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Endo Tribune Middle East & Africa Edition No. 5, 2016

Dental Tribune Middle East & Africa Edition | 5/2016 endo tribune 2 “Using our new software in combi- nation with our ORTHOPHOS units will provide practitioners the best image quality at the lowest dose and significantly improve their endo- donticworkflow.Byworkingcollabo- ratively with the Endodontics team, we were able to best identify and ad- dressanunmetneedanddevelopan ◊Page1 easy to use, integrated solution for ourcustomers,”saysDrStefanHehn, Group Vice President, Dentsply Si- ronaImaging. Dentsply Sirona as The Den- talSolutionsCompany As a result of the recent merger, DentsplySironaistheworld’slargest manufacturer of professional dental products and technologies. As The Dental Solutions Company, Dentsp- ly Sirona’s comprehensive solutions offering includes leading products and brands across consumables, equipment, technology and special- ty products. With the broadest clini- cal education platform and an un- paralleled commitment to R&D in dentistry, the company’s vision is to deliver innovative dental solutions toimproveoralhealthworldwide. “This new software collaboration is further evidence that Dentsply Si- rona is truly better together,” says Jeffrey T. Slovin, CEO of Dentsply Si- rona.“Ourunrelentingcommitment tocustomersandtocontinuouslyin- troduce innovations and end-to-end integratedsolutionswilldrivebetter, safer and faster dentistry around the globe.” “Find it, fix it, and leave it alone” ByProf.PhilippeSleiman,Lebanon This three-part principle, though originatinginthefieldofosteopathy, can find great application in modern endodontics, where we deal with routine root canal treatment, as well as with cases in which a patient is in a compromised state of health for which the solution may be a routine root canal treatment, and anything more than that would be overtreat- ment. Initially,weneedtofindtheproblem, by analysing the clinical situation and identifying what is going wrong. Thistaskistrulydifficult.Makingthe correctdiagnosisbasedon: -thepatient’saccount;here,weneed tolistentoourpatient,tolearnabout his or her local problem, where it is locatedandwhattriggersit· - the patient’s history, that is overall health, any diseases and/or condi- tions,systemicmedication,etc. - the proper use of the appropriate diagnostic tools, including pulp test- ing,responsetocoldandhot,thebite test, radiographs and CBCT scans; additionally, the latest software can help us in reading and analysing the data that we have, including in 3-D—I recall the words of my radiol- ogyprofessor,remindingustostudy radiographs and be attentive to eve- ry small detail, not just look at them - the logical connection between the patient’s account and history, the clinical findings and the imaging data—sometimes, putting the piec- es of the puzzle together can be fast; sometimes,itmaytakelonger. Once the diagnosis has been estab- lished, the choice of treatment mo- dality and selection of the best tools to perform the treatment follow. At this stage, focusing first and fore- most on the patient’s health, it is im- portant to choose the most effective and efficient treatment that would be as minimal as is practical and suf- ficient. The rest should be taken care ofbyMotherNature. Casepresentation Case1 The first case that I would like to pre- sent was a referral patient. Sitting back in the chair, the patient started givinghisaccount:overtheprevious six months, he had twice travelled to somewhere in Asia for surgery on his left-sided submandibular lymph nodes (Fig. 1), which had apparently been swollen. Each time, pathology tests were clear of any cancer-spe- cific markers. CT scanning and con- ventional radiographic assessment were conducted, with no findings recorded. Having shared this, the patient re- ported that he felt his lymph node becoming swollen again, and he was anxious about it. His account was takenveryseriously.Additionally,he reported that two of his mandibular premolars were aching, since root canal treatments had been started at a different clinic, but the dentist had been unable to finish them. With the patient’s permission, a new CBCT scan was obtained, and I asked the patienttowaitforanhourtogiveme timetostudyit. Judging by the general view first and then going into local details, I real- ised the two mandibular premolars were indeed in need of endodontic retreatment. However, knowing fromclinicalexperiencethatpremo- lars may have various clinical mani- festations, I continued looking for other sources of potential problems, butwithoutdisregardingthepremo- larsastheculprits(Fig.2). Analysing the CBCT sections, trying different filters and settings, look- ing at the mandibular molar with a large filling, and studying the bone around it, my eye caught something unusual. There was a small abscess migratingtowardstheinternalangle of the mandible (Fig. 2) and creating an area of bone erosion (Fig. 3). This could be the pathology causing the patient’s suffering, in addition to the twomandibularpremolars. At this point, one might be happy withthediagnosticfindingsandrace to treat the problems affecting the mandibular dentition. However, still unsatisfied with the overall findings, I turned to analysing the maxilla, where I found that the second molar hadinternaldecayandcervicalinter- nal resorption, creating an infection pathway into the maxillary sinus (Fig.4). I explained the situation to the pa- tient and proposed retreating the two mandibular premolars, as well as conducting primary root canal treatment on the mandibular molar andthemaxillarymolar.Thepatient agreed,andthefourtreatmentswere performed in one session, using the TF Adaptive system (Kerr) for shap- ing and EndoVac (Kerr) for chemical preparation according to the “A” se- quence of irrigation protocol,2 fol- lowed by 3-D obturation of the root canalsystemusingtheElementsOb- turation Unit (Kerr; Fig. 5). Antibiot- ics were prescribed for the patient to help his body combat the subman- dibular infection. Although I pre- scribesystemicantibacterialmedica- tion very rarely, I did so in this case because it was not clear what had happenedwiththelymphnodesand if they were still functional based on the immediate postoperative radio- graphsofthemandibular molar (Fig. 6) and the maxillary molar (Fig. 7). A minor postoperative reaction (mod- eratepain,noswelling)wasobserved and had completely resolved a week later. Case2 The next clinical case is somewhat similar and involved an extra-oral sinus tract (Fig. 8). A middle-aged fe- male patient was referred to the of- fice with an extra-oral fistula in the posterior submandibular area. Ac- cording to the patient, she had had no pain or swelling and the fistula had appeared several weeks before shepresentedtotheclinic. At first, she thought it was a skin problem,butthenrealisedthatthere was pus draining and the opening was growing larger. Upon consult- ing with a dermatologist, who said the problem was most probably of dental origin, the patient consulted her dentist, who had previously placed an implant for her. The den- tist thought the infection was associ- atedwithherthirdmolarandnotthe implant,andsuggestedextractionof the tooth. The patient wanted to re- tain the tooth and hence sought an endodontic consultation regarding thisoption. A new CBCT scan (i-CAT, Imaging Sciences International; Fig. 9) con- firmed that the third molar had an internal sinus tract, which had creat- edthefistula.Thiscouldallbesolved by root canal treatment on the mo- lar, followed by a crown and follow- up treatment, with a good prognosis for overall long-term success. The patient was happy to hear that and requested treatment as soon as pos- sible. The root canal was treated (Fig. 10), using the TF Adaptive system for shaping and EndoVac for chemi- cal preparation according to the “A” sequence of irrigation protocol, fol- lowed by 3-D obturation of the root canal system using the Elements Obturation Unit (Fig. 5). Follow-up records were taken (Figs. 11 & 12), with radiographic control to check for bone healing and external facial photographs to compare. The pa- tient was extremely satisfied that hermolarcouldbepreserved. Conclusion These clinical examples illustrate the importance of diagnosis as the main piece of the puzzle the impor- tance of “finding it”. Today, the state- of-the-art approach in endodontics requires the use of sophisticated equipment and software to comple- ment the expertise and experience Fig1 Fig2 Fig3 Fig4 Fig5 ÿPage 3

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