The Dilemna of treating the Fractured tooth…. An Endodontist’s perspective.
Fractured teeth are commonplace in the dental practice. Today’s practitioners are inundated with patients presenting with fractures ranging from a simple cracked tooth syndrome to fractures within the crowns of teeth extending into the root surfaces and periodontium. Management of these teeth can present inherent dilemmas. Attaining the desired clinical outcome and meeting the patient’s expectations are two areas that often present the most challenges. Unfortunately, often times, this management can be less than clear cut and more dependent on the clinician’s mindset. The decision to extract a tooth or to recommend a coronal restoration and/ or root canal therapy lies in assessing the patient thoroughly and achieving a proper diagnosis. In addition, addressing the patient’s chief complaint may likely better enhance a more desirable outcome.
Simple Coronal Fractures
Coronal fractures often present as microscopic lines that are in the enamel and sometimes dentin. In acute cases, they may be compounded enough to have portions of the tooth break off. In these cases the practitioner may use subjective evaluations such as thermal sensitivity and biting pain to determine if the tooth may be well suited for root canal therapy. In other cases, a provisional restoration can be made prior to full coverage to assess the pulpal response to fracture. Interestingly, I have found many times that what appears to be a fairly extensive fracture coronally, for example a M-D fracture in a lower molar, is not so extensive at the furcation level. This is largely due to the ingenious design of teeth where the pulp chamber can act as a stress breaker, a firewall if you will, to prevent such injuries from reaching the periodontium and lower root structures.
Moreover, in some instances where a coronal micro-fracture is noted, there may be associated deep periodontal probing in the area and an assumption could be drawn that the tooth is beyond repair. However, in these cases, the fracture may be extensive enough to cause pulpal necrosis in the crown and present as a root fracture when in fact it is a simple endo-perio problem. In general the management of coronal fractures is dictated by the severity of the symptoms. If the tooth is further compromised, then treatment may be influenced by the remaining available tooth structure to support a new restoration. The practitioner must look at ferrule (The amount of supragingival tooth structure) and the tooth’s inherent characteristics to support restoration. Furthermore, we must not discount the value of looking at the patient’s overall occlusion profile and the basic crown to root ratio. At minimum, a ratio of 1:2 is necessary, but prognosis is further enhanced in ratios of 2:3. These are the criteria used to determine if a fractured tooth may be better suited for extraction.
Fractures extending into the root surfaces can often be more challenging to diagnose and to form a prognostic opinion about. Patients presenting with these types of fractures often have similar complaints to those seen in simple coronal fractures. At times however, symptoms may seem more acute. Many times the practitioner may look for periodontal clues to better diagnose root fractures. A common finding may be normal periodontal probings of a tooth in question with the exception of one surface where the probing depths may be significantly deeper. Isolated ( > 5 mm.) periodontal readings adjacent to a tooth can be a good indicator that a root fracture may be present, however not pathognomonic.
Isolated Deep Periodontal Probings
clientuploads/GPNewsFlash Archives/Issue 3 Oct 2012/image04.jpgThis points to some matter of discussion. Isolated periodontal defects can be caused by orthodontic movement where the root surface may iatrogenically erode the cortical plates. Moreover, isolated periodontal pockets may be caused by isolated periodontal pathogens. Lastly, isolated periodontal defects may be caused by root canal infections where an abscess, for example, may trace the side of a root to follow the path of least resistance to where the infection may drain (Fistula). The latter is what is most often seen in routine practice.
Differentiation of these is critical in determining what the best course of action may be, especially to avoid unnecessary extraction. The first step is to achieve a proper pulpal diagnosis. This has proven to be a very useful tool, as many de-vitalized teeth can present with isolated deep probings. Currently the most diagnostic conclusion is reached with the use of the SOM (Surgical Operating Microscope). This is especially true as many root fractures will lack a biological response (where we may see periodontal probings > 5mm.) An SOM can often be used to rule in/out the presence of a VRF (vertical root fracture). Without proper illumination and magnification (>10x) the fracture may go unnoticed. In the absence of root displacement, VRF’s are not visible on 2-D radiography. In some cases, the practitioner can look for clues, see att. figure (tooth 19) where a tooth with poor crown to root ratio, which is restored with a post in the mesial root for added core retention, presents with isolated deep probing.
Despite manufacturer claims, most VRF’s cannot be diagnosed using cone beam imaging. The resolutions we are achieving with cone beam imaging are not detailed enough and very often the presence of metal restorations produces scatter making the interpretation of images next to impossible.
(A “tear drop” shaped PA lucency #8 in conjunction with isolated deep periodontal probing in the palatal aspect and normal pulp testing indicative of root fracture)
Extraction vs. Retention
clientuploads/GPNewsFlash Archives/Issue 3 Oct 2012/image03.jpgThe management of fractured teeth can often present the practitioner a treatment dilemma. In the case of simple coronal fractures, where the pulp may be minimally involved, the first line of defense may be full cuspal coverage. In cases where the fracture may extend deeper into the tooth, either into the furcation or root surfaces, the management can be more elusive and treated on a case by case basis. The factors that the practitioner may consider include the severity of the fracture, as evidenced both clinically and by the patient’s chief complaint. Further, the current restorability status must be accounted for, including the amount of remaining tooth structure and if root canal therapy and build up may be suitable for a particular tooth. In cases where there are isolated periodontal probings ( > 5mm.) and orthodontic and endodontic causes are ruled out, then extraction may be the best alternative. Consideration for these factors is crucial to avoid unnecessary extraction of teeth.
Many teeth can be maintained with 5-6 mm probing depths and managed accordingly. In some cases endodontic therapy may be recommended to manage a pulpal response to fracture. This includes any associated thermal sensitivity and biting pain which can be completely eliminated or greatly reduced by treatment. The other added advantage of endodontic therapy which may be ancillary, is the proper internal imaging of a fracture. Many times endodontic therapy in combination with the SOM can be helpful in determining the prognosis for treatment. Many practitioners may be weary of completing treatment in cases where the fracture extends to the level or slightly below the level of the root orifice. In practice however, many of these teeth can be retained successfully especially in cases where the patient’s occlusal pattern is accounted for. This is especially true when there is absence of swelling or periodontal pocketing > 5mm. in the area.
The current consensus for treatment of fractured teeth varies between practitioners. There are few studies that can point out an objective approach to treating fractured teeth largely because of diagnostic limitations and confounding factors within a patient population, such as occlusal patterns and parafunctional habits. It makes intuitive sense that teeth subjected to higher occlusal loads may fail quicker over time. The current AAE (American Association of Endodontics) guidelines recommend extraction for teeth where fractures extend below the level of the orifice (see below). Although this may be a good baseline approach for treatment it does necessarily apply to all teeth.
Nader M. Vafaie, DMD, MMSC
Social Media Dentist
The world of Dentistry has definitely changed over the past several years. It is no longer a business where you can put up a sign and expect to have hundreds of patients knocking down your door. Dentists have embraced marketing and now employ several different methods to drive traffic. Nowhere has this been more noticeable than on the Internet. Dental websites are now a ubiquitous tool, and offer everything from computer graphics to appointments. They may range from the simple to the complex, but the common consensus is that everyone should have one.
But the web is evolving. More and more of the web content is being created by ordinary users like you and me. The web is no longer an environment of static websites, it is a thriving community that allows for immediate communication and information sharing. People don’t just visit websites anymore, they live on them. We are in the world of Web 2.0 and Social Media. These are terms that are tossed around quite a bit, but many don’t really know what they mean. Web 2.0 and Social media is the next step in the evolution of the web. The ordinary user has taken control of their own web destiny and can create a web environment that is specific to them.
This type of environment makes it much more conducive to share information and to connect with other people around the world. It also marks a new era of dental marketing. The era of Social Media for dentists. Many dentists are embracing social media, by creating pages on Facebook, YouTube, Twitter, and LinkedIn. These platforms allow dentists to step out of the static framework and become more engaging. Dentists can easily share their knowledge and become a real person, not just a name and a logo. Still others don’t see a need to try this alternative marketing. The problem is, this alternative marketing is becoming the new main stream.
Let’s look at the statistics of one of the major social media outlets, Facebook. Facebook is the biggest social utility website out there. It has over a billion users. It comes in a close second to Google as the most visited website in the world, and it has actually beaten Google on several occasions. Almost 60% of the American population has a Facebook account. That in itself is amazing. Try to get 60% of Americans to the polls on election day! The average user has over 130 friends on Facebook, and spends almost 55 minutes each day on the site. No other website can match this. Google may have more traffic, but no one spends almost an hour on Google. A majority of these active users believe that every business should have a presence on the site.
What do all of these statistics mean? It means that people are living their lives on Facebook. They are connecting with friends, shopping, and getting their news from one place. It also presents a wonderful opportunity for dentists to connect with over 60% of the population. These are not all teenagers either. One of the fastest growing Facebook demographic is users from 55-65. Social media viewership is a true phenomenon that encompasses people of all ages, races, and creeds. This type of thing doesn’t happen very often.
Business have also jumped on the social media bandwagon. The static website has become so ingrained in our consciousness, that many major businesses don’t advertise them anymore. What you will see is fortune 500 companies say “Find us on Facebook” or “Follow us on Twitter”. Before long the Facebook page or Twitter account will be the standard.
What are the benefits of using social media for dentists? The most obvious reason is the sheer number of people using these platforms. Conventional media like T.V. , radio, and print is a crap shoot. There are too many alternatives out there for people to view. More people get their news from the Internet than newspapers. Tivo and other video on demand options have lessened the power of commercials. Many people are watching TV shows on the Internet. Satellite and Internet radio is crippling the radio broadcasting industry. But more than half of the population still returns to Facebook each day for almost an hour. Most dentists would kill to reach 60% of the population in their area.
The financials of Facebook marketing are also strong. Operating a Facebook fan page or a Twitter account is free, so the R.O.I. of social media can be very high. Facebook does offer some pay per click advertisement much like Google. Where else can you find an effective way to advertise your office for free.
The great thing about social media is that word of mouth advertising is built right in. It is extremely simple to share content with another user on Facebook or Twitter with the click of a button. That is why many pundits say it is word of mouth on steroids. Information can travel very fast on these sites and can easily go viral.
Take for instance the aforementioned factoid that most Facebook users have 130 friends. If a Facebook user posts a comment or picture, it will be seen by 130 people, then to almost 17,000 viewers (130 x130), and so on. Within minutes content can be seen by thousands of people. All with the click of a button. When people ask me why I would encourage social media use instead of a phone book ad, I usually reply “The phonebook doesn’t have a share button”.
One of the strongest reasons a dentist should use social media is because of fear. Thousands of patients cancel their appointments each year because of fear. Many others don’t make an appointment because of fear of the unknown. They don’t have a dentist and they are afraid to start with a new doctor they don’t know. Social media allows dentists to build an online personality and reduce fear. They can express themselves and not only prove their knowledge, but show their human side. Social media is about building relationships online, and building these virtual relationships will help build your practice. Social media also gives dentists the power to become the local expert. Patients and potential patients often have many questions or concerns. They often are afraid or embarrassed to ask them. Using social media gives them a feeling of anonymity, and allows them to ask questions more freely. Dentists can then answer these questions and it gives them an air of professionalism and compassion. It also cements their status as an important figure in the community, virtual or real.
Although these social media websites may seem like they are all fun and games to an outsider. They contain a lot of powerful marketing information. Facebook and other social media outlets collect great amounts of demographic information from their willing participants. Users freely hand over their address, phone #, birthday, and etc. This is a shrewd move on their part, because if any other website, even Google, were to ask for this information red flags would be waved. Social media users tend to acquiesce and give out a lot of information. Much of this information can be used to target audiences for social media marketing, and really let you hone in on a specific demographic. Targeted marketing in any campaign will make marketing efforts more effective and drive traffic.
So where should the average dentist get started with social media. There are many social media platforms to explore, and it can be quite daunting for the newbie. It is best to pick one type of social media at first. Some dentists jump into several different platforms at once, and it is very easy to become burned out or watered down. Be diligent and do your research. Start an account on one platform and play around with it. Learn the “language” of the website. Each type of social media has its own set of rules and etiquette, and it is best to learn this well before diving in.
Time management is a very big part of social media for dentists. Dentists must figure out how much time they are willing to spend on a campaign, and how many new patients will validate the usage. Too much or too little time can kill a social media campaign. Creating a weekly calendar of goals and procedures will be a big help for most dental offices. Learning how to get a campaign going and maintained without taking up too much time is one of the biggest hindrances for dentists. A successful social media campaign can be managed in just minutes a day if the correct parameters are put in place. Many dentists believe that they have to constantly contribute creative content to be successful. Contributing content can be as simple as uploading a picture with a short description or as complex as a two page blog post. As long as you keep your audience engaged with something, however simple, you are making an impact. Many dental offices find it helpful to incorporate their staff or spouses into their social media campaign.
Privacy is also a major concern with dentists using social media. We as dentists often treasure our privacy and time away from the office, and many see social media as a threat to privacy. Don’t let privacy be a deterrent. It is only a speed bump. Many successful social media campaigns have been successful without giving up privacy. The one thing to remember about social media is, you get out what you put in. Much of the personal information they request is not necessary. It is helpful but not necessary. You can operate a Facebook account on a name only. No picture. No birthday. No credit card number. You may also have a profile for your business, and have no personal information available at all. Google already knows more about you than will ever be found on social media. Phishing and other security concerns are still a very real threat on social media, but they are no more of a concern than they are on email accounts. A certain level of common sense must be maintained. Don’t fall for the prince from Nigeria who needs $10,000 to get 1 million, no matter how they contact you.
This is the future of the web, like it or not. Years ago just having a website was a major accomplishment, now it is a necessity. Soon a Facebook or YouTube account will turn from a novelty to a necessity. Dentists need to be there with an established following. And why not? We spend hours and hours on patient education to keep them informed, and explain our methods. Their level of understanding makes our job easier and also helps with case acceptance. Social media marks the first time in history that we can connect with the public, educate them, and have them share their experience in one package.
Jason Lipscomb D.D.S.
Dr. Lipscomb is a general dentist with offices in Fredericksburg and Richmond Virginia. Dr. Lipscomb also travels the country teaching dentists about social media and web marketing. Dr. Lipscomb has also co-authored a social media guidebook titled “Social Media for Dentists” which can be ordered by contacting Dr. Lipscomb at [email protected]
The Hero’s Journey
Aah, the dream of owning and running your own practice. Never thought you’d have so much fun, right? Easy hours, being your own boss, Wednesdays off—a breeze! When I was in dental school, I was sure that every dentist took off Wednesdays to play golf, so, as a student, I played a lot of golf to hone my game. I think after nearly 24 years of practice, I’ve had time to play a round maybe 10 times—OK, maybe 11.
Even now, many dental students probably can’t envision how much work will actually be involved and how many different jobs we actually do. Soon after starting practice, my father said to me, “Now you’re a manager, and yesterday you didn’t even know how to spell it.” Oh, how right he was—well, mostly. I’m not just the manager, but also the CEO, human resources coordinator, teacher, marketer, mechanic, trainer, and a whole lot more—including the dentist! What was I thinking when I began dental school?
Dentistry is a difficult profession—very difficult. We have so many things to manage, so many decisions to make, and so many people who depend on us. With all of the different aspects of our professional lives, how can we enjoy ourselves and experience fulfillment, success, and peace without selling our souls or literally working ourselves to death? That’s a loaded question, for sure. It can happen, if you’re willing to take what I call the “hero’s journey.” According to Pablo Picasso, “Action is the foundational key to all success.”
The hero is a person who takes action. As I’ve coached clients throughout the past decade, those who took action reached their goals—both the tangible and intangible ones. Those who didn’t—well, at least we had good conversations. One way to start the journey and take action is to first think about what I call tolerations. Tolerations are all of the things in life that you’re currently tolerating. This includes situations that irritate you, frustrate you, and push you to the point of emotional explosion. Tolerations also include the everyday things—large and small—that need to be done, checked off your list, changed, delegated, corrected, and so forth.
Maybe your mind is racing now, thinking of all of the things that you need to do. As a coach, I want to help you relieve some of that weight. In order to do that, I need you to grab a blank piece of paper (or five). You’ll need a writing utensil, too. Start by labeling the top of the page with the word “Office.” Now, make a list of everything you’ve been tolerating, from the biggest to the smallest, in no particular order. I’m not asking you to do anything about the items you write. Just list them as they come to mind. Maybe you want to get the lab organized; fire that troublesome team member; learn how to take better impressions; get the carpets cleaned; or talk with your assistant about having the rooms set up properly. Go on—get it all out there on paper. (Expect this to take you about 30 minutes.) Now, on another page, write “Home” at the top. I know there are projects at home you just haven’t had time to complete, so list those. List the aspects of your family that need attention too, including behaviors that you want to change. Remember, you don’t have to fix them right now— just list them.
Next, on the third list, write the word “Relationships.” I’m sure you have great friends who are always thoughtful, giving, and understanding. Your spouse is probably a very loving and supportive person, too. But think about those relationships that aren’t working so well, and make a note or two about what you’re tolerating and the aspects of those relationships that you would like to change.
Finished? You can always add more later, so keep your lists handy. It’s not unusual to have lists that contain more than 100 items. Now read each list, and spend some time pondering how you can resolve some of your tolerations. For example, your shrubs need a major pruning. Do you have time to do that? If not, consider hiring someone, or pry your son away from his video game and ask him to do it for you. At first, you probably won’t have answers for the majority of the items, but as time progresses, you will. Review your lists on occasion and delete or add items. Your goal is to reduce the tolerations to zero. Your energy is valuable and shouldn’t be squandered. I’m not asking you to act on any of these things right now. But if you’re ready to, go ahead. It’s best to build on success, so start with the easiest items first. So, if you wrote “build a new office, ” you may want to tackle a few of the smaller issues first, OK?
When we begin to get rid of the stuff we tolerate, we make room in our lives for the things that matter most. We don’t feel so burdened. We’re not so angry. We begin setting boundaries and elevating our standards. In order to be successful at reaching your goals, you’ll have to build a foundation so strong that you will be able to withstand anything that comes your way. For now, do your homework by compiling those lists of tolerations and start whittling them away as you’re able. If something isn’t going well as you try to correct it, set it aside; it’ll still be there later. Remember what Pablo Picasso said: “Action is the foundational key to all success.” I challenge you to take action and begin the hero’s journey today.
Don Deems, DDS, FAGD, known as The Dentist’s Coach®, is a trained professional, personal, and business coach and a practicing dentist. A top leader in continuing education for the past seven years, his newest book, “The Dentist’s Coach®: Build a Vibrant Practice and the Life You Want” is available by visiting his website, www.thedentistscoachbook.com or www.drdondeems.com. He also can be reached at 501.413.1101.