Everything is going well. Our patient has gotten over her major initial anxiety. Her Dad voluntarily left the room at the beginning of the appointment so he’s not transferring anxiety to her. Her breathing is regular…and there’s a good flow through the nitrous/oxygen line.

The canals have all been instrumented, I’m getting ready for obturation, and then a thought surfaces briefly and then sinks away at the back of my mind, “She seems pretty relaxed now…maybe even dozy. I wonder if I should turn the nitrous down a bit. But she really likes this level…but we’re almost done…yeah but she’s been doing so well at this level…Naw, we’re almost done. I’ll turn it off soon.”

So I go back to doing my thing.

Her left hand comes up.

“You want me to turn it down?” I ask.

“Mmmhmm,” she murmurs.

“Ok, I’m turning it down a bit. We need to give it a couple of…”

“Mmmhmm! MMMHMM…”

Read the rest of this entry »

I couldn’t make it into work today because of the icy roads. I did try, but ended up going so slow that it was painful and still dangerous. Then once I got to a 5 car pile up at the bottom of a hill I turned around and came back.

I’m going out to the garage now to fix up the snow blower.

Now that the leaves are off the trees, from the street we can see the rock walls that the landscapers placed in the front.

Thanks to Chris again:

“…express an interest in learning about that particular breed; cater to the ego and ask how long they’ve been breeding/exhibiting – in dogs longevity is a source of pride. Ask a breeder how they choose prospective mates or how they choose which pup to keep.

I’d stay away from the usual….how do you walk that many dogs; or how do you deal with mealtimes; or do you win any money at dog shows (the answer is no haha); or how much do you sell your puppies for.“

An hour later and this is what I ended up with. I usually don’t charge for lawyer letters, but this one took me away from Heroes so I think I’ll send the lawyer a bill.

As I wrote this I was thinking that the exam candidates could probably quote literature like crazy back at me with respect to dental trauma while here I am slowly forgetting even the classic Andreasen stuff. Oh well, such is life in the fast lane.

Dear Mr. Lawyer,

Thank you for your inquiries regarding XXX (your file No. XXX).

Dental trauma generally leaves involved teeth with a guarded long-term prognosis. This is especially true in luxation injuries (injuries where the tooth is physically displaced in one direction or another and requires repositioning). Delayed sequela of trauma such as internal or external resorption (reduction of root structure), root canal infection, or ankylosis (loss of the tooth’s physiologic attachment apparatus to the jawbone) can become obvious and problematic many years later.

XXX’s tooth 12 currently appears to be in a stable situation and does not demonstrate obvious signs or symptoms associated with infection. This is subsequent to trauma that occurred over three years ago. My testing, however, does provide some evidence consistent with a necrotic (dead) pulp (nerve) within the tooth.

Endodontic (root canal) treatment of a tooth with a necrotic pulp is not essential as a therapeutic measure. Should the pulp become infected, however, endodontic treatment then becomes necessary. The period of time between pulpal necrosis and infection varies from case to case. Generally, the easier it is for bacteria to penetrate into the canal space of the tooth, the faster necrosis will convert to infection.

Because tooth 12 is intact, has no decay, and no pre-existing fillings, the chance of infection developing within the near future is slim. The elective option of pursuing root canal treatment of this tooth for prevention of future potential infection does have some risk associated with it and could actually potentiate other issues with the tooth. I am of the opinion that the tooth should be monitored for problems (through the usual dental recall visits) and any future problems be addressed as needed.

The root canal space within this tooth has become significantly restricted. This is a reactive response of the pulp to the injury before it died off. The more restricted the canal space is, the more complicated root canal therapy becomes and the greater risk of irreparable damage to the tooth whilst searching for an opening into the canal.

At this point the best indicator of retentive potential of the tooth is the external resorption that I observe radiographically. The tip of the root is shorter and more blunted than it should be. This occurred as part of the biologic repair process in the area subsequent to the accident. I have no historic radiographs to compare current ones to, so I am working under the assumption that the resorptive process is currently arrested. If this is not the case and the resorption is in fact progressive, the tooth will be lost once the root is completely resorbed. This is the other reason the tooth needs to be monitored for some time longer at regular recall intervals.

Should this tooth be lost, an osseointegrated dental implant would be the ideal way to replace it. Permanent tooth replacement is best done once jaw growth is complete (generally between 18 and 21 years). Because my expertise lies within the bounds of retaining this tooth, replacement options, costs, and timeline are best discussed with the dentist who would actually perform the replacement procedures.

I hope this information is of value to you. Should you wish to further discuss this case, please feel free to email me at XXX.

Sincerely,

Ameloblast

Oh I almost forgot. Canadian oral specialty exams are this weekend. Good luck to the 4 endo candidates. I’ll be chatting with 3 of you…and you’ll probably teach me a few things about endo.