August 19th, 2017
Just anterior to the epiglottis at the base of the tongue are two bilateral spaces, the Valleculae. These should be symmetrical spaces which are clearly seen on axial sections. However, in the section below there is a soft tissue nodule 8 x 10 mm in the right space.
In the images below, there are two nodules on the left side of the base of the tongue.
The differential diagnosis includes lymphoid hyperplasia (the lingual tonsils are in this region), benign and occasionally malignant tumors. The patient should have an examination by an ENT specialist.
-Dr. Douglas K Benn DDS, PhD
Oral and Maxillofacial Radiologist
Posted in Radiology |
July 14th, 2017
Something that most patient remember about dental pain is referred to tooth pain and tissue swelling. Sometimes this problem refers to the loss of vitality of a tooth but it can also be referred to periodontal problems. We will analyze the second scenario and we will compare it with the classical tooth that needs a root canal therapy by the endodontist.
The periodontal abscess is a localized purulent inflammation of the periodontal tissues. It can be classified according to the structure that it affects in gingival, periodontal and pericoronal abscess. The gingival abscess affects the marginal gingival and interdental tissues. The periodontal abscess is an infection located in the periodontal pocket and may result in destruction of the periodontal ligament and bone. The pericoronal abscess refers to the area next to a tooth crown that is not fully erupted in the mouth.
Periodontal Abscess
The periodontal abscess is typically found in patients with active periodontitis and in association with moderate-to-deep periodontal pockets. Periodontal abscesses often arise as an acute episode of a preexisting periodontal disease. Among the difference causes, the most common is the incomplete calculus removal from a gingival pocket. Abscesses can occur after periodontal surgery, after preventive maintenance, after systemic antibiotic therapy and recurrence of periodontal disease. Other causes of periodontal abscesses can be tooth perforation or fracture and foreign body impaction. The importance of periodontal abscesses is high. Their presence is a leading cause of tooth loss. However, proper treatment and constant follow up can help to retain affected teeth for many years.
Acute versus Chronic Abscess
Abscesses are categorized as acute or chronic. The acute abscess is often a sudden episode of an existing periodontal lesion with no liquid drainage through the gums. The result is a painful, red, smooth swelling of the gingival tissues. The tooth may be percussion sensitive and feel elevated in the socket. The chronic abscess form after the infection spontaneously drains or it’s treated by the periodontist.
Periodontal versus Pulpal Abscess
The following table summarizes the main differences between Periodontal and pulpal abscesses. Sometimes symptoms are mixed and do not help with correct diagnosis and an interdisciplinary consultation with the endodontist may be necessary
Treatment of the periodontal abscess includes the resolution of the acute lesion, followed by the management of the resulting chronic condition. Treatment options include drainage through pocket retraction or incision, scaling and root planning, periodontal surgery, systemic antibiotics or tooth removal*. The treatment of pulpal abscess is usually the completion of a root canal therapy by the endodontist that in severe case may have to associate this pathology with systemic antibiotics and drainage of the swelling for acute abscesses.
Acute abscesses can be a very bad experience for the patient. Due to complexity of appearance, it may be difficult to differentiate between endodontic and periodontal abscesses, It is important to urgently contact the periodontist that is trained to tackle and treat this pathology and improve the fate of the affected tooth.
References
*(Modified from Sanz M, Herrera D, van Winkelhoff AJ: The periodontal abscess. In Lindhe, J: Clinical periodontology, Copenhagen, 2000, Munksgaard).
The body of this article is referred to Carranza’s Clinical Periodontology, 12th Edition By Michael G. Newman, DDS, Henry Takei, DDS, MS, Perry R. Klokkevold, DDS, MS and Fermin A. Carranza, Dr. ODONT.
- Lorenzo Mordini DDS, MS
Posted in Dental Implants, Periodontics |
June 19th, 2017
Dental implants are a successful and predictable tools to replace missing teeth. If planned and executed with precision the risk of failure can be reduced to a minimum.
Among risk factors for implant placement one could list patient related risks and technique related risks. Among patient related, uncontrolled systemic diseases (diabetes), smoking and poor oral hygiene are the mayor risk factors.
As far as technical, malposition and mechanical parts breaking may lead to implant failure or disease.
We report a case where the implant on the central area of the upper jaw of the patient was placed partially outside the bone volume available.
Since the patient was already missing a tooth, a new plan was offered to replace it along with extraction of the failing implant and simultaneous replacement with a correct-positioned one.
Due to lack of bone, an augmentation was performed simultaneously in order to prevent future resorption of existing bone.
It has to be noted that the use of modern tools to explant existing implant and the use of digital implant planning with surgical computer guide, helped the surgeon to provide a correct and precise placement with a decrease of technical risks of failure.
- By Dr. Lorenzo Mordini
Fig 1 a, b. (below). Frontal and lateral view of the implant (crown right to the space) and missing tooth.
Fig 2.(below). Implant guided placement after malpositioned implant extraction with dedicated tools.
Fig 3 a, b.(below). Healing after implant placement and bone grafting.
Fig. 4 a, b (below). Radiographic image of implant (white image) that is outside the bone volume. In green, the digital plan of the new implants.
Fig 5 a, b (below). Software combining 3D radiograph with digital implants in order to create surgical guide.
Fig 6. (below). Radiographic image after placement of two new implants
Posted in Dental Implants |
May 31st, 2017
In CBCTs which include the cavernous sinuses, just medial and posterior to the back of the orbit lie the internal carotid arteries.
The cavernous part of the artery has a tortuous path which causes turbulance and is more likely to calcify than the straighter portions.
The calcified walls of the artery may be single white lines or parallel lines if both walls are calcified as in this sagittal image.
In coronal images the arteries can appear as opaque circles.
Calcification of the carotid artery walls is a sign of advanced atherosclerotic disease and likely affects other vessels such as coronary arteries.
If you find calcifications, you should advise your patient to consult with their doctor and send a brief letter to the physician.
-Dr Douglas K Benn DDS, PhD, Dipl. Dental Radiology (Royal College of Radiologists, England)
Oral and Maxillofacial Radiologist
www.ReadCTs.com
Posted in Radiology |
May 2nd, 2017
Dentinal hypersensitivity is a diffused problem that patient complain about, usually associated with exposed tooth root surfaces. Any age patient can be affected (20–50 years, with a peak between 30 and 40 years of age 11) and most of the times is present on the canines and premolars of both the arches. A slightly higher incidence of sensitivity is reported in females than in males. It is clinically described as an exaggerated response to application of a stimulus to exposed root surface (dentin). Dentin hypersensitivity is characterized by short-lasting, acute pain arising from exposed root or dentin in response to insults that most of the time is thermal (cold or hot food/drinks). Direct pressure on the exposed dentin or substances may trigger this sharp pain too (Dentin hypersensitivity: Recent trends in management Sanjay Miglani, Vivek Aggarwal, and Bhoomika Ahuja J. Conserv Dent. 2010 Oct-Dec; 13(4): 218–224).
The identification of this condition can be obtained by clinical examination. Some patient self report to the dentist this condition due to its severity. A simple clinical method that the dentist can use includes a jet of air or using an exploratory probe on the exposed dentin, examining all the teeth in the area in which the patient complains of pain (Gillam DG, Orchardson R. Advances in the treatment of root dentin sensitivity: Mechanisms and treatment principles. Endod Topics. 2006;13:13–33). The severity of pain can be quantified either according to categorical scale (i.e., slight, moderate or severe pain) or using a visual analogue scale (Orchardson R, Gilliam D. Managing dentin hypersensitivity. J Am Dent Assoc. 2006;137:990–8).
Fig 1. Patient presenting with gingival recession, root exposure and subsequent dentinal hypersensitivity on canine and first premolar. The cause of this situation was attributed to heavy tooth brushing with hard bristles and use of abrasive toothpaste.
The cause of dentinal hypersensitivity can be found in incorrect and too aggressive tooth brushing, poor oral hygiene, gingival recession caused by other dental therapies (i.e. periodontal treatment, dental bleaching). Incorrect tooth brushing includes hard brushes, excessive forces associated with the use of abrasive toothpaste, excessive scrubbing at the cervical areas or even lack of brushing which causes plaque accumulation and gingival recession (Suge T, Kawasaki A, Ishikawa K, Matsuo T, Ebisu S. Effects of plaque control on the patency of dentinal tubules: An In vivo study in beagle dogs. J Periodontol. 2006;77:454–9).
The first approach is to teach the patient the correct method of tooth brushing to avoid further extension of gum recession and dental wear at the gingival level. Highly abrasive tooth powder or pastes should be avoided (Orchardson R, Gilliam D. Managing dentin hypersensitivity. J Am Dent Assoc. 2006;137:990–8). Also, the patients should be instructed to avoid brushing for at least 2 hours after acidic drinks to prevent agonist effect of acidic erosion on tooth-brush abrasion (Dentin hypersensitivity: Recent trends in management Sanjay Miglani, Vivek Aggarwal, and Bhoomika Ahuja J. Conserv Dent. 2010 Oct-Dec; 13(4): 218–224).
Erosive agents (carbonated drinks, citrus fruits, wines, yogurt and cosmetic products) are also important in initiation and progression of this condition. They act by thinning the superficial layer of teeth (cementum on the roots and the enamel on the crown) and exposing the most porous part of them (dentin) (Eisenburger M, Addy M. Erosion and attrition of human enamel In vitro. Part I: Interaction effects. J Dent. 2002;30:341–7. Osborne-Smith KL, Burke FJ, Wilson NH. The aetiology of the non-carious cervical lesion. Int DentJ. 1999;49:139–43). Dietary counselling should be suggested. Other sources of acid come from gastroesophageal reflux or regurgitation (patients with eating disorders too). A medical consult should be requested from the dentist. By removing the causative factors or limiting them, the condition can be prevented or at least limited.
As far as treatment, the severity of the condition may dictate a more invasive intervention rather than topical solutions. The patient can correct their faulty habits by utilizing some desensitizing agents (fluorides toothpastes with 5% potassium nitrate and 0.454% stannous, mouthwashes or chewing gums) and modifying their predisposing diet. Professional treatment includes topical application of agents that can cover the porosities of the teeth and block nerve triggering (0.4% stannous fluoride along with 0.717% of fluoride can provide an immediate effect after a 5 minute professional application) (Thrash WJ, Dodds MW Jones DL.
The effect of stannous fluoride on dentinal hypersensitivity. Int Dent J. 1994;44:107–18), restorations to cover exposed tooth surface that is creating sensitivity, root coverage in terms of gingival augmentation to replace or augment the tissue lost during the development of hypersensitivity.
-By Lorenzo Mordini DDS, MS
Posted in Dental Implants |
April 25th, 2017
It is common for the IANC to be close or even touching the apices of unerupted third molars. However, it is rare for the IANC to actually pass between or through the roots.
In the images below, the IANC passes between two mesial roots of #32.
- By Dr. Douglas K Benn DDS, PhD, Dipl. Dental Radiology (Royal College of Radiologists, England)
Oral and Maxillofacial Radiologist
www.ReadCTs.com
Posted in Radiology |
April 3rd, 2017
The American Academy of Prosthodontists reports that more than 35 million Americans do not have any teeth, and 178 million people in the U.S. are missing at least one tooth. These numbers are expected to grow in the next two decades.
Most of the time, the teeth that are missing are the molars, either in the upper or lower jaw. After missing a molar in upper jaw, the patient experiences both bone resorption and expansion of the maxillary sinus. With the increase in popularity of dental implants and the increase quality of life of patients, rehabilitation of the edentulous posterior jaw often represents a clinical challenge.
Before the utilization of dental implants, patients with missing teeth and deficient bone in the posterior maxilla could only be rehabilitated with removable prostheses or short implants that prevent invasion of the sinus. Sometimes bone resorption and sinus expansion is so advanced that even short implants cannot be placed.
In those cases, advanced procedures like maxillary sinus elevation are needed to increase the amount of vertical bone height in the posterior maxilla for the placement of implants. Generally speaking, two procedures are available depending on the quantity of bone left.
In case of small augmentations needed, the use of a tapping motion on blunted posts can create sufficient space for implant placement (Internal or Direct Sinus Lift).
Internal Sinus Lift. Before and After augmentation, a dome of grafting material and the implant can be noted after healing (right image). The red line highlights the contours of the sinus before and after. The orange line shows the initial lack of bone. In case of more bone required, a more invasive procedure is required. A small perforation on the lateral wall of the sinus is performed and the creation of a window in that area can favor deposition of more grafting material for larger augmentation (External or Indirect Sinus Lift). Also, the quantity of bone available before the augmentation can allow the simultaneous placement of the implant, which tip will be surrounded by the graft material used for sinus augmentation.
External Sinus Lift. Before and After augmentation, a dome of grafting material can be noted after healing in the right image). The red line highlights the contours of the sinus before and after. In case of minimal bone levels before the augmentation, the sinus lift is performed and implants are usually placed 6 to 9 months after healing. It is very important that patients are healthy individuals with no uncontrolled systemic pathologies and conditions (uncontrolled diabetes, uncontrolled hypertensions for example). Also, the sinuses need to be clear from any diseases like cysts, sinusitis and infections.
In conclusion, sinus augmentation can be a valuable option to restore the posterior upper jaw in case of long absence of teeth, bone loss and sinus expansion.
- By Lorenzo Mordini DDS, MS
Posted in Dental Implants, Periodontics |
March 28th, 2017
Although I have in the past shown some images I wanted to provide some clinical relevance regarding the prevalence of CACNs and the role of dentists.
In adults with a negative history for cardiovascular disease, diabetes, hypertension and chronic kidney disease about 5-7% of adults over the age of 40 years may have CACNs seen of pans or CBCTs. In patients with diseases listed, the prevalence will approach 50%.
To put this in context, a dentist with an average sized dental office population may see 3-5 oral cancers in their practicing life time.
However, the number of CACNs will probably be in the 100s of patients. For those patients who do not know they have hypertension, diabetes or kidney disease, the first indication of their cardiovascular disease may be a fatal heart attack or stroke.
If a dentist sees a CACN in a patient with a normal medical history and refers them to their MD to further evaluate, they will probably save many lives.
By Dr. Douglas K Benn DDS, PhD, Dipl. Dental Radiology (Royal College of Radiologists, England)
Oral and Maxillofacial Radiologist
3610 Leavenworth Court
Omaha, NE 68105-1200 USA
Tel: (402)-953-6264
Fax: (866)-420-4903
www.ReadCTs.com
Posted in Radiology |
March 7th, 2017
Dental implants are gaining more and more popularity among patients and dental providers. Many implants are being placed everyday in USA and in the world. The represent a tool in the hands of the dentist that can solve many problems when the natural dentition in failing or classic treatment does not provide long term expectations. Even though dental implants do not suffer from the same pathologies as teeth, they are prone to suffer from the so-called peri-implantitis.
This inflammatory and infectious process determines problems of bone resorption and gum inflammation around the implant, that can eventually lead to implant loss. The most important step to avoid peri-implantitis is to prevent it by correct professional and patient oral hygiene. This article reports the most important questions and answers on implant maintenance extracted and adapted from a book chapter “Patient’s plaque control around implants (Clinical Cases in Implant Dentistry Wyley Blackwell. Edited by Karimbux N. DMD, MMSc, Weber HP. DrMedDent. 2017)“ by the same author.
Should implants be cleaned similarly as natural teeth?
Studies demonstrated that an effective and accurate oral hygiene technique prevents an increase in the severity of gingival inflammation if performed at least once every 24 hours. Nonetheless it appears that often patients have not been taught accurate plaque removal techniques and some have difficulties with manual dexterity. It is usually recommended that a patient with implants perform oral hygiene based on their individual needs between 1-2 times a-day. Devices that are effective in removing plaque from a crown on a natural tooth will be also effective in removing plaque on an implant crown.
However, there are differences found in the shape of implant crowns when compared with a natural tooth. Thus, although plaque control techniques for dental implant supported restorations are generally similar to traditional oral hygiene procedures on natural teeth, modifications are dependent on the crown design.
Is there a contraindication to using toothpaste when cleaning implants?
The agents contained in these pastes are multiple and they offer different functions (i.e. detergents, abrasives, polishing agents, binders, humectants, water, flavoring, coloring agents, active ingredients such as fluoride, anti-plaque, anti-calculus, desensitizing). It has been noted that the abrasives in the dentifrice mainly cause hard tissue damage when proper brushing technique is not practiced. However, there has been no evidence suggesting contraindication of toothpaste for patients with dental implant prosthesis.
What brushing technique(s) should be used?
Various studies demonstrated that different brushing techniques are almost similar in plaque removal efficacy. Cleaning the gums around the implant may be more challenging for the patient because the weaker nature of the implant gums compared to teeth. It is recommended a thorough instruction from the professional dental provider in order to customized the technique for every case and patient. The wrong technique may create damage and problems on the implant. Some studies have suggested that electric toothbrushes might be more better than the manual brushes, however the most important factor is the technique used not whether the brush is powered with a battery or by hand.
What is the optimum stiffness of the bristles of a toothbrush and why?
There are many different toothbrushes available in the market. Some have harder bristles some very soft. However, it is generally recommended to prescribe soft bristle toothbrushes to avoid damage of the gingival tissue around teeth and implants and to better access the areas around the implant gums. The shape of the toothbrush is not so important. The important step is how to use it in the right way.
What interproximal oral hygiene aids are available to remove the biofilm from implants?
The oral hygiene aids for proper plaque removal around implant-supported restorations are the same as those commonly used for natural teeth. Dental floss, interdental brushes and rubber tips can be used safely around dental implants, and just as with natural dentation, it should be customized on an individual basis. The patient’s manual dexterity, the design of the prosthesis, and the type of the prosthetic component must be taken into consideration when customizing interproximal hygiene techniques.
- Dental floss: It is generally recommended to use floss around implant restorations for each individual unit, once or twice daily, doing plaque control techniques the same as for natural teeth. The number of times per day to use floss depends upon the patient’s susceptibility to peri-implant inflammation.
- Super Floss®: It is known that the use of regular dental floss can be extremely difficult when attempting to remove plaque deposits in implant supported Fixed Partial Dentures. The great advantage of Super Floss® stands in its stiff end that can be introduced between the crowns.
- Interproximal brush: Also known as interdental or proxy brush is used as an effective device in plaque removal in the interproximal tooth surfaces. It is important to select the brush head of an appropriate size to fit into the interproximal area without creating damage to the soft tissue and to the root surface. In order to minimize the risk of hard tissue abrasion it is also advised to avoid the use of dentifrice with an interproximal brush. The brush should be replaced whenever the filaments appear to be deformed.
Despite the strong structure of dental implants, they should be respected and treated like a normal tooth. Even though patients are the responsible for everyday oral hygiene, implants should be evaluated regularly by a periodontist and dental hygienist to complement their cleaning.
-By Lorenzo Mordini DDS, MS
Posted in Dental Implants, Periodontics |
March 2nd, 2017
Chance finding on a 42-year-old man of a well-defined unilocular lucency 8 x 9 mm in the incisive canal. The normal maximum diameter of the canal is 6 mm.
The patient should be referred to an oral surgeon for surgical evaluation as these cysts can grow to a large size.
In addition, there is mucosal thickening of the left maxillary sinus floor probably due to sinusitis.
By Dr. Douglas K Benn DDS PhD
Oral & Maxillofacial Radiologist
www.ReadCTs.com
Posted in Periodontics, Radiology |
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