Dr Shalin Desai - Endodontist

Case #6: Dens-in-Dente Interesting case of unusual dental anatomy - Dens Invaginatus or Dens-in-Dente.
This case depicts the importance of active irrigation for effective disinfection and warm vertical compaction for satisfactory root canal filling.

I would like to thank you all referring doctors for their kind support to our practice. I certainly feel appreciated and motivated for continual good work.

Case #5: Vertical Root Fracture
VRF - a completely different disease entity and NOT related to coronal cracked tooth (syndrome).
As the name says - its a root fracture, running vertically in apical/coronal direction and usually on buccal-lingual (palatal) plane.
... The key features to diagnose vertical root fracture in a tooth -
1) Root canal treated tooth - likely with a wide / uneven canal preparation / post in the root canal space
2) Draining sinus on attached gingiva portion on labial or lingual or both aspects
3) Deep narrow pocket as we walk periodontal probe along the sulcus - on buccal / lingual or both aspects
4) Extensive lateral radiolucency (or J-shaped radiolucency when apical and lateral lesions combine)
Diagnosis based on clinical / radiographic signs and for many cases, CBCT (see attached image showing MB root fracture line in B-P direction).
Long-term prognosis for any conservative treatment is poor and the only option is extraction of the tooth.
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Case #4: Large PA pathology
An interesting case of large periapical pathology treated with non-surgical endodontic intervention only.
The patient was 26 years old female who complained of slowly developing palatal swelling in the pre-maxilla region. Clinical assessment, pulp sensibility tests, intra-oral radiographs and CBCT scan confirmed the diagnosis of necrotic pulp and associated extensive periapical bone loss with the tooth 12.
... Non-surgical root canal treatment was an obvious choice by a young female patient to save the tooth. However, large periapical pathology like shown in the attached image could require a more aggressive surgical approach in many cases.
So when do we perform apical surgery?
My strategy is very clinical -
1) Start non-surgical root canal treatment and shape / thorough disinfection of the entire root canal system and fill with ca-hydroxide paste.
2) Monitor for clinical healing (draining sinus, swelling, pain, other) for 6-8-12 weeks. If favourable clinical healing noted consider placement of root filling and monitor for progressive hard tissue healing (see images). Apical surgery only if no progressive bone healing at 12 months review.
3) If no soft tissue healing in 2 - 3 months - consider apical surgery immediately (possible aetiology - extra-radicular bacteria? true radicular cyst? non-endodontic lesion?).
Periapical healing is favourable with non-surgical endodontic approach if the root canal system is thoroughly disinfected / filled and satisfactory coronal seal is achieved. Size of the periapical lesion does not dictate severity of the disease process, it only reflects the (Im)balance between microbial activity and host immune response. Conservative approach is recommended and in many cases surgical approach is not warranted (can be avoided).
Your thoughts on this topic are appreciated.
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Case #3 - Access Cavity - Avoid furcation perforation
Furcation perforation is an annoying procedural complication. How to avoid removal of excessive dentine structure from floor of the pulp chamber? ----------------------------------------- ---------------------------------------- ----
... 1) The most efficient approach - PATIENCE - slow and careful preparation of endodontic access cavity. Make the access cavity "AS SMALL AS POSSIBLE, BUT AS LARGE AS REQUIRED".
2) Understand the pulp chamber morphology - Large chamber space / pulp stones in the chamber / calcified (COMPRESSED) pulp chamber.
BITE-WING radiograph is the best view to assess the chamber morphology (See image).
3) Use of high speed burs only up to the roof of pulp chamber. Once the roof is exposed at one spot, further lateral opening and complete de-roofing of the chamber should be done using either small & long-shank slow speed burs or preferably diamond coated ultra-sonic tips.
Pulp stones are loosely attached to walls / floor of the chamber. They can be easily dislodged by simple vibration of ultra-sonic tip.
Colour of the floor of pulp chamber is darker (blackish grey) as compared to the walls (yellowish white) - see image
4) Where is roof of the pulp chamber? - The roof of pulp chamber is at the level of horizontal line connecting Cementum - Enamel junction on proximal aspects (see image).
- The anatomical crown (the portion covered by enamel) of the tooth contains pulp horns only and rest of the complete pulp chamber is contained within pericervical dentine and cementum.
- Calcification of pulp chamber is in fact a boon to avoid furcation perforation. The roof of the chamber is static and the dentine deposition is usually on the floor of pulp chamber. The floor elevates and the roof stays stable at a level that corresponds with a line connecting proximal CEJs.
Keep your burs / ultrasonic tips away from the floor of the pulp chamber. The anatomic grooves on the dentinal floor would guide you towards the root canal orifices (See image).
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Norwest Endodontics presentation night at Novotel, Baulkham Hills
Thank you all 113 colleagues to make the night memorable and a grand success. A special thanks to Dr Anthony Naim, Stephanie Green, Lorraine, Laura and Sabrina.

Case #2 - Locating MB2 canal orifice
MB2 canal is a mystery for many dentists and is a leading cause of treatment failure for maxillary molars.
This case demonstrates a typical location of MB2 canal orifice. Finding MB2 can be predictable if few simple rules are followed.
... 1) The MB root of maxillary molar is oval in cross-section - with long-axis of oval being Buccal-Palatal. Note DB and P roots are mostly circular in cross-section (See image)
2) The MB, DB and P canal orifices are relatively standard in position - usually under MB cusp tip, oblique ridge and MP cusp tip respectively.
3) Once three canals orifices located, search for MB2 orifice requires knowledge of following facts -
- MB and MB2 canal orifices joined in a straight line, it will be more or less parallel to the mesial marginal ridge
- The MB2 canal orifice is usually slightly mesial to the line joining MB and P canal orifices
- Most important - the MB2 canal orifice is usually hidden under thick dentine cover
4) Use either small half round long shank slow-speed bur OR fine diamond coated ultra-sonic tip to explore from MB orifice towards palatal direction but must be parallel to mesial marginal ridge to expose MB2 orifice (see images)
5) Once the orifice sighted - use a small hand file to negotiate the root canal - however must keep in mind that direction to enter the orifice is not straight down but angled from DP direction towards mesial-buccal corner
6) Insert hand file with watch-wind motion to avoid ledge in the root canal.
Note in many cases, the MB2 ends up meeting MB canal in mid-root or apical region. But that doesn't mean that we don't need to find and negotiate this canal. Bacteria / debris left behind in untreated MB2 canal is a most common reason for molar treatment failure.
Happy MB2 hunting. !!!
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Case #1 Incomplete cracks in teeth - Two different clinical situations -
Image 1 - minimally restored tooth with crack running in Mesial-Distal direction as well as wide crack filled with debris and plaque. High resolution small focus CBCT revealed crack on the occlusal surface (M-D direction as well as deep up to roof of the pulp chamber). This was confirmed by exploratory procedure to access pulp space and visualising the crack on floor of the chamber. In my opinion, this... deep / wide incomplete crack on sound crown has poor prognosis. The aetiology for such crack is usually extreme para-functional activity. This cracked molar should be removed and replaced appropriately.
Image 2- large amalgam restoration, close to pulp space and eventually plupal flare up due possible secondary carious lesion and/or leakage around the filling. No crack was visible on high resolution small focus CBCT. however, once the amalgam removed, a small crack was noted under the filling. Unlike the image 1 tooth, this crack was not wide / open. Further, it did not enter pulp space or floor of the chamber. In my opinion, this crack was not related to bruxism or clenching habit but appeared due to flexural movements of unsupported cusps around large metallic restorations. The crack in this tooth did not change endodontic or periodontal tissue prognoses. Following satisfactory endodontic intervention, adjacent cusps / occlusal surface should be adequately covered with appropriate indirect restoration.
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Privileged and spoiled to work around great team - Laura, Maree, Sabrina, Tammy and Lorraine.

An excellent initiative by ADA NSW to visit Tamworth for Endodontic day course. ADA NSW Centre for Professional Development Shalin Desai

Hands-on course for a big group of dentists in Adelaide. Thank you all the participants for a great day of Endodontic fun.

Very interactive group of dentist in Adelaide.

Dr Shalin Desai is a board registered dental specialist, specialising in the field of root canal treatments and related microsurgery as well as dental trauma. Dr Desai has been practicing in the Hills district of Sydney over six years with surgeries located at Bella Vista and Hornsby. A branch surgery is located in the beautiful mid-north coast town of Coffs Harbour.

Master at Endodontics! Everything he teaches is also super useful

Master at Endodontics! Everything he teaches is also super useful