Clinical case endodontic treatment upper incisors with heavily sclerotic canals. How to navigate a situation where there are “no mouths.”
The reference patient was referred by a colleague with a request to help carry out endodontic treatment before prosthetics in teeth 12 and 21. The doctor made an independent attempt at treatment, but unexpectedly the problem of severe obliteration of the orifices in both teeth was revealed, which did not allow the doctor to find the entrances to the root canals. The referring dentist only had binoculars in his arsenal, which, alas, did not allow him to confidently navigate inside the tooth.
This is how these teeth came to me. What do we see?
Firstly, we see that the doctor is great for realizing in time the risk of searching for the mouths “blindly”, without magnification. Since in both cases there were a couple of strokes of the tip left before the root wall was perforated.
Secondly, the search vector was shifted to the palatal side in both cases.
Thirdly, the obliteration really did not leave even a hint of the mouth where it should have already appeared. The situation in tooth 21 turned out to be especially difficult.
The green line shows the outline of the actual root canal. And here you can clearly see how the search for the mouth was carried out away from the true course of the root canal, threatening to end in perforation.
How to find the entrance to the channel when even the thinnest file (No. 6, No. 8) does not “catch” anything? It is necessary to remove sclerotic dentin. This can be done with a rotating instrument on a long stem or with an ultrasonic nozzle. But the main thing to remember is 2 important rules:
1. Any actions with aggressive instruments inside the tooth (canal) can ONLY be carried out under visual control. Ideally, under the control of armed vision, i.e. good lighting and magnification. We predictably can only do what we see with our eyes. If we work virtually, by touch, “by experience” - predictably, we can only do perforation, which will significantly worsen the future prospects of the tooth and the confidence of your patients.
2. Use practical laws of orientation in the pulp chamber when searching for orifices. One of the most important is the color of the fabrics...
This helps to understand where to “dig” to find the entrance. By removing a certain amount of sclerotic dentin under a microscope, we obtained a point that was barely noticeable at high magnification.
However, this turned out to be quite enough to make sure that this was the entrance to the root canal. Further work on processing and expanding channels in this situation was quite simple. The working length was determined using manual K-files No. 10, No. 15. Further instrumentation of the channels was carried out with the BioRaCe system to sizes No. 50.04.
Filling of the canal in the 12th tooth was carried out only in the apical third using hot gutta-percha (for subsequent restoration of the tooth using a pin structure). In 21 teeth, cold hydraulic obturation of gutta-percha with a bioceramic coating and a bioceramic sealer was used.
Progress of treatment of both teeth according to radiographs:
The patient was returned to the referring doctor for continued treatment and prosthetics.
Conclusions from this case, especially for young doctors:
- Inside the channels, do only what you see, do not work by touch!
- If you encounter a problem, stop on time! There is no need to be a hero if you do not have enough equipment, skills, or experience to cope with the situation. Refer the patient to more experienced and equipped colleagues, or at least warn the patient of the significant risk to him if he continues. This will be better for both of you and will save you from unnecessary conflict situations.
- use the rules of orientation in the pulp chamber! They are very effective, there are only a few of them, we talked about one of them today.
In subsequent articles and cases, I will tell you about other rules of orientation inside the tooth, which will help you not to make any mistakes. Stay tuned!
Today you will learn what an impassable dental canal is, why it can actually be passable, and what you can and should do about it.
What is an impenetrable root canal? This is a channel that is closed due to obliteration or other diseases, into which it is impossible to “get” or impossible to “break through” in order to cure it.
What to do if you find an impassable channel?
First of all, don't be scared. Firstly, it all depends on the clinic where you are being treated. Secondly, the doctor’s experience also plays a 30 percent role when performing manipulations with an impassable dental canal. Therefore, in the first clinic they will tell you about the obstruction of the canal, and in the second they will cure you.For what reasons is a dental canal called “impenetrable”?
In some cases, the dental canal is actually impassable. To give an example, when a tooth becomes obliterated due to age/ inflammatory processes This outcome of the situation is very likely.And they are also called impassable depending on the complexity of the location, the depth of the caries, the presence of low-quality depulpation, any inflammatory processes and a couple of dozen other reasons: because of them, it is really difficult to get to the root.
Why is it worth coming to the Dental Practice clinic?
We monitor our equipment, its novelty and quality. We monitor the experience and qualifications of the clinic’s staff.Come to the Dental Practice clinic. We monitor the equipment and its novelty - only people in the clinic are older than 2012.
head of the expert magazine about dentistry Startsmile.ru,
“We did this back in 1990!”
Dentistry, like medicine in general, does not stand still. But individual professionals are still treading water in the same spot where they were presented with a diploma. If, of course, you want to save as much as possible on your health, you can put, for example, a chemical filling instead of a light-curing one completely free of charge. However, good doctors do not cling to the sacred traditions of Soviet dentistry, but willingly use new, advanced techniques in practice - from laser to 3D diagnostics.
“I can’t tell you the price yet - everything is individual”
And then patients urgently need Corvalol and valerian when they are shown the bill. In fact, the doctor has access to price lists for all services he provides. If a doctor says that he knows nothing about prices, he is, to put it mildly, disingenuous. The professional is honest about everything, including the cost of treatment. Moreover, he should recommend you several options for solving the problem - both expensive and budget ones.
“So, I don’t see any problems. Are you sure it hurts?
Visual inspection - that's all? When a piece of a tooth breaks off, the naked eye may be enough. However, if you come with a complaint of hellish pain in half of the jaw, then refusal to conduct an X-ray diagnosis is an argument in favor of immediately leaving the doctor alone with the dental chair. A good dentist not only studies the image before treatment, but also, if necessary, checks the result after, for example, when filling canals. In the absence of proper diagnostics, you can easily miss serious problem.
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“Everything is very bad: two caries, pulpitis, removal”
The opposite situation is when the doctor suddenly finds so much caries and other diseases in your mouth that it is unclear how you survived to your age. Most often, such unexpected discoveries are also accompanied by a refusal to show, at least on an x-ray, where all this horror is hidden.
The goal is to defraud you of as much money as possible for treatment. healthy teeth. This is how you can distinguish a good doctor from a bad one: an honest specialist will always show the real condition of your teeth and gums using an intraoral video camera. When you see for yourself in 56-fold magnification how far the caries has reached in the seven below, the doctor will not need to convince you of anything.
“No need to tell me, let me see for myself”
So, you did something, but after treatment it got worse, or the filling scratches your cheek, braces don’t allow you to close your mouth, and whitening makes you want to bang your head against the wall. A good dentist will always say the magic phrase at the end of the appointment: “If anything bothers you, contact us immediately!” If you experience discomfort, the doctor will try to find the cause, and not throw you out the door so that he can quickly take care of a new patient.
The same rule applies to yours individual characteristics: hypersensitivity teeth and gums, drug intolerance and even panic fear in front of the drill. A professional will never brush aside information that a patient tells him.
“There is no point in treating, only removal”
The goal of a good dentist is to preserve as many of the patient’s original teeth as possible. Tooth extraction is almost always a last resort. The doctor must argue why this tooth needs to be removed, which brings us back to the question of the intraoral camera, X-rays and detailed answers to all the patient’s questions. Acute excruciating pain may turn out to be pulpitis, which is now successfully treated by keeping the tooth in its proper place. When the dentist just sends something for removal, it is better to look for another doctor.
“We cannot do without these procedures. Yes, yes, they are not cheap, but there is no other choice."
There is another category of doctors who avoid intraoral video cameras like hell. Those who certainly want to treat you for a long time, a lot and with the help of the most expensive techniques, devices and materials.
Yes, modern technologies are a good thing: such treatment is faster and more comfortable, and gives reliable, long-term results. But only you have the right to decide whether you want to use these super-sophisticated technologies or whether it’s better to do everything the old fashioned way. Blackmailing a patient with his life and health is unacceptable! It is also important to remember that the doctor should always offer alternative treatment: either traditional methods or modern ones. And the choice is yours.
“It shouldn’t hurt you, don’t make things up!”
Favorite phrase with which the toothache of our mothers and grandmothers began! Now is a good reason to never again cross the threshold of the office where such a “specialist” sits. IN modern dentistry applies wide range painkillers, including those without adrenaline, which can be injected even to pregnant women in the second trimester. A good dentist will always select the drug necessary for your case and make sure that you do not squirm in pain.
“Sorry, pregnant women are not allowed anesthesia”
But no. Long gone are those wild times when toothache during pregnancy it was necessary to either endure or be treated without pain relief. Of course, there are procedures that expectant mothers cannot undergo: for example, installing an implant, removing complex figure eights, or performing a telex-ray. But, despite the special caution that should be observed when treating teeth in pregnant women, doctors, armed with modern techniques and methods, will always find a way to help. A doctor who, upon learning about your “interesting situation,” changes his face and refuses to look for ways to solve the problem is not your option.
“All these pieces of paper are just fooling your brains”
Having diplomas and certificates is not always a 100% guarantee of high professionalism. But nevertheless, if you are going to submit to a doctor for a complex operation, say, installing an implant, then it is better to choose a specialist who has received a certificate confirming his knowledge and skills. It’s especially good if this “piece of paper” is an international-class document issued by an implant manufacturing company.
Dentistry is a branch of medicine where unnecessary services are often offered.
How dentists deceive patients
Every year, the “horror” stories about dishonest doctors do not decrease, but just the opposite. Then a child’s teeth are removed by a cleaning lady who decides to make money. Then instead of an anesthesiologist in the hospital there was a visiting “tourist”, and as soon as the situation got out of control, he quickly retreated. No less scandalous stories involve dental treatment by persons who have nothing to do with medicine.
More often, such “non-doctors” can be seen in the field of cosmetic dentistry. Just think about it - teeth whitening at home by 8-20 shades on the Vita scale - this is the result most offices promise “ beautiful smile».
For reference, Vita is a standard scale of enamel colors and shades used in dentistry and has 16 shades.
Such guarantees do not leave many patients indifferent, running to appointments in such “beautiful smile” offices and wanting to receive their portion of beauty and perfection. What's the result? As a rule, expectations and reality do not coincide, but possible consequences can be more than sad: enamel damage, necrosis.
The Dental Society has identified points that protect patients from such unscrupulous entrepreneurs:
- Clinic documentation: permits, diplomas, certificates and the right to operate must be freely available to patients. Typically, these documents are located in the information window;
- Carry out any manipulations with teeth, even professional cleaning, only persons with medical education can;
- Clinic performing complex surgical procedures: implantation, treatment under anesthesia, sedation must have the appropriate permits, equipment, a separate room for the patient’s recovery and a staff of anesthesiologists;
- Choose only proven clinics that have reviews, including bad ones;
- You need to quickly retreat from the clinic if the doctor insists on immediate complex treatment and offers to apply for a loan (well, if there is not enough money). Any dental procedure, unless it is an acute emergency, can be delayed for a short period of time. And such persistent actions on the part of dentists should be alarming.
How dentists scam money
The issue of deception in medicine, even in the provision of paid services, is controversial and very delicate. It cannot be said unequivocally that dentists deceive patients when one amount is announced before the start of treatment, and then another.
Let’s say, based on the results of a preliminary examination, a diagnosis of “deep” is made; during treatment it turns out that this is no longer caries, but complications. It is difficult to disagree that the cost of treatment with mandatory canal treatment, rinsing and filling will be different. And this is not a money scam, but a necessary dental procedure.
Of course, there is another side to the coin when deception occurs. For example, the volume of medical procedures, materials and work units spent has not changed, but the cost of treatment has increased significantly, in this case, patients have the right to understand, demand a detailed report and explanation.
In order not to fall into the trap of unscrupulous doctors, every patient has the right to inquire about the procedures performed, their purpose and justified necessity. Prices for services that are not included in the compulsory medical insurance system should be freely available in front of the reception desk. If there are no documents, run away from such a clinic.
By the way, we must not forget about compulsory medical insurance and voluntary medical insurance - after all, in Russia there is free medicine.
How dentists cheat on fillings
Filling is the most common manipulation in the dentist's chair. Today the best materials Light-curing fillings are recognized; they are more durable, meet aesthetic qualities and differ in cost. The cost of filling is precisely the stumbling block between the doctor and the patient.
The price for the material varies widely and, perhaps, unscrupulous doctors take advantage of this. To protect yourself from expenses, you need to read the price list in advance and ask the treating doctor how much the filling will cost, or better yet, ask him to draw up a treatment plan on paper. Dentists are required to answer your questions for your money. In addition, each clinic has filling materials of varying prices from economy class to VIP.
Before talking about dentists cheating on fillings, evaluate the doctor’s qualifications and the upcoming procedures. Filling the chewing group of teeth, even with the restoration of fissures, tubercles and aesthetic restoration of the anterior group, cannot be compared in terms of cost and cost of materials.
By the way, poor-quality filling is another opportunity to deceive the patient. Below are some examples of work. The conclusions, as they say, are obvious.
If they try to sell you a Lada Vesta for a couple of million, then, of course, it’s a scam. But if they offer to buy a luxury car for this money, then no complaints will arise. The same principle applies to fillings. Good doctor can evaluate his services accordingly and it cannot be said that he is simply inflating his price and trying to cheat everyone out of money: demand creates supply.
Was the photo necessary?
How we are being tricked into additional procedures
You can often hear that doctors impose additional and paid services during treatment, it can be anything: various photographs, whitening (by the way, this procedure does not cause any complaints), saturation of teeth with minerals, etc.
So a patient came for an appointment to treat a disturbing problem, and the doctor: examined the oral cavity, wrote dental formula, reflected all the existing problems, cured them, then began to recommend professional teeth cleaning, saturation of teeth with minerals, dentures, etc. What is this? Divorce? No way.
Dentists work according to a specific algorithm, and their scope of action does not end only with dental treatment. This also includes prosthetics, prevention, bite correction, aesthetic restorations, which the doctor will recommend.
If the patient has any doubts about the importance of a particular procedure, then you can consult with your doctor about the need for it. Each procedure, no matter whether it is therapeutic or prophylactic, has its own indications and contraindications.
It is impossible to say with certainty that in dentistry, and in all medicine, there are no entrepreneurs who are trying to profit from patients and earn extra money. But the problem does not have such a serious scale as is commonly said and thought.
Today, many patients position themselves as clients and can make recommendations for treatment. And if the plan drawn up by the patient and the doctor does not agree, conflicts arise. To avoid misunderstandings and conflicts, you need to choose a dentist you really trust!
