Can We Save This Tooth? Utah Dental Association Convention 4/21/2016

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Can We Save This Tooth?

Utah Dental Association Convention

What is the “question” with questionable teeth?


Process Centered

Diseased Centered

Patient Centered

What is value?

We are loss averse

The psychophysics of chances

Tooth risk ratio

What does (any) technology offer us?

When is screening beneficial?

When the test doesn’t miss too many cases of the disease or condition.

When the test doesn’t harm you significantly.

When the treatment for the disease doesn’t cause more harm than good.

What do tests tell us?
System 1 and System 2

System 1 is effortless and immensely powerful

System 1 resolves ambiguity

Cognitive bias


When is new information a game changer?

It changes treatment plan

It alters proposed treatment

What is an “X-ray”?


Cone Beam Computed Tomography


Beam Hardening


Root Fractures
Interpreting CBCT Image

Longitudinal Tooth Fractures

Dentin Properties

Varying Strength of Dentin

Dentin Aging

Water and dentin

Intrapulpal pressure of 10-28mm Hg

Water is bound to collagen

Water has a hydraulic cushioning effect

Hydrated dentin has significantly higher crack initiation and crack growth toughness

Existing Tooth Structure

Pericervical Dentin

Occlusal Risk Factors
Predisposing Factors


Cracked tooth

Mesio-distal direction

Coronal to apical progression

Vertical root fracture

Bucco-lingual direction

Apical to coronal progression

Radiographic Features

Clinical Exam

Longitudinal Tooth Fractures

Entities That Mimic Root Fracture

Why Are There So Many Nerves in Teeth?

Dentin is an intimate structure of organic and inorganic components

Endodontic irrigants are formulated to degrade organic material

Endodontic Decision Making

Changes in Access

Gates Glidden Use

Coronal Reinforcement
“Cleaning” a Narrow Shape

Importance of NaOCl Agitation

Indications for a Post

Principles for Posts

Types of Posts

3-D Ferrule

Difficulties Bonding Within the Canal

Resin Cements

Is It Good to Have the Same Modulus of Elasticity as Dentin?

Can We Re-Grow a Ferrule?

Can We Re-Grow the Dento-alveolar Apparatus?

Root Resorption

Root Resorption:

A condition associated with a physiologic or pathologic process that causes a loss of cementum or root dentin

Homeostasis of Pulp and PDL

Mechanism of Hard Tissue Destruction

Osteoclast in Repair

Classification of Root Resorption
Internal Root Resorption
Internal Radial Root Resorption

Internal Replacement Resorption

External Root Resorption

Pressure Resorption

Orthodontic Related/External Apical resorption (EARR)

Infection Related Apical Resorption

Trauma/Infection Related Resorption

Replacement Resorption/Ankylosis

Invasive Cervical Root Resorption
Diagnosis of Resorptions
Treatment of Resorptions

Start With The End In Mind

Diagnosis driven

Do we understand etiology?


Traumatic Injuries to the Teeth




Family Violence


Pulp tests:

use as baseline only

cold and electric pulp tests

be aware of false negative response

retest at 30-90-180 days

Treatment timing

Crown Fracture
Pulp Capping

Pulpal response to trauma:

1. Repair

2. Mineralization/Obliteration

3. Internal resorption

4. Necrosis

Pulpal Revascularizaton/Regeneration
Treatment codes for Regeneration

3351 Pulp debridement and placement of antibiotic medication

3352 Interim medication placement

3354 Pulpal regeneration

Non-Vital Bleaching
Horizontal Root Fractures
Management of Tooth Luxations
Primary Teeth

Overall goal of Primary Tooth Treatment is to Preserve the Developing Permanent Tooth


Extraoral time is a key factor. 90% success if replanted in less than 30 min.

5 Min is critical.

E.O. time less than 1 hr, perioidontal healing possible

For adult teeth, start RCT 1-2 weeks later with Ca(OH)2

RCT may not be required in immature teeth with short extraoral time.

Fair/poor prognosis. Ankylosis likely.

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