our referring doctors better their clinical practice. The information will be clinically based and laid out in a simple and concise format to respect your time. Information will be supported by research and explained after we have gotten 2theapex. Thank you for visiting. Any feedback is appreciated.Sincerely,Dr. Derek B. Nordeen