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any thermal tests, both hot and cold, it is a sign that the pulp is necrotic, dying or infected. In this instance, studying the digital imaging may aid the diagnosis. One caveat: It is possible to have a necrotic pulp without being able to quantify it via digital images In many incipient pathology issues, it takes approximately 90 to 120 days for breakdown to manifest itself on imaging. Today’s cone-beam imaging technology can shorten that process to 30 days. It is not uncommon to have a patient in the chair with symptoms that you cannot quantify radiographically. Radiographic findings Radiographic findings (Figs. 8a & b) are the road map for endodontics. Thorough study and evaluation of imaging allows the clinician to determine a multitude of facts about the tooth in question. What does the image reveal? Can you see if there is a widening of the pdl? If there is a widening of the pdl, it is essential to have the patient bite down on a bite stick. Once he or she does that, you must ask if the pain, if present, is worse upon bite or upon release of bite. The latter is highly correlated with root fracture. Once that is confirmed, the next step is to prepare the patient for a root canal.The dentist must convincingly explain the procedure’s value as well as caution the patient about the possibility of losing the tooth due to the fracture extending apical from the cementoenamel junction (CEJ). Is there a lesion (Figs. 3a & b) present? This information allows me to frame my diagnostic questions to the patient. These include: Is the tooth sensitive to cold? I know from the lesion that the answer to that should be no. If, however, the answer is yes, it automatically triggers my mind to look for another tooth. Generally, speaking teeth with lesions of endodontic origin (LEOs) test non-vital to thermal or electric pulp testing. In sequencing, I first ask for the patient’s report, followed by radiographic findings, which I then augment with clinical testing to tie it all together and arrive at a diagnosis. Lastly, are caries present? The location of caries is a determining factor as to whether a root canal is needed (Figs. 4a & b). Restorability Restorability is an issue that has been a hot topic in dentistry for years. Its meaning has evolved as technology has become the backbone of modern dentistry. Prior to the incorporation of implant dentistry, restorability had a very different meaning. Dentists were much more motivated to save teeth. Options and creativity were necessary for clinical success, both in endodontics as well as in restorative dentistry. Technology has taken away one form of resourcefulness and replaced it with the promise of a panacea. It has become far too easy for general dentists to recommend removal of a tooth to a patient with the promise that an implant will save the day. ‘In modern endodontics, as technology advances and we bring on file systems that shape more efficiently and safely—and we develop a greater understanding of the role of irrigation in endo - dontics—we can offer higher success rates than at any time in history.’ Historically speaking, the diagnosis of a tooth being non-restorable came after a myriad of attempts to save the tooth. Every aspect of dentistry came into play. Periodontists did osseous surgery and root amputations. Endodontists performed conventional endodontics and, if necessary, surgical intervention to do everything possible to save the tooth. Decisions involving the long-term prognosis of the tooth were relevant. Decisions about the type of restoration were discussed. Decisions about the osseous health of the roots and surrounding bone structures were relevant. The goal of every specialist is to be an extension of the general dentist’s practice. To that end, deciding whether a tooth was restorable or not was, at a minimum, a conversation to be had between the specialist and the general dentist. Leap forward to the new millennium, and dentists no longer fight to save teeth. Dentists realize the financial windfall that implants offer their practices. Dentists can attend a myriad of continuing education courses over a weekend and on Monday become nascent implantologists. This fact makes diagnosis and saving a tooth the most important facet of restorative dentistry moving forward. Treatment planning and restorability are integral to success both for the patient and the dentist. A patient in pain presents a unique opportunity for the dentist. Many questions need to be asked and answered. Among them: What can the dentist do to manage the pain? What is the cause of the pain? How long has the patient been in pain? Once the initial triage phase is complete, other factors must be addressed. These include: Is the tooth restorable? If endodontic treatment is indicated, what further treatment will be needed? Is there a need for periodontal intervention? If so, what type of treatment is it? Osseous surgery? Does the tooth need crownlengthening surgery? How will these procedures affect the adjacent teeth? The above paragraph speaks volumes as to the complexities of treatment planning in dentistry today. Every day in offices around the world, a patient visits his or her dentist in pain. How the dentist responds to this will go a long way in determining the patient’s dental well-being. A well rounded practice with high moral fiber will enable the dentist and patient to work synergistically to develop a realistic treatment plan. The last essential ingredient to success is that the dentist knows “when to say when” (Fig. 7). As a specialist and lecturer, I believe that if a general dentist does roughly 80 per cent of the endodontic cases that walk in the door of his practice and refers out the remaining 20 per cent, he or she will have a very busy endodontic practice. In the past five years, especially since the decline in the economy and busyness of practices, more than 50 per cent of my practice consists of retreatment. The general dentist should have never attempted more than half of those cases. I can only speculate how much more there would be if dentists didn’t have implants to fall back upon. Implants vs. endodontic treatment The next aspect of the diagnostic conundrum is the increasing role implants play in treatment planning. When I first began practicing endodontics in 1988, implants were in their nascent stages. If a patient had a root canal and continued to experience pain or discomfort, both the dentist and the endodontist had a myriad of choices, from retreatment to surgical correction. In 2013, the knee-jerk reaction to placing implants has never been greater. More and more general dentists go to weekend “seminars/courses,” and on Monday morning they are placing implants. Much of this is based on the financially lucrative aspect of Continued from page 11 Fig.4a The presence of caries under the margin of a restoration. The caries extend to the pulp and will need endodontic treatment. Fig.4b The endodontic treatment is completed. In this case, the patient was lost to the practice for three years and came back when his face was swollen because of incomplete treatment. Fig.5a Cracked tooth syndrome. Pre-treatment radiograph. Fig.5b What can happen in a cracked tooth when you obturate with warm, vertical condensation of gutta-percha. Fig.6 Well-done endodontic treatment of tooth #6. Notice the multiple portals of exit as they relate to the presence of lesions. Fig.7 Know when to say when. This dentist attempted to do an endodontic procedure that should not have been done. Fig.4a Fig.4b Fig.6 Fig.7 Fig.8a Fig.8b Fig.8c DENTAL TRIBUNE 5Pakistan EditionJuly 2014 Fig.5bFig.5a Fig.8a Initial digital image with a patient whose chief complaint was mild pain to bite and chew. Fig.8b Digital photo of the tooth after I extracted it, showing a gross negligence. The tooth was perforated through the furcation, and gutta- percha was placed in what the dentist thought was the root canal system. Fig.9 The complexities of maxillary molar endodontics and multiple portals of exit. Of note, I was never able to shape the MB2 canal. Clinical Study

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