Consultant Endodontist
This case took me 3 hours and the use of the whole armamentarium to be completed.
Never give up, just be patient and everything is possible.
PhD. MSc. Dr. Pablo Salmeron.
Today’s case is a 11 year old patient with a big caries on the second maxillary molar referred to me to save the tooth. My duty as endodontist is not only providing root canal treatments but also preserving teeth from them too.
In this particularly case I performed a pulp horn amputation.
These are the steps taken:
– Rubber dam isolation.
– Microscope magnification.
– Manual removal of the soft dentin with excavator.
– Pulp horn amputation.
– Disinfected and rinsed with NaOCl from “outside” to achieve haemostasis.
– Dried with sterile cotton pellets.
– Bioceramic capping.
– Direct glass ionomer as temporally filling on top.
Dentistry today is about the small details.
PhD. MSc. Dr. Pablo Salmeron.
Last month I gave a lecture at The Palestinian International Dental Conference. I have to start this post thanking particularly to the BAIRD Academy and the Palestine Dentistry Society for inviting me to the congress and make me feel like I was at home. I want to thank especially Dr. Hassan Maghaireh, Dr. Raed Junaidy, Dr. Anan Amro, and Dr. Ahmad Abd El-Ghani for all their help and for showing me the most beautiful areas of Jordan, Palestine and Jerusalem.
The topic I covered was about Magnification, Cumulative Trauma Disorders (CTDs), Ergonomics and 4 Handed Workflow. For me, all those 4 concepts, are intimately related.
Our manual capacity is limited by our own eyes. It’s because of that why we cannot be more precise, simple as that. To be able to see fine details, we have to bring the object closer to the eye. This is why dentists have to bend down over the patient’s mouth, and this is why dentist have back problems.
The use of magnification is the way to overcome our eye’s limitations. This will also make us work in a neutral and healthy position resulting in long lasting professional career.
4 handed workflow is the masterpiece which completes the ergonomic puzzle. Here you have a couple of videos where I show basic movements which you can start using till you develope your own technique. The first video has been recorded in 30 minutes with an assistant with no previous experience at all; and the second one with a new assistant after one month training. Watch in HD.
“Make it a point to do something every day that you don’t want to do. This is the golden rule for acquiring the habit of doing your duty without pain.” Mark Twain.
PhD. MSc. Dr. Pablo Salmeron.
In this post I’m going to talk about vertical fractures regarding a case I had a few months ago, the one on the right picture. This maxillary first premolar was ready to get a root canal therapy but presented a mesiodistally vertical coronal fracture that continued to the furca which divided the tooth in two roots, bucal and palatal. The tooth had an old restoration on the distal side that was not in occlusion and that probably let the fracture appear on the mesial area where you can see the line fracture. The tooth was also sensitive to vertical percussion and had some mobility, however, there wasn’t significant evidence or bone loss on the radiographic tests.
Most of the vertical fractures are due to excessive concentration of loading over some areas of the root canal. Studies have shown that the curvature of the root canal seems more important than the external morphology of the root, in terms of stress concentration, the remaining thin dentin increases the magnitude but not the direction of the stress generated by forces. In fact as thinner the mesiodistal dentin walls are, the concentration of forces on the lingual and bucal walls increase the risk of fracture in this direction contrary to what one might think at first, more dentin thickness the harder it is to break in that direction, well… it is not like that.
There are three factors that determine the distribution and direction of forces, a) the anatomy of the root canal, b) the anatomy of the root, c) the thickness of the dentin. The canal anatomy seems to be the most important factor determining the distribution of forces.
The vertical fractures most often occur in premolars, both maxillary and mandibular, followed by fractures on the mesial root of mandibular molars and central incisors.
One of the biggest problems we find in cases of vertical fractures is that they aren’t easy to diagnose. Most symptoms usually appear years after the fracture. We may well find, sensitivity to percussion and vertical palpation, presence of fistula, or a large and isolated periodontal pocket that doesn’t correspond to a general periodontitis. Radiologically we can observe a radiolucent area with horizontal bone loss along the affected root.
Diagnosis vertical fractures are a challenge for the dentist because the symptoms are similar to a failed root canal treatment and usually radiographic test doesn’t show evidence of a fracture clearly. Another problem in endodontically treated teeth is often the filling materials doesn’t allow us to see the fracture line on the radiograph as they’re in the same plane. Patients may experience anxiety to thinking that the endodontic treatment is not working when, in fact, the problem is a fracture prior or post to the root canal treatment.
PhD. MSc. Dr. Pablo Salmeron.
Discipline is any training intended to produce a specific character or pattern of behaviour. Discipline is nothing but point a goal and achieve it through a protocol, discipline is consistency, discipline is hit the stone always in the same place, always with a good guidance of course.
We live in an age where there aren’t dragons to slay or lands to conquer, and where access to resources and opportunities are so abundant that to know what we want and go after it’s the only gap from heroism. Today the (main) problem isn’t that you can’t get what you want, but you don’t want it enough. Most things we want to achieve aren’t difficult, it’s only lack of desire or fear what separate us from it and it’s at that point where discipline plays a key role.
I have always considered myself a very disciplined person, but discipline doesn’t mean success if isn’t focused on the right direction. A high-level athlete needs self-discipline but also a coach to motivate and guide him through the whole process, no one born knowing everything.
Let’s transfer this to dentistry and the topic I want to address, “the importance of discipline taking records“. A long-term success treatment is based on good planning, today we know that this is not applied in everyday dentistry. We diagnose fast and wrong without a good analysis of the situation; in the same way we live fast our live. This is often because of fear of understanding the complexity of the case or because we’re afraid that the patient won’t accept treatment. If we’re at that point, we are doomed to failure.
We have to understand that being in a situation of discomfort is good, it makes us be more aware, it makes us want to investigate and understand what’s out of our control. To be in a discomfort situation makes us progress!
To understand what’s happening in the mouth is essential to design a good treatment plan, it’s critical for long term success, it’s essential to avoid unexpected surprises and is essential to the patient. The first step in all this starts with taking good records, we must be careful, we must be precise, there are too many steps in the process in which we can miss some information, so the closer we are to perfection, the better will be our job.
Understand all this has taken me a while, and it was not until I started working with Dr. Ian Buckle when I started to fit the pieces of the puzzle, “discipline is perfection Pablo, we must be precise!“.
We work in a multidisciplinary team in which excellent records is critical. What for me may not be relevant as endodontist can be critical for the orthodontist or the surgeon, details are perfection.
We can have many years of experience, we can have a lot of knowledge in our field, but if we don’t understand that a good treatment plan begins with good records, we are doomed to be an average dentist.
“Discipline is the bridge between goals and accomplishment“. Jim Rohn.
PhD. MSc. Dr. Pablo Salmeron.