Dentaltown May 2017 - 124
continuing
education
Fig. 15
Fig. 14
Fig. 14. Apical lesion centered around apical exit point of untreated MB2 canal (frontal plane).
Fig. 15. Bone loss around #3 MB root with untreated MB2 canal. Lesion around untreated MB2 canal in #3.
examples of scenarios and means to manage
potential difficulties, refer to Table 2.
If a tooth seems too calcified or the roots
too curved, or the tooth too difficult to access,
then you and your patients may be better
off with a referral to an endodontist. An
endodontic headache mid- or post-treatment
is not going to benefit anyone.
With respect to teeth, some present
greater challenges clinically (Table 3).4
A couple of teeth to keep in mind are
maxillary molars and maxillary lateral
incisors.5 Maxillary molars may be more
difficult for a couple of reasons
We are aware of the presence of the infamous MB2/fourth canal that should always
be treated.6 However, it's well-known that
locating and negotiating MB2 canals may be
a challenge. An untreated MB2 canal could
result in periapical pathology (Figs. 14 and
15). A less obvious issue with maxillary molars
that often gets us in trouble is the curvature
Discover more
about endo from
Dr. Manor Haas
The author covers even
more endo topics in a new
companion video to this
CE piece. To find it, head to
dentaltown.com and click
"Magazine" to find the online
version of this article.
124
MAY 2017 // dentaltown.com
of the palatal roots. Although these roots
may seem straight in a 2-D radiograph, they
often have an apical curvature to the buccal
(Fig. 22). If this curvature isn't appreciated
in advance and negotiated properly, it may
ledge, block or transport the canal. Such a
problem may translate to the inability to
treat the most important part of the root's
canal, the apical third.
The maxillary lateral incisor may seem
easy and simple to treat but turn out to be
the opposite. Maxillary lateral incisors are
some of the most likely teeth to present
with root canal failures.4 This is because no
matter how they look in 2-D radiographs,
they often have an apical disto-palatal
curvature that must be carefully negotiated.
Poor management of this curvature could
compromise the procedure (Fig. 25).
In summary, these clinical scenarios
and potentially difficult teeth may seem
obvious to many of us, but there are still
many dentists getting into trouble with
them. Hence, they can't be stressed enough
and need to be kept in mind when deciding
whether to perform root canals in-house.
Final comments
I have been humbled many times in my
career, so it's with sincerity that I ask you
to consider and know your limits. In my
endodontic practice, I mention to patients
that an honest, humble and experienced
dentist knows how to judge the complexity of
a case and when to refer to a specialist, instead
of getting into trouble. Th is may sound
patronizing toward my referring dentists
but when done sincerely, those patients
understand and walk away appreciating
and respecting their dentists even more.
So, ask yourself if performing RCT
is worthwhile for your patients and your
practice. If you're proficient in performing
root canal treatments and have the necessary
armamentaria, go ahead and help your
patients and your practice. If not, then
perhaps it's best to let a specialist perform
the endo, allowing you to not risk anything
and your patients to return to you for the
post-endodontic restorative work.
We face enough stresses in our practices.
Why create more? ■
References:
1.
Hargreaves KM, Berman LH. Cohen's Pathways of the
Pulp. 11th ed. St. Louis, MO: Elsevier;706, 2016.
2.
Bartols A, Laux G, Walther W. Multiple-file vs. single-file
endodontics in dental practice: a study in routine care.
PeerJ. 2016; 4:e2765
3.
Zanin, AA, Herrera LM, Melani RF, Civil liability:
characterization of the demand for lawsuits against dentists.
Braz Oral Res. 18;30 (1) 2016.
4.
Iqbal, A. The factors responsible for endodontic treatment
failure in the permanent dentitions of the patient reported
to the college of dentistry, the university of Aljouf, Kingdom
of Saudi Arabia J Clin Diagn Res. 2016 May; 10(5)
5.
Ng YL, Mann V, Rahbaran S, et al: Outcome of primary
root canal treatment: systematic review of the literature.
Part 2. Infl uence of clinical factores, Int Endod J 41:6,
2008.
6.
Schwarze T, Baethge C, Stecher T, Geurtsen W. Identification of second canals in the mesiobuccal root of maxillary
first and second molars using magnifying loupes and operating microscope. Aust Endod J. 2002 Aug: 28(2): 57-60.
http://www.dentaltown.com/magazine/articles/6382/continuing-education-endo-risks-and-benefits
http://www.dentaltown.com
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