Endodontic radiographs: realities and illusions.

Several case reports show how, on occasion, radiographs fail to disclose important realities. The illusions that are presented radiographically have the potential to misdirect diagnosis and treatment as well.

A suspected periradicular scar: treat or not?

This paper presents an unusual case of a tooth with multiple adjacent endodontic problems. The diagnosis was complicated by a bony scar that untypically was located around the apex of one of the teeth.

Central giant cell granuloma: a troublesome lesion.

This case reports a central giant cell granuloma, an uncommon but potentially troublesome idiopathic benign lesion. Its radiographic similarity to a routine inflammatory periradicular lesion led to not only delay in diagnosis, but also further delay in successful treatment.

A successful nonsurgical treatment of an endodontic failure.

This study presents a relatively uncomplicated endodontic failure that responded to nonsurgical treatment. Speculation as to other interpretations of the failure with related treatment plans is offered to highlight how significant diagnosis can be in determining outcomes.

Diagnostic thermal pulp testing: a technique.

This paper presents a technique for thermal testing that has proved useful where the usual diagnostic routine was unable to clarify the problem.

Endo-Antral syndrome and various endodontic complications.

The purpose of this paper was to examine the varied impact of the pathological spread of dental sepsis into the adjacent maxillary sinus. This complex of tissue destruction is called Endo-Antral Syndrome; the usual radiographic diagnostic features are identified in the paper. The four different cases presented serve to illuminate a few of the many diagnostic and treatment challenges involved. Emphasis is placed on the utilization of a keen sense of wariness when endodontically treating maxillary posterior teeth whose apexes are close to the sinus. Dental examination should include an appraisal of antral health prior to root canal therapy to best plan treatment and to establish a base line against which to judge subsequent developments.

Periradicular scars: a sometime diagnostic conundrum.

This paper presented illustrations of two different clinical cases that developed residual bone scars. The first case dealt with the evolution of a bone scar after surgical removal of a large cyst with a "thru-and-thru" defect, not an uncommon event. The second case showed a typical periradicular lucency associated with a nonvital pulp, which evolved into a bone scar after nonsurgical root canal therapy.

A conservative biopsy technique for periapical lesions.

This paper presented a conservative technique for biopsy of periapical lesions. The case report demonstrated the insertion of a flexible microsurgical biopsy forceps through a labial sinus tract into a lesion for removal of specimens for histopathological evaluation. This limited tissue removal seemed to induce a change from a cyst to a granuloma, as well as stimulate a degree of repair.

Metastatic carcinoma to the mandible that mimicked pulpal/periodontal disease.

An oral cavity metastasis from a poorly differentiated carcinoma, presumed to have originated in the pancreas, mimicked a dental abscess. An additional metastasis to the lung caused a postobstructive lobar pneumonia that masked the lesion, thereby delaying the diagnosis of malignancy. This case report illustrates how the clinical manifestations of a widely disseminated neoplasm led to initial medical confusion and subsequent dental misdiagnosis, and serves to caution of a possible pitfall in the dental evaluation of endodontic lesions.

Patient records and referral correspondence: a time-saving method.

This article offers a time-saving method to deal with nonroutine chart entries and related correspondence. The doctor should dictate an abbreviated chart entry and utilize copies for correspondence.

Repair of incomplete vertical root fractures in endodontically treated teeth--in vivo trials.

An in vivo clinical study was performed to evaluate the healing of a new approach to the repair of incomplete vertical root fractures. The two-stage surgical procedure incorporated ultrasonic fracture cleaning, bonding of the fracture repair with silver glass-ionomer cement, placement of a bone graft material, and application of guided-tissue regeneration. Of the six roots in the study, five failed within 2 to 11 months. One root continued to be symptom-free, without periodontal pocket formation for 1 yr, but then failed because of extension of the incomplete root fracture to the lingual of the root.

Diagnostic radiographic findings and symptom-free teeth.

The determination of whether a symptom-free tooth has pulpal and periapical disease relies heavily on radiographic findings and pulp tests. A case of a symptom-free upper left first molar is presented. The radiographic evidence of pathological changes associated with the endo-antral syndrome coupled with diffuse pulpal calcifications facilitated the diagnosis of chronic pulpal periapical disease. Non-surgical root canal therapy resulted in periapical healing as shown on a follow-up radiograph.

Patient empowerment--a strategy for pain management in endodontics.

In order to promote rapid resolution of symptoms associated with root canal treatment, a multifaceted program was implemented. One-visit endodontics was performed universally, antibiotics were prescribed when infection was detected within the root canal, and nonsteroidal anti-inflammatory drugs were widely used at the time of treatment. The centerpiece of the program was the integration of various behavioral strategies designed to strengthen the patient's inherent coping capacity. The combination of clinical, pharmacological, and psychological approaches was collectively called patient empowerment. Five hundred forty patients were asked to contact the office the day after treatment. Four hundred twenty (78%) called and 390 (93%) reported a reduction in symptoms. Twenty of the 30 (7%) who were not relieved within the first 24 h reported significant improvement 1 day later. No patients experienced a flare-up or a worsening of symptoms.

Radiographic pulpal calcifications: normal or abnormal--a paradox.

A survey was sent to all 525 (domestic) Diplomates of the American Board of Endodontics. It inquired as to the interpretation of the findings of radiographic pulpal calcifications (RPC) and how it might impact on treatment. The response to the question of pathological significance of RPC was divided equally between those who felt it was a sign of pathosis and those who did not. The remaining seven questions were overwhelmingly agreed upon: RPC are important findings included in differential diagnosis; nonsurgical root canal treatment was routinely attempted regardless of the extent of RPC; patients were informed prior to treatment of potential obstacles; and as a rule diplomates devote no more than 10% of their practice to surgical endodontics.

The endo-antral syndrome: an endodontic complication.

Infection of pulpally involved teeth near the maxillary sinus sometimes spreads into the sinus and causes serious complications. This pathological complex, involving both antral and periapical tissues, is referred to as the endo-antral syndrome (EAS). It includes diagnostic difficulties, treatment considerations, and occasionally persistent pathological antral alterations after nonsurgical endodontic therapy. Surgical measures are occasionally required to stimulate healing and preserve the teeth.

The role of a dental operating microscope in improved nonsurgical treatment of "calcified" canals.

Three cases illustrating successful nonsurgical treatment of "calcified" canals are presented. Careful round bur drilling through dense calcified deposits in the pulp chamber and into the canal may uncover a treatable apical canal remnant. The dental operating microscope (Dentiscope) is an invaluable aid.