Welcome, Aaron and Jason

We welcomed two new Endodontists to the Coastal Dental Specialist Team in March. Aaron Gascoigne and Jason Bulmer will work at CDS on Mondays, Tuesdays, and Fridays. Both are qualified to provide the exceptional, patient-centred, restorative-focused care we pride ourselves on. Read more about Drs. Gascoigne and Bulmer here.

 

Request from our Clinical Team

Including as much clinical detail as possible when submitting a referral (such as clinical history, pain levels and tests performed) benefits your patients. It allows us to triage patients better and determine whether a full consultation is necessary. In cases where consultation is unnecessary, patients can avoid the extra time and fees associated with one, allowing us to move directly to treatment. Of course, some patients will still require a consultation, but having this background allows us to make that decision more efficiently.

 

Case of the Month

 

Teeth with apices that sit outside the alveolar bone can cause diagnostic and treatment challenges. Fortunately, our Carestream 9600 CBCT can perform small field of view endodontic specific scans at 75 Microns, enabling detailed visualisation of intricate anatomical structures like root canals, periapical lesions, and root fractures,

 

Read more here.

 

Product We’re Loving

It’s a small thing, but I much prefer using small foam pellets under Cavit for our temporary restorations. Cotton wool has long been known to be a breeding ground for bacteria, and the threads of the pellet can be left passing through the temporary restoration. These tiny foam pallets are easy to pack into small accesses, covering orifices well and are easy to remove. Use the larger size for larger canals, such as those in the central incisors. A size 30 or 40 Hedstrom file can be used to retrieve them if necessary, but they will usually come out with an ultrasonic device.

Available from Henry Schein Halas: https://henryschein.com.au/search?ProductSearch=Voco%20Pele%20Tim%20Foam%20Pellets&FilterFeature=

 

Research Article We’re Reading

Davis MC, Shariff SS. Success and Survival of Endodontically Treated Cracked Teeth with Radicular Extensions: A 2- to 4-year Prospective Cohort. J Endod. 2019 Jul;45(7):848-855. doi: 10.1016/j.joen.2019.03.015. Epub 2019 May 20. PMID: 31122690.

This research article presents a prospective study investigating the success and survival rates of endodontically treated cracked teeth that exhibit cracks extending into the root. The authors followed a cohort of patients over 2 to 4 years, employing modern endodontic techniques, including the placement of intraorifice barriers, and specific postoperative protocols. Their findings suggest that, contrary to previous beliefs, such cracked teeth can achieve high rates of success and survival, comparable to non-cracked teeth receiving root canal treatment when these specific protocols are diligently followed. The study highlights the potential for saving teeth previously considered hopeless, emphasising the importance of meticulous treatment and restoration.

Key Findings:

• High Survival Rate: The study reported a 100% survival rate in the first 2 years and 96.6% survival up to the 4-year period.
• High Success Rate: 90.6% of the teeth were classified as “success” based on the strict criteria at the 2- to 4-year follow-up (mean 2.8 years).
• No Significant Impact of Pretreatment Variables: No statistically significant differences (P > .05) in success were found for pretreatment variables such as periodontal pocketing (up to 7mm), marginal ridge involvement, crack depth, or pretreatment diagnoses.
• Importance of Coronal Restoration and Occlusion: The mean time to final restoration was 47.8 days. A significant proportion (78.7%) required occlusal adjustment at follow-up.
• Radiographic Healing: An overall mean PAI reduction of 1.16 was observed, with a greater reduction (2.14) in teeth with pretreatment apical periodontitis.

Discussion and Implications:

• Challenging Previous Beliefs: The high success and survival rates suggest that cracked teeth with radicular extensions may have a better prognosis than previously thought, potentially similar to endodontically treated non-cracked teeth.
• Key Factors Contributing to Success: The authors attribute the positive outcomes to several factors, including:
• Microscope-assisted intraorifice barriers placed apical to the extent of the crack: This is highlighted as potentially crucial for coronal seal and potentially improved fracture resistance, especially given that the crown margin may not cover the entire crack. The study explicitly states, “Treatment outcomes in cracked teeth with radicular extensions may be improved by using the following protocols: microscope-assisted intra-orifice barriers placed apical to the extent of the crack…”
• Complete occlusal reduction: To minimise the risk of further crack propagation.
• Specific postoperative instructions: Emphasising a soft diet and avoiding chewing on the affected side until final restoration.
• Expeditious placement of a full-coverage restoration: Underscoring the critical role of the crown in protecting the tooth. The study references existing literature on the significantly lower survival rate of endodontically treated teeth without crowns.
• Careful occlusal equilibration: The high percentage of required occlusal adjustments indicates the importance of managing masticatory forces. As the study notes, “This is significant because of the likelihood that masticatory forces, parafunctional stresses, and malocclusion are etiologic factors that initiate and induce apical propagation of the crack…”
• Periodontal Considerations: While periodontal probing depths generally remained stable or improved slightly, the authors acknowledge that periodontal “success” in these cases may involve preventing further deterioration rather than complete resolution of deeper pockets. They suggest periodontal referral may be necessary in some cases.
• Comparison to Existing Literature: The survival rate is comparable to general endodontic outcomes and higher than some previous studies specifically on subgingivally cracked teeth. The success rate is also higher than some reported for cracked teeth without specific focus on radicular extensions.
• Limitations: The authors acknowledge the small sample size as a major limitation, classifying the study as a pilot study. Further research with larger cohorts and longer follow-up is needed. The use of periapical radiography over CBCT was justified based on existing literature comparisons and ethical considerations.