How many canals are in that tooth?

2TheApex: Expect multiple canals until proven otherwise.

Except for maxillary anteriors, all teeth should be expected to have more than one canal. Some commonly missed canals are MB2, the lingual canal in mandibular anterior teeth, second (or third!) canals in premolars, and a second distal canal in mandibular molars. Recently I had a very interesting case that was a new one for me: a second palatal canal in a maxillary molar.



Cone fit: Note palatal cone offset to the distal of the root.


Final: 4 canals, with 2 canals in the palatal root.


The palatal canals shared a common orifice, and the additional canal was not evident on initial access.  The canals bifurcated apical to the orifice, and the second canal was located with the aid of the dental microscope to the mesial.  A very interesting case, and a good reminder to always expect the unexpected.

When to use the CBCT?

2TheApex:  When a conventional periapical radiograph is inadequate. (the uber simplified answer)

The AAE has published a revised position paper on the use of CBCT.  You can find it HERE(click).  This is the complete answer of when CBCT is indicated.  It’s a quick and easy 7 pages.

Example Case

CBCT Vs. Conventional Periapical radiograph. (recent case from Dr. Nordeen)

Pre-op periapical Image of Maxillary right

#4 PA

Obvious Findings: Radiolucent lesion tooth #4. Possible lesion tooth #2???

CBCT (mid-retreatment of tooth #4) of the same area using a custom curve. Note apex of tooth #7 caught in the field.

CBCT 2,4,7

Video while scrolling through CBCT. (from cervical to apices and back) Video is slightly zoomed in, so the detail we view images is better than this normally.

Obvious findings with Cone Beam: Radiolucent lesions on teeth #2, #4 and #7.  Almost complete furcal bone loss on tooth #2.

In our practice we use it routinely for surgery, retreatment, resorptive defects, inconclusive diagnosis and trauma. This technology has become as important in our practice as the microscope in providing the best care possible for our patients.  We have gone from using it only several times a month to almost daily.  This has been the next “game changer” in endodontics.

One poke or two??


2TheApex:  Two inferior alveolar nerve blocks (IANB) are more effective than one in both symptomatic and asymptomatic patients.

A recent article published in the Journal of Endodontics showed that administering 2 carpules of local anesthetic was significantly more effective at achieving profound lip anesthesia.  3169 people participated in the study with failure rates of 7.7% with one carpule, and 2.3% with two carpules of 2% Lido with 1:100,000 epi.  Although this may seem like common sense, it is the first article to show that increasing volume will increase IANB success rates.  This study only examined anesthetic success in terms of lip numbness, not as a pain free procedure.  As we all know, pain can still be present during the procedure even with profound lip numbness. However, adequate anesthesia will almost never be achieved without first achieving lip numbness as a sign of a successful IANB first.

Which irrigating solution is the best?


2TheApex:  Sodium hypochlorite

An ideal endodontic irrigant disinfects the canal, act as a lubricant, removes debris, dissolves tissue, removes the smear layer, and is safe for the patient.  Although there is no perfect irrigating solution, one does stand head and shoulders above the rest: sodium hypchlorite (NaOCl).  In a review article of irrigating solutions, Haapasallo stated “It is difficult to imagine successful irrigation of the root canal without hypochlorite.”  Sodium hypochlorite cannot fill all the criteria by itself, and so a chelating such as EDTA is used to help facilitate smear layer removal, but no other irrigant fits the criteria of an ideal irrigating solution better.  There are risks to using sodium hypchlorite, and it must be used with caution to avoid extrusion into periapical tissues.  Other irrigating solutions have been shown to be potentially beneficial in some circumstances, but if possible they should be used as an adjunct and not as the only irrigant.  At this point in time, the research is clear that NaOCl is the best endodontic irrigating solution available.


What is that purple stuff in my access?


2TheApex: It’s PermaFlo Purple, a colored flowable composite.

Coronal seal has been shown to be critical in the long-term success of endodontic treatment.  (click on “Coronal Seal” for flagship research on this subject) PermaFlo Purple is a flowable composite that will provide an excellent seal and is easily identifiable for when the Cavit is removed after treatment for the final restoration or if retreatment should needed in the future.  It is useful in teeth that have deep caries or small crack making a coronal seal with Cavit questionable, or in patients that may have difficulty returning for a final restoration within the 30 days recommended following root canal treatment. It is bonded and placed as a thin layer, so does not need to be removed and can be bonded to just like any other composite restoration.


What is Gutta-Percha made of?;-paper-point-gp.jpg

2TheApex: 65% Zinc Oxide; 20% Gutta-Percha; 10% metal sulfites; 5% waxes and resins (Friedman)

It’s mostly Zinc Oxide.  We call it Gutta-Percha since that is what gives it unique properties we enjoy, like plasticity.  The material was used as an obturation material over 100 years ago.  It comes from the sap of a tree that grows in Malaysia.  It is also safe to use in patients that are allergic to latex.  (American Latex Allergy Association)  Gutta-percha has stood the test of time and it still the standard by which all obturation materials are judged.

How do I do an oral cancer screening?

2TheApex: Very Easily

Oral cancer still has a poor 5 year survival rate although it has improved in the last 10 years to 57 percent.  Early detection is key!  Taking the time to do a screening could save someone’s life.  Here is a video on how to perform a comprehensive screening.  It’s worth the 11 minutes for a refresher.

Early in my practice this patient was referred for treatment of tooth #15.  I found this tongue lesion upon exam.


The lesion was squamous cell carcinoma.  It was removed in total by an oral surgeon and the patient needed no further care.

April is Oral Cancer Awareness month.  Click here for info on how to promote it within your practice.

Can you call in a RX containing Hydrocodone?

2TheApex:  Not any more (as of today)

Effective today any medication containing Hydrocodone is Reclassified as Schedule II.  Yes, Hydrocodone combined with Tylenol is now Schedule II.  (Click here for the DEA ruling on this) This means you CANNOT give an oral order for Hydrocodone.  The pharmacy will need a physical prescription brought in to the pharmacy.  Back to writing (or printing) and signing paper again.  No more phoning it in unless it’s an “emergency.”  Click below for the rules in our area.

Wisconsin           Minnesota         Iowa

Weekend pain control after October 6, 2014.  First determine the patients pain level and how they are currently trying to control it.  Sometimes patients are inadvertently doing things to make the pain worse. (Like placing ice on an swelling caused by infection)  Be sure they are taking OTC pain medications properly.  Taking 800 mg Ibuprofen every six hours with an Extra Strength Tylenol (500 mg) staggered between the Ibuprofen can manage most pain we encounter.

Other options:  Call in for Schedule III (Tylenol III) or call Hydrocodone in as an “emergency” and most states will allow you 7 days to get them a physical prescription.

Another medication that works well for dental pain is Ultram (Tramadol) Schedule IV

If you think the pain source is primarily inflammatory a Medrol dose pack can be very effective.

When prescribing, the patient’s heath history is paramount as well as current medications and allergies.  A proper diagnosis is always critical to managing a patient’s pain.

What do you plan to prescribe for a patient, if needed, after hours?

Is diagnosis more challenging with a patient taking Ibuprofen?

2TheApex: Yes!

If a patient has been taking Ibuprofen symptoms can be masked.  Read found palpation to be masked up to 40% of the time.  Cold response was masked 25% of the time.  Be sure and ask patients if they have been taking any NSAIDs and at what dosage prior to pulpal testing.  The bite stick test is one test that seems to be least affected by taking NSAIDs.  We encourage patients to cease taking any pain medication at least 6 hours prior to the appointment if it sounds like the diagnosis might be challenging.