This tooth has cracks on all four sides around the old silver filling.  After it was removed a white medicine can be seen that was appropriately placed long ago before the silver was placed on top.  This should be removed to get at the bottom of the cracks to properly remove all remaining tooth decay.  The result is a tooth preparation that is deep and close to the nerve.  Sometimes post operative tooth pain requires root canal therapy to be performed by an Endodontist.

Removal of a deep cavity and why some teeth may also need Root Canal.

Today in the dental office there was a case that was very complex not only because of the dental work that was involved but because there was also issues of finance and patient management involved. The patients was chief financial officer of his company and had a lot of dental work that needed to be done. This patient was overweight as an adolescent and suffered from anorexia and bulimia. These two disorders ruined his upper teeth and neglect over many years worsened the situation. When he presented to the office the patient had almost no coronal tooth structure left on any of the maxillary teeth.

It was charted that 6-11 and 14 and 15 were restorable with guarded prognosis and any other root tips in the mouth were to be extracted. 6-11 and 14 and 15 were all to be treated with RCT in one visit and to be restored a few days later also in one visit with temporaries.

One of the main concerns with this patient was the loss of vertical dimension. After many years of going with the wrong vertical we were concerned that opening the bite again would cause stress to the TMJ. After endo and OS consults however it was deemed that restoration of the occlusion could be done immediately. It was also noted that this patient was very phobic and was pre-medicated prior to any treatment for the phobia.

The treatment time was about 4 hours in which 8 root canals, post space preparations, and impressions were done. The lab tech was on hand to observe the case so that he could process temps for the patient within 4 days when the post/cores are inserted. This is a case that would normally have taken months and a lot of patient visits but is going to be taken care of in a short span of time with specialist attention.

H.A., New York University College of Dentistry, Patient 10

Today at Dr. Dorfman’s office I got to see a new procedure. Yesterday a patient came to the office and had RCT done on tooth #8. This patient had visited the office previously with a chief complaint about tooth #8 which had changed color within the past 3 months and she wanted to whiten it. Even though external bleaching was performed on that tooth it had not changed the color, so the decision was made to do an internal bleaching. So after the RCT was completed the tooth was then filled with bleaching material and packed with Cavit. Overnight the patient achieved the desired result. However the tooth became one shade lighter and the patient felt as though the tooth was too light compared to the adjacent teeth.  

When she presented we were able to concur on the discrepancy in color. The patient however was happy with the result of the bleaching and felt that she wanted all her anterior teeth to be that shade.

We started the procedure by removing the cavit and rinsing out the bright red bleaching material. It was important to watch the buccal wall of the tooth and to watch how apically the tooth was being prepared in order to avoid ruining the endo fill. After all the material is rinsed out we see that the access has been preserved and it is ready to be filled with composite until it is deemed necessary to fill it. It is important again to create a barrier between the gutta percha and the composite fill with a layer of cavit. After the final fill and polish the patient made an appointment to have full arch, maxillary and mandibular bleaching.

Later in the day a patient of 15 years came in and needed a new crown on #2. It was interesting to see a different way that an existing PFM, which had decay on the distal margin, was removed in order to prep the tooth for a new crown.

H.A., New York University College of Dentistry, Patient 9

This turned out to be a great day for me because I learned many new things about endodontics and the different technologies that they have at their disposal.

The endodontist was telling me about D-MTA, which is a substance that contains tetracycline and a few other chemicals in it. It can clean the canal and kill the bacteria and works very quickly so you don’t need to pack the canal with CaOH and send the patient home to do the obturation a week later. With this product it is possible to clean and obturate all in the same visit. She also taught me about the different ways that gutta-percha can be melted and packed into the canal so it is easy to reach lateral and accessory canals and that reduces the incidents of retreats.

She taught me how products are compared and how different solvents and products are tested: The test involves packing the canal and checking for how much of a substance can pass through, thereby testing the seal. It was interesting to see how well she was able to laterally condense the gutta-percha without using too much cement. One of the roots had a bifurcation right near the apex and that had to be repacked and it was interesting to learn how that was done.

I also learned how the apex locator was used specially in conjunction with regular endo files as a self check. The patient had come from another country and was seeking full mouth reconstruction over the course of the next few years in multiple phases. This visit was focused on extractions and endo procedures in order to preserve teeth and allow for healing of extraction sites so that implants could be placed.

H.A., New York University College of Dentistry, Observation