Endo Tribune Italian Edition

3 Endo Tribune Italian Edition - Novembre 2016 Pratica & Clinica This three-part principle, though orig- inating in the field of osteopathy, can find great application in modern en- dodontics, where we deal with routine root canal treatment, as well as with cases in which a patient is in a com- promised state of health for which the solution may be a routine root canal treatment, and anything more than thatwouldbeovertreatment. Initially, we need to find the problem, by analyzing the clinical situation and identifying what is going wrong. This task is truly difficult. Making the cor- rectdiagnosisbasedon: – thepatient’saccount;here,weneed to listen to our patient, to learn abouthisorherlocalproblem,whe- reitislocatedandwhattriggersit; – 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 testing, response to cold and hot, the bite test, radiographs and CBCT scans; additionally, the latest sof- tware can help us in reading and analysing the data that we have, in- cludingin3-D—Irecallthewordsof my radiology professor, reminding us to study radiographs and be at- tentive to every small detail, not justlookatthem; – the logical connection between the patient’s account and history, the clinical findings and the imaging data—sometimes, putting the pie- ces of the puzzle together can be fast;sometimes,itmaytakelonger. Once the diagnosis has been estab- lished, the choice of treatment modal- ity and selection of the best tools to perform the treatment follow. At this stage, focusing first and foremost on the patient’s health, it is important to choose the most effective and efficient treatment that would be as minimal as is practical and sufficient. The rest should be taken care of by Mother Na- ture. Casepresentation Case1 The first case that I would like to pres- entwasareferralpatient.Sittingbackin the chair, the patient started giving his account: over the previous six months, hehadtwicetravelledtosomewherein Asia for surgery on his left-sided sub- mandibularlymphnodes(Fig.1),which hadapparentlybeenswollen. Eachtime,pathologytestswereclearof any cancer-specific markers. CT scan- ning and conventional radiograph- ic assessment were conducted, with no findings recorded. Having shared this, the patient reported that he felt his lymph node becoming swollen again, and he was anxious about it. His account was taken very seriously. Additionally, he reported that two of his mandibular premolars were ach- ing, 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 patient to wait for an hour to givemetimetostudyit.Judgingbythe general view first and then going into local details, I realised the two man- dibular premolars were indeed in need of endodontic retreatment. However, knowing from clinical experience that premolars may have various clinical manifestations,Icontinuedlookingfor other sources of potential problems, but without disregarding the premo- larsastheculprits(Fig.2).Analysingthe CBCT sections, trying different filters and settings, looking at the mandibu- lar molar with a large filling, and stud- yingthebonearoundit,myeyecaught something unusual. There was a small abscess migrating towards the internal angle of the mandible (Fig. 2) and creat- ing an area of bone erosion (Fig. 3). This could be the pathology causing the pa- tient’s suffering, in addition to the two mandibular premolars. At this point, one might be happy with the diagnos- tic findings and race to treat the prob- lems affecting the mandibular denti- tion.However,stillunsatisfiedwiththe overall findings, I turned to analyzing themaxilla,whereIfoundthatthesec- ond molar had internal decay and cer- vical internal resorption, creating an infection pathway into the maxillary sinus (Fig. 4). I explained the situation to the patient and proposed retreat- ing the two mandibular premolars, as well as conducting primary root canal treatment on the mandibular molar and the maxillary molar. The patient agreed, and the four treatments were performed in one session, using the TF Adaptive system (Kerr) for shaping and EndoVac (Kerr) for chemical prepa- ration according to the “A” sequence of irrigation protocol,2 followed by 3-D obturation of the root canal system us- ingtheElementsObturationUnit(Kerr; Fig. 5). Antibiotics were prescribed for thepatienttohelphisbodycombatthe submandibularinfection. Although I prescribe systemic antibac- terial medication very rarely, I did so in this case because it was not clear what had happened with the lymph nodes and if they were still functional based on the immediate postoperative radi- ographs of the mandibular molar (Fig. 6) and the maxillary molar (Fig. 7). A minor postoperative reaction (moder- atepain,noswelling)wasobservedand hadcompletelyresolvedaweeklater. Case2 The next clinical case is somewhat similar and involved an extra-oral si- nus tract (Fig. 8). A middle-aged female patient was referred to the office with an extra-oral fistula in the posterior submandibular area. According to the patient, she had had no pain or swell- ing and the fistula had appeared sev- eral weeks before she presented to the clinic. At first, she thought it was a skin problem, but then realised that there was pus draining and the opening was growing larger. Upon consulting with a dermatologist, who said the problem wasmostprobablyofdentalorigin,the patient consulted her dentist, who had previously placed an implant for her. The dentist thought the infection was associated with her third molar and not the implant, and suggested extrac- tion of the tooth. The patient wanted to retain the tooth and hence sought an endodontic consultation regarding this option. A new CBCT scan (i-CAT, Imaging Sciences International; Fig. 9) confirmed that the third molar had an internal sinus tract, which had cre- ated the fistula. This could all be solved by root canal treatment on the molar, 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 treatmentassoonaspossible. The root canal was treated (Fig. 10), us- ing the TF Adaptive system for shaping and EndoVac for chemical preparation according to the “A” sequence of irri- gation protocol, followed by 3-D obtu- ration 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 photographstocompare. The patient was extremely satisfied thathermolarcouldbepreserved. Conclusion These clinical examples illustrate the importance of diagnosis as the main piece of the puzzle the importance of “finding it”. Today, the state-of-the-art approach in endodontics requires the use of sophisticated equipment and software to complement the expertise andexperienceoftheoperator.Onlyall thisinconcertallowsustoputthepiec- es of the puzzle together. The patient’s subjectiveaccountcanleadusorsome- times mislead us. We should keep in mind that most of our patients do not know how anatomy works or that pain can be referred from a distant area in the mouth. That is where the objective historyandadequateanalysisofthedi- agnostic and clinical findings lead the way. Fixing the problem requires the most biological approach to root canal treatment, putting our clinical experi- ence to work to provide the best treat- mentforourpatients.Oncewearesure we have done the best we can to elim- inate all kinds of aggressive conditions and disease, we need to let nature take careofthehealingprocess. TheauthorwouldliketothankYuliaVorobyeva Sleiman,interpreterandtranslator,forherhelp withthisarticle. L’erticoloèstatopubblicato suroots,n.12016. Find it, ﬁx it, and leave it alone1 Prof. Philippe Sleiman, Lebanon Fig. 9 Fig. 5 Fig. 1 Fig. 2 Fig. 3 Fig. 4 Fig. 10 Fig. 6 Fig. 11 Fig. 7 Fig. 12 Fig. 8 1. “Find it, ﬁx it, and leave it alone”—an axiom attributed to Dr Andrew Taylor Still, the founder of osteopathy, and recorded by his students and followers. 2. Published earlier in Sleiman, P., “‘A’ sequence of irrigation”, roots international, 1 (2014), 14-7. references

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