Figure 5. Mesial marginal ridge crack stained with methylene blue under microscopy. Figure 6. Vertical root fracture visible on a diagnostic scan. Figure 7. Tooth 24 previously treated with chronic apical abscess. Missed distal buccal canal. while relatively rare, requires evaluation with cone beam computed tomography (CBCT). Figure 3 demonstrates a radiolucent lesion just mesial to the pulp chamber of tooth 46 extending to the dentinal enamel junction. Easily interpreted as caries, this presentation is pathognomonic for External Invasive Resorption (EIR). This condition requires early intervention for a favourable outcome. Figure 4 provides an example of multiple occurring EIR, which was diagnosed after significant progression. The patient subsequently had several extractions due to the extent of resorption over time. Teeth that are cracked (Fig. 5) or fractured (Fig. 6) may require a referral for an accurate diagnosis. Cracked teeth often present with inconsistent symptoms that are diagnostically challenging. Exploratory access and staining with methylene blue under microscopy may be required for an accurate diagnosis and determination of long-term prognosis. Cases with significant calcification or pulpal canal obliteration (i.e., in cases of trauma) have a higher level of difficulty and will not always respond to cold testing. In this case, an electric pulp tester (EPT) should be used, if available. An expanded armamentarium including Munce burs, surgical length stainless steel Minimally Invasive (MI) burs, and ultrasonics will be required for heavily calcified canals. CBCT is often needed in these cases to prevent the risk of perforation. Likewise, apical surgery will be an adjunct treatment option if orthograde root canal therapy is unsuccessful. Dentists that are uncomfortable using these instruments or prescribing advanced imaging ought to provide a referral. 3) Other Considerations Cases with periodontal involvement, a history of trauma, or previous root canal therapy are classified a higher difficulty and will likely necessitate a referral. Figures 7 and 8 are examples of post-treatment disease in teeth that normally fall within a low to moderate difficulty level. Although anterior and premolar teeth are often considered more straightforward to treat, careful evaluation of the radiographic presentation is essential. The presence of a fast break, second periodontal ligament (PDL), or canal asymmetry indicate increased complexity. Endodontists Cases with significant calcification or pulpal canal obliteration (i.e., in cases of trauma) have a higher level of difficulty and will not always respond to cold testing. frequently note that premolars can be some of the most time consuming and challenging cases. Lower mandibular premolars may present with an extra root, canal(s), or even C-shaped configuration. A maxillary premolar that appears to have asymmetric buccal and palatal canals upon endodontic access often has a third canal (Fig. 7). 29 Issue 1 | 2025 | Supporting Your Practice
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