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Diagnosis
Efficient diagnosis is not only essential for correctly treating the symptomatic patient. It is also important for maintaining consistent practice production and ensuring against costly interruption of a scheduled day. There is nothing more stressful to a clinician or a practice than a patient who constantly returns with the same undiagnosable complaint. An efficiently treated patient can be one of your best "missionaries" and can help your practice grow. An unsatisfied patient, sitting in your waiting room complaining of a problem can be very detrimental to your practice.

Lets examine some of the essential tools for treating the potentially endodontically involved tooth.



Endo Ice by Hygienic

Endo Ice is the standard tool for cold testing pulp vitality. I prefer to use it on cotton pellets of different sizes. Larger pellets can be used with large tooth surfaces. When applied to smaller pellets it can be used to test along crown margins and in areas of cervical resorption. Do not spray it directly on the tooth as it can cause craze lines in the enamel.

Cold tests are best used to check for lack of vitality. It is difficult to correlate pulp pathology with the "degree" of response to application of cold. Patients may have different responses due to natural sensitivity or the presence of deep restorations or castings.

You may also use or the old method of making "ice pencils " by freezing plain water in a used sterilized anesthetic carpule. In any case, if you don't cold test the tooth you are not performing an adequate endodontic examination.

A cold test of this type is an essential part of any dentists diagnostic toolkit. Hygienic Corp products are available through your local dental products supplier.

 

Tooth Slooth

Increased numbers of teeth with CTS (Cracked Tooth Syndrome) mean that we always have to be testing for weak cusps and possible fractures. One of the best devices for testing teeth is the Tooth Slooth. There are two versions: The white version on the left is used by apply pressure to each individual cusp. The cusp tip is seated in the depression and the patient is asked to bite. Cracked cups are indicated with a reproducible sharp response to pressure. The blue sleuth has one side with a smaller version and a pointed crown seater on the opposite end. The Tooth Slooth is another essential tool for detecting weak cusps and fractured teeth. See Tooth Slooth link for details.
 

Cotton Roll

Another basic but useful tool for cracked tooth/cusp detection is the cotton roll. The patient is asked to clench on the cotton roll as it is moved from one occlusal surface to the next. Cracked teeth respond to this test with a reproducible sharp discomfort upon release. Some clinicians have recommended the use of a small rubber wheel or bb-shot covered in tape. I prefer this method. Why? Because, using a cotton roll is cheap, reliable and fast...a rare commodity in any dentally related product. Cotton Rolls will sometimes give you better results than a Tooth Slooth because it moulds more closely to the occlusal surface.

 
 
Heat Test

I use Hygienic's white stopping compound and a flame. The material is heated and then applied to a tooth surface. Although it is a bit messy to use, this material still is a very inexpensive way to heat test a tooth. The tooth surfaces should be lubricated to prevent the material from sticking, although it is relatively easy to remove if it does stick. Heat it to the point where it begins to slump and always have a 2x2 gauze ready to wipe the end of the stick and tooth surface.

Occasionally ( with crowns, for example) it may be necessary to isolate individual teeth with rubber dam and test them with hot water applied to exposed margins by irrigation syringe.

The heat test represents the most reliable clinical test to detect late irreversible pulpitis. Application of heat to a symptomatic tooth will generally bring about an intense response, the severity of which correlates with the delay.( I.e./ The longer the delay, the sharper the "spike") Anesthesia or application of cold ( such as Endo Ice) should be ready immediately after this test is performed since both will provide immediate relief. Hygienic Corp products are available through your local dental products supplier.

 
 

Schick CDR Dicom Digital Radiography


The Schick system continues to perform very well, though I have had to replace 2 sensors over he years.. One was a wire failure. The sensors appear to be extremely rugged. Although we have noticed some cracking in the area of the wire/sensor attachment area – this has not affected performance over many thousands of images. Schick now has "kits" to allow you to replace their wires.




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The software is bulletproof. I have heard of some small bugs when converting from the original version to the Dicom version. The Digital Imaging and Communications in Medicine (DICOM) standard was created by the National Electrical Manufacturers Association (NEMA) to aid the distribution and viewing of medical images, such as Radiographs, CT scans, MRIs, and ultrasound. Most people refer to image files which are compliant with Part 10 of the DICOM standard as DICOM format files.  The software easily integrates with TDO Endodontic Software and it is seamless.

The TDO/Schick system has performed flawlessly. When I need holders, covers, or any other Schick related product, I phone my local Patterson rep and I have it the next day. The same could not be said for other digital radiography products that were previously installed in my office.

Is it the best? Maybe not. But it has several big advantages over the competition:
1. Initial investors at Schick were Endodontists - Product was developed with Endo in mind.
2. Simple interface is learned quickly by staff.
3. Virtually all software integrates with this Dicom standard product. No stupid proprietary file formats.
4. After several years of bad PR, Schick finally understood that their great product needed a stronger distribution network, hence the Patterson partnership. Good move.

Their most recent product is a wireless version of the sensor. I thought it was a but thick for my liking and I had visions of one of my assistants accidentally throwing one of these sensors ( at around $10,000 CDN each !) in the trash. I've stayed with the Dicom version because I picked up a used #1 and #2 sensor almost brand new for a a greatly discounted price. See Schick CDR for further details about the product..

 
 

Surgical Operating Microscope

Dentistry has undergone a revolution that is only now moving into the ranks of General Dentistry... the ability to use very high levels of magnification to improve diagnosis and treatment. Postgraduate Endodontic programs now require Surgical Operating Microscope (SOM) training as a standard part of the curriculum. I must admit to have been very skeptical about the capabilities. However, after taking two SOM demo courses courtesy of ROOTS, ( www.rxroots.com) I began to see what I was missing. Unfortunately, you can not truly appreciate the benefits of Microscopic Dentistry unless you are using one. But once you do, you will understand what a huge difference it makes in the quality of treatment that can be performed.

There are several good SOM manufacturers. They include Zeiss, Global, Leica and Seiler. For my first SOM purchase I chose Global Surgical Corp.'s Entree Extra ( 4 step) and Starlite Halide lighting system. (See Global's site for more info). Global has taken a particular interest in Dental Microscopy, has been very supportive of ROOTS and it's Summits as well as being a very high quality product. Global scopes are not inexpensive but the "hands on" support that you get from your representative , the quality optics and the large numbers of Endodontists that use them are testimony of their general acceptance as a very fine choice. Mine includes inclinable binoculars and a beam splitter. I consider both an essential part of the SOM. With those additions my SOM was purchased for about $33K CDN. That is a LOT of money for any piece of equipment, but the improvements in visibility are well worth it.

The SOM is a serious investment. It requires a complete paradigm shift in the way Dentists regard their sight. It also means a totally different way of interacting with assistants, discipline in patient positioning and a decision to "stick with it" until the SOM becomes an integral part of the Diagnostic and Treatment regimen. Yes, there is a learning curve, but the benefits far outweigh the initial inconvenience and initial slowdown in production. In the long run, quality work means less retreatment, less problems and overall increase in satisfaction. Buy one. It will make you a better dentist and energize your practice.


Global Surgical Operating Microscope

I purchased a 3rd SOM ( A Global G6) and could not be more pleased with it.  The simple fact was that I had grown so accustomed to the good visibility offered by the SOMs in 2 operatories that I started to become uncomfortable when moving into the third (exam/emergency) operatory and working without one. It soon became apparent to me that while having one in the working ops was important, it was just as important to have one in the operatories where examination and diagnosis was being performed. I moved the 4 step Global into this operatory. With the attached Xmount and camera/mini monitor combination, I could examine the patient and have them see EXACTLY what I was seeing.  This made a very powerful impression on them when we examined fractures, open margins and caries.  I can honestly say that I would never consider going back to being a “NED” (Naked Eye Dentist). While loupes or an intraoral camera are a start, they really cannot compare to the visibility and clarity offered to you (and your patient!) with the use of an SOM.

Here is a cheap and easy LCD mount for your SOM Nikon 950 camera output.  Should you be unable to mount a TV in your ceiling to allow viewing of your scope images (or should you use a portable scope on wheels) , here is a very inexpensive way for you to show your patients what you are seeing by using the output of your Nikon 950 (or other) camera. This is a small LCD display (this one is an old Xenarc) that originally was interned for dashboard mount use in cars.  I merely crimped the metal mounting flanges and secured them to the scope with a regular stainless steel hose clamp. It is very secure. The advantage is that the screen can be moved in all axes, to allow visibility by both patient and assistant. Although the screen is small – it is positioned so close to the patient that the image is equivalent to that of a 27” screen mounted in the ceiling.  The biggest advantage is that this method watching an image does NOT require a dedicated $5K video camera attached to the scope. Although the images are not equivalent to that of a dedicated video camera, they are certainly good enough for patients and assistants to view.

The 6 step Global G6 (Below) has become the workhorse of the practice and performed flawlessly. The light source also is much "whiter" than the Global Starlite I have with my previously purchased 4 Step Protoge Plus, which is now in my examination chair. Unfortunately, the same cannot be said for the 6 step Seiler Revelation Scope I have in my 2nd chair. The optics are Ok but the I am constantly wrestling with the mounting arm to position the scope properly. The Global scope swings into position effortlessly with the light touch of a finger.  The same cannot be said of the Seiler. In retrospect, I wish I had purchased another Global. 


A remote RF Switch for your scope light.  One of the most convenient ways to turn your scope on and off is NOT through the use of a wall toggle switch.  For about $10 US!! Radio Shack (now called the Source) used to sell a small RF activated switch that you can mount on the scope arm with double sided sticky tape. The scope AC is plugged into a remote box that is attached to the wall outlet. The buttons on this device (On and Off) merely allow the AC to flow through the box. Therefore – the scope is always left in the “On” position and this device remotely allows the AC to be turned on and off. See http://www.radioshack.com/sm-wireless-rf-remote-control-on-off-switch--pi-2103886.html  Thanks to Dr. Gary Carr for showing me this nifty little device. It is now an indispensable part of my SOM.


 
 
Seiler Revelation Surgical Operating Microscope


After approximately 8 months, it became apparent that I was favoring the operatory with the Surgical Microscope. When I was working in the 2nd operatory without the SOM, I was finding it difficult to see as well as in the operatory equipped with an SOM. I decided that a second purchase was necessary. Unfortunately, I just could not justify spending another $ 33K (Canadian) when I was contemplating other purchases such as Digital radiography. See Seiler for details.

I decided to investigate other microscope manufacturers and concluded that Seiler's Revelation 5 step (with video included) offered the best combination of features for the $19K (Canadian) price tag. So far my experience with the scope has been mixed. e. I plan to amend this entry once I have had further experience using it and I will provide comparison's with the Global.

The initial installation of the Seiler scope was unsatisfactory. One of the problems that Seiler were having in Canada was that the scopes were being sold through Patterson Dental in Canada. Frankly, Patterson technicians had little if any experience in my area with scope installation and I finally had to ask Seiler to fly up to Winnipeg to install the scope properly after the second installation went awry. . Although the scope has been repositioned, there is no question that it does NOT have as smooth a movement as the Global. Although it is a good product and is very competitively priced, I probably would have gone with a second Global if I had the choice now.

Problems with the mounting of the scope were resolved in late ’04. Seiler representatives actually flew up to Winnipeg to supervise the reinstall. A total of 3 ceiling mount boxes had to be constructed before the right position was found. The scope has performed well optically, though maneuverability cannot be compared to the Global’s Entrée Extra or my new Global G6 (which is a dream!) I'm still wrestling with the Seiler on a daily basis.

Update 2009

Further exposures to other scopes ( such as the marvelous Zeiss ProErgo) have highlighted the deficiencies in the Seiler. In retrospect, I am disappointed that I did not spend more and buy a G6. The Seiler Revelation scope simply is not in the same class. I constantly fight with positioning ( the arm is TERRIBLE) and while teh optics are acceptable for the less discriminating eye, in comparison to the Global or Zeiss ( especially teh light source) it is obviously inferior.  I suppose the classic statement applies " You get what you pay for".  If you are in teh market for a scope, I would not recommend a Seiler and suggest you go with a Global G6 or Zeiss Pico. Going cheap simply is not worth it.

 
 

DFV Loupes

Although I have them available, my loupes have been replaced by the SOM for virtually all clinical applications. There simply is no comparison between the two. The SOM far exceeds anything I can see with Loupes.

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For those wishing magnification (but not wanting to purchase a microscope) DFV loupes offer one way to see better. I only wish they'd update their "Woody Allen" frames! Since DFV Loupes were initially popularized by Medical Surgeons (most of whom were working on patients who are asleep!) I suppose fashion was not the highest priority. They are rugged. I use 4.5 X narrow field. More importantly, they service what they sell. I must admit that I am pretty rough on mine and DFV has been marvelous when the loupes need adjustment or repair. Once you start using them, you will wonder how you ever managed without magnification. Make sure to ask them for their DFV string-type holders. They attach to the glasses and have a knob that slides up the string to prevent them from falling off your nose. This is important because the larger lenses can get heavy. See DFV for details.
 
 

Brynolf Magnifier

 

The Brynolf magnifier is used to examine radiographs. It has the advantages of magnification and blocking out ambient room lighting. The black hood is placed over the eyes while a film is viewed at the narrow end. The effect definitely increases readability of films and enhances the ability to obtain more accurate working lengths, especially when small file sizes are used. When you are forced to use or read periapical film , this is an inexpensive (analog!) way to see films better.

Brynolf Magnifiers are available for purchase in the US under the name "Viewscope 2x" and are sold by JS Dental Manuf. Ltd. Its the best $100 US you will ever spend if you have to read dental films rather than digital images.

WIth increasing use of digital imaging ( and scanners) viewing images with this device is rapidly becoming obsolete. Digitization of images allows for contrast and brightness adjustment, something that analog films cannot do.

Update 2009

This device ( and the associated viewboxes) have been rendered obsolete by digitization, scanning and moving to TDO software. The ability to magnify, adjust contrast and brightness of digitized images has largely surpassed the capabilities of regular film viewing.


 
 

Intraoral Camera (IOC)

Updated April 07
The IOC has been replaced by the SOM . SOM camera adapters such as the X mount and Carr adapter allow mounting of a 35 mm digital camera to the SOM.  These digital images are MUCH better than anything that can be obtained with an IOC.

I have not used the IOC in several years and will probably sell the Acucam system, should I be able to find a buyer.
The Vipersoft software will be included, since again this is obsolete and all images can be stored in Schick. The Schick program itself does not allow serious manipulation or image editing but this can be solved by copying and pasting to any number of inexpensive editing programs such as Photoshop Elements. Anyone interested in purchasing the system (3 docking stations, IntaOral Camera with 0 and 90 degree lenses, 4 software keylocks ( including server lock) and Vipersoft software should contact me by Email.


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The intraoral camera is the "poor man's microscope". It offers the advantages of magnification and illumination as well as transportability. I use one of the original Acucam PC Plus models that was one of the first "dockable" cameras (1995 vintage). This allows me to move it as required to each of 3 operatories. The cameras are attached to ATI All in Wonder video capture cards in each operatory PC. Both moving and static images can be captured and displayed.

For those without an SOM, the intraoral camera is useful in diagnosis because it:

(1) enhances the examination of teeth for fractures and deficient restoration margins.
(2) also doubles as a fibreoptic illuminator. This allows for transillumination of teeth that is extremely important for diagnosis of Cracked Tooth Syndrome.
(3) is occasionally useful for examining the access of endodontically treated teeth for additional canals.

The Dual lens (separate 0 and 90-degree lenses) system has been very reliable. I have had no problems with it since I purchased it. Interestingly, I recently performed a side by side test with my 4 year old Acucam vs. a Welch-Allyn Reveal Camera (provided to me for evaluation by my Patterson rep.). We used the same capture boards (ATI All in Wonder) and Vipersoft software. There was no comparison; Images on the Acucam were clearer and sharper. Even the Patterson rep agreed!

Imaging, in general, has been instrumental in converting my practice to one that "partners" treatment decisions with the patient. When combined with a simple MS "Paint" program, (used with a light pen, tablet or mouse) quickly drawn sketches and intraoral images can convey complex treatment in only a few moments. Unlike with prepackaged "CD-ROM" type media, patients appreciate the way I take a few moments to customize the images I draw when discussing their particular case. Monitor placement must be sufficiently close to allow good patient visibility. My 15" Viewsonic monitors are mounted on fully articulatable swing arms. This allows them to be positioned right in front of the seated patient or swung away as needed. With the newer, lighter flat screen LCD monitors, strategic placement of imaging technology is even easier. If you are redesigning your office or looking to renovate, do not overlook this method on monitor placement. It is MUCH better than a 27 or 32 " TV mounted 10 feet away from the patient.

 
 

The Electric Pulp Test

The EPT has fallen into disfavor in the last few years because of its unreliability. The EPT really should have only two indicators, VITAL or NONVITAL. The numbers on the device are totally meaningless. They cannot tell you the "relative" health of the pulp and are often misinterpreted by clinicians. Deep restorations, calcification, crowns and open apices routinely affect accuracy. At best, the EPT can indicate that the tooth MAY be vital. It should not solely be relied upon for determination of pulp vitality. In the case of the suspected necrotic tooth, a cavity test MUST be always performed to confirm diagnosis.

If you are considering purchase of an EAL  ( Electronic Apex Locator), the EPT is sometimes included at minimal extra charge. In that case it may be cost effective. Purchase of a separate unit is becoming a rarity and is not recommended.

I very rarely use this device. But it is good to have it in situations where thermal tests may be ambibuous.

 
 

Methylene Blue Dye

Methylene Blue Dye is an important tool for diagnosing coronal cracks and fractures. It is applied with a bendable brush. The suspect area is then rinsed and the area is examined with high magnification.

When a root fracture is suspected, it is important to clearly illustrate the fracture during surgical exposure. Methylene Blue Dye is also useful for identifying VRF cracks and for outlining the limits of the PDL during resection procedures. It may also occasionally be helpful in identifying accessory canals on the surface of roots. Methylene blue dye is available from most pharmacies. It is also available as shown in a Unidose version through Vista Dental.

Some Dentists have had also success with use of Caries Detector solutions and Ophthalmic dyes.

 
 

Rapid Developing Solution                                                

230 gm NaOH
230 gm Sodium Sulfite
57 gm Potassium Bromide
3000 cc Distilled Water

Activate 4 oz. of liquid with
3.9 gm Hydroquinone

Offices without the advantage of digital radiography often require speedy films for diagnostic or other purposes. Portable darkroom development is sometimes preferred over machine development. This formula allows for hand development of periapical and bite wing films within a few seconds of immersion into the solution. For even faster results develop this way:

(1) Develop the film until an image is visible through the developing box cover.
(2) Dip film into water and immerse once in the fixer.
(3) The films can now be read "green." i.e./ unfixed with reflected rather than direct light.
(4) Return film to the fixer, fix and wash as usual.

The formula is a recipe given to Endodontic graduate students of Boston University. Photographic or chemical supply stores should have the materials. Ask them to package each of the chemicals in good quality heat sealed plastic pouches. In that way, all your staff have to do is mix the chemicals with the distilled water to create the stock solution. Each 4 oz. batch is then activated with the Hydroquinone as required. 

I haven't used regular films in years but it is a good backup in case of software or digital x ray sensor problems.