Modern dentistry with precision and comfort

Excellence under magnification

An upper first molar usually has three root and 3 to 4 canals, however, this case present here, tooth 26 only has two roots. The pre-operative periapical radiograph suggested that a mesiobuccal canal may be present in the buccal root because the canal was not in the centre of the root. Hence, the patient was sent to me for retreatment, although the tooth was asymtomatic. Under excellent magnification and illumination from the operating microscope, the MB canal was located. Buccal canal bifurcated into MB and DB canals at the apical one third. Canals were filled with the warm vertical technique.

Healing Power

Human being has excellent healing power. For a dento-aveolar infection, once bacteria is eliminated, soft tissue will heal and bone will regenerate. In this case, the post-op periapical radiograph was taken less than five months after initiation of the root canal treatment on the first molar. There is evidence of almost complete resolution of the periapical lesion.

Here, it takes five months, for Wolverine in X-Men, it's five seconds!

The MB2 challenge

For upper sixes, I usually spend half an hour preparing the three canals and the remaining time attending to the MB2. It is difficult locating its orifice most of the time and negotiating this fine canal is also a challenge. Working with an operating microscope is beneficial for this purpose. I have retreated many failed RCT of upper sixes due to neglected MB2.

The case above belongs to an uncle of the referring dentist, hence additional stress for me to produce good work, but I'm glad that it didn't take too much trouble treating the MB2.

Another C-shaped canal

Mostly seen on mandibular second molars among Chinese, incidence reported to be 27.5%, but I think it is higher than that. Fused roots, long pulp chamber with a C-shaped orifice are common characteristics. A single ML canal and a long oval extending from MB to D is a the most common configuration. ML canal is usually curved. High tendency to strip perforation due to thin lingual wall. Obturation technique used here is warm vertical. Post should be avoided as well.

Save the Root

To save or not to save?

This tooth is badly broken down, you can choose to extract and have an implant, option two is to keep it. Its kind of a borderline case because there is only minimal coronal tooth structure left. I supposed there is no right or wrong on whichever treatment option . It depends on how keen the patient is saving his tooth and what the dentist is comfortable doing, really. So, it also depends on who you seek the professional advice from.

I will choose to save if this is my own tooth. In order to restore this tooth, root canal treatment and crown is a must. To hold the crown, a post is placed into the palatal canal and an amalgam build-up is done.

The question is how long will this tooth last? I have been asked this question everyday! I honestly can't predict, I can offer data/statistics on success/failure of root canal treatment or longevity of root-treated teeth but then again, each tooth is different . What I can be sure is that this tooth is weakened but I can try my best to restore it. The rest is up to the patient and God.

Life is about making choices and I'm glad I'm a root saver!

New York New York!

This is during my endodontic attachment in USA. Dr Kim, my mentor runs a specialist in the Rockefeller Center in NYC, and I was about to witness the"guru" in surgical endodontics, performing an apical surgery. This is where the "rich and famous" fixed their teeth :) Apparently, the rental for this office unit at the Rockefeller Centre is USD10,000 per month, but it has got a fantastic view of the ice staking rink and the gigantic Christmas tree in December!

New York has became one of my favorite cities and if you ever visit there, don't miss the sushi at Hatsuhana Sushi Restaurant, http://www.hatsuhana.com/hatsuhana

The best that I ever had.

Back to the Grind and Drill!

My first patient in Petaling Jaya after being away in Philadelphia for more than a month. It did feel a bit awkward, trying to adapt to the environment at my own clinic again and at the same time, to apply and incorporate what I learned at UPenn into my daily practice. Retreated root canals on 37 and placed Ca(OH)2, three months ago. Its a C-shaped canal. The patient came back today symptom-free. Completed the canal obturation and felt satisfied with the resolution of the periapical lesion. I would say it was a good start to the week !

Ramadan Buffet @ Le Meridien 10th August, 2011

Perforation Repair

When I was at Penn someone said that you have not been doing enough root canals if you haven't perforated a tooth. I am not sure if that is an accurate statement. At least not when you are working with a microscope.

This is a case of a lower right first molar that was left open for drainage by a previous dentist and a perforation occurred at the furcation during cavity access. The patient failed to return for further treatment and the tooth was left opened for more than two years. Hence, the large radiolucency on both roots and furcal area. A discharging sinus was present at lingual sulcus. I dont agree with the practice of leaving the tooth open for drainage and sending the patient home because it will cause more damage than good with all the contamination.

RCT was initiated and the furcal perforation was repaired with MTA. CaOH was left in the canals for three months. When there

was evidence of healing/ bony repair, canals were obturated. The six month review radiograph showed complete periapical healing and the radiolucency around the furcal area reduced in size. Although the lingual sinus has completely closed, I expect to see more healing at the furcation when I review this case in six months.

Willkommen in Malaysia!

Chris is a friend from Germany, who came to visit Malaysia this week. We have a common friend and this is his first trip to Kuala Lumpur. He is a very talented person because not only he practises as a dentist, he is also an architect, a yoga teacher teacher and a professional photographer (This is his website: www.dade.de )

So, my nurses and I were very excited when he expressed his interest to visit my clinic in Petaling Jaya because he wanted to see how I worked with the operating microscope on root canal treatment. I scheduled a RCT on a lower first molar. My patient didn't mind having an observer during his treatment. He asked us if there was any dental equipment in my dental office that has German technology. The first thing that came to my mind was my BMW, which I simply loved, but my car was not a dental equipment. Looked like Dr Chris was

the only one there that was made in Germany.

At first, I was a little bit nervous. The last time another dentist looked over my shoulder and watched me worked was when I was in dental school. The treatment went smoothly and I was satisfied with my work, as shown in the final radiograph, which I always regarded it as my "report card".

The next patient came in for a routine check-up. She was such a good sport. Chris and I had a good discussion on the best dental treatment plan for her and she even helped us snapped some photos after her treatment.

I hope my friend enjoyed the rest of his stay in Malaysia and that he will have many good reasons to visit Kuala Lumpur again.

Kong Hei Fatt Choy!

Today is the fifteenth day or the last day of Chinese New Year, also known as Chap Goh Meh. It was a great new year celebration, and I think the highlight of this CNY was our Yee Sang dinner at the Toh Yuen Restaurant, PJ Hilton. I kept my promise to treat my nurses, Asma and Banun, to an eight course dinner. It was a joyous occasion, attended by Banun and Asma, accompanied by their respective families, my friends Dalia, Matt, Shiamala and Azura. That made up to a table of nine adults and four children. The staff of the restaurant was very nice to offer us a room with beautiful oriental deco. We had fun toasting yee sang as Matt explained the significance of this Chinese New Year tradition. We ordered the Happiness Set Dinner. The food was halal of course and very tasty. I can tell the chef had put in a lot of effort preparing all the special dishes and I love the roasted chicken most. It was a nice surprise for me to see the kids, aged between three to nine year old, enjoying every course! The servings were large and it was just enough for all of us. My only complaint was the waitresses there were not very attentive and friendly. Maybe, they were too busy serving the Datuks and VIPs in the restaurant that night.

I take this opportunity to wish all friends of Soo Dental Surgery a happy and prosperous Chinese New Year and may the bunny brings lots of joy, good fortune and good health throughout the whole year. Kong Hei Fatt Choy!

Analyzing toothache

A toothache that brings a patient to the dental office may either be inflammation of the dental pulp or when the pulp is already dead (necrotic). Although lack of pain does not represent a healthy pulp. Pulpal pain symptoms occur with different intensities, e.g. mild, moderate, or severe which is governed by frequency of firing, number of nerves and type of nerve fibres.

A-delta fibers are fast-conducting and evoke a rapid, sharp, lancinating pain reaction, and C-fibers are slow-conducting and cause a slow, dull, crawling pain. C-fibers have a higher excitability threshold than the A-delta fibers. A-delta fibers are located the periphery of the pulp, mostly at the coronal portion, and C-fibers are found centrally in the pulp proper.

Severity and duration of pain is related to the status of pulp pathosis.

Pulp inflammation may be reversible (reversible pulpitis) or irreversible (irreversible pulpitis). Information provided by the patient on nature of pain is important to differentiate between reversible pulpitis and irreversible pulpitis. Standard dental procedures on a tooth with reversible pulpitis is expected to reverse the inflammation of the pulp to a healthy state, whereas tooth with irreversible pulpitis will require an aseptic removal of the entire pulp (root canal treatment).

Symptoms associated with reversible pulpitis: No pain or sharp pain (mild) on contact with cold/hot liquid or sugary substances. Pain goes away when stimulant is removed. Peripheral A-delta fibers are stimulated.

Symptoms associated with irreversible pulpitis: No pain or pain on contact with cold and especially hot liquid, relieved by cold liquid. Pain is severe, throbbing, spontaneous, lingering and wakes the pain from sleep at night. There is usually a past history of pain and severe pain that is difficult to locate accurately (referred pain). The centrally located C-fibers are involved with these pain symptoms.

At this stage, the dentist should have an idea of the diagnosis of the tooth in question. The subsequent step is to determine the tooth that caused pain. A series of test that follows (cold test, heat test and electric pulp test) will determine whether the tooth is alive (vital) or dead (necrotic). These test are rather subjective and are not sensitive to differentiate between reversible pulpitis and irreversible pulpitis. One study shows that 83% of the teeth with a necrotic pulp were identified as necrotic by the cold test, while 93% of the teeth with vital pulp were identified as vital by the cold test. 86% of the teeth with necrotic pulp were identified as non vital by the heat test, while only 41% of the vital teeth were identified as vital by the heat test. For the Electric Pulp Test 72% of the teeth with necrotic pulp were identified as non vital, while 93% vital pulp were identified as vital in EPT test.

Percussion (tapping on tooth with a metal instrument) and palpation, are to evaluate periodontal inflammation. Necrotic or irreversibly inflamed pulp can lead to inflammation of the periodontal ligament. Inflammation of a tooth with referred pain remains confined within the pulp. The inflammatory process has not yet extended into the periapical region to engage the tactile fibers to give the clinical percussion sign. Sites of referred pain are always the posterior teeth and always unilateral, involving only one tooth in either maxilla or mandible.

In some situations, even the most experienced dentist may not be able to detect the culprit tooth or arriving to a diagnosis. The rule of thumb is to adapt the "wait and see" policy and in most cases, signs and symptoms will be more clearer in the subsequent appointments.