19 AP : two visit retreat with Caoh - Courtesy ROOTS
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Photos courtesy Sashi Nallapati / Randy Hedrick- ROOTS
From: sashi nallapati
To: ROOTS
Sent: Saturday, February 25, 2006 5:35 PM
Subject: [roots] recall this week
only one recall from this week.......
6 month and 15 months recalls
19 AP, two visit retreat, with Caoh , HEALING IN PROGRESS..
its taking longer than i expected... sashi nallapati
Itīs looking nice at 6 months - Jorge
Sashi:
The distal canal is definitely healing...just look at the floating gp hugging the apex while the lesion is shrinking....))
did you use CHX as part of your irrigation? Do you BELIEVE that CHX or Steriolox has any merit upon healing lesions of
this size? MTAD is sold at 1 million dollars a gallons, but there are studies indicating not much better than EDTA+CHX
rinse?
So much of what we do is working so perfectly despite of imperfect technique for addressing the apical 1/3.
and if you happen to see this in 4-5 years (with incomplete osseous repair) what do you think you could improve internally
by NSRT?
I am not saying it will fail as I think it has an excellent chance to heal,,,but since it is quiet around here, I was
hoping to drag you in to a discussion,,,)) - ahmad
ahmad, I may have used chlorhexidine in this case but i am not 100% certain.
my experience with MTAD ,chlorox and chlorhexidine on the rate of healing is none and the literature that
i have read so
far has not mentioned any thing on the rate of healing.
caoh has been associated with faster healing rates though......
I think lesions of this size in retreatments may take a longer time than in initial treatments as the
microflora is shown to be different and more resistant perhaps???
if I see this treatment fail in a few years and if i rule out coronal leakage, then i do surgery...
I am not sure if i can improve this result by going back again nonsurgically - Sashi Nallapati
Interesting, that the best intra-canal irrigant is still hypochlorite....and the rate of healing is overwhelming when
utilized liberally.
As you pointed out, the change of microflora to more anaerobic strains makes control of the bacteria even more difficult
in AP cases.
Perhaps that's why we try different solutions to kill all.
CHX is also a very effective against E.facealis, if you believe it has anything with endodontic failure....do you?
and what about CH? I remember you did many single visit and 2 visits w/ CH cases? what was your recall results like?
which regimen are you going to partake in private practice?
Sashi, I don't think anyone can improve what you have done.
How many apical surgeries on molars have you done?
and do you submit all lesions for a histology report? - ahmad
e feacalis has been increasingly being shown not that significant in endodontic failures. its importance
in biofilm formation as a monoinfection and its role in creating an ideal environment for biofilm formation
in a polymicrobial infection has been implied in tx resisitant periodontitis but current lit in the last few
months seem to think the pathogenecity of these bacteria may not have anything to do with the symptomatic AP
and they may be just innocent bystanders..
atleast that's my take on this
caoh is a good meidcament but not perfect. Clinical trials looking at the efficacy of this drug have been
equivocal and there seem to be evidence supporting both one visit and two visit with caoh tx modalities.
my recall rate is minimal and so far i am yet to see a failure in any of these categories, but the recall
number and the recall period are too short for any valid conclusions.
I presented a topic presentation to my faculty and residnets on one vs two visit endo and my conclusions are
IN my treatment philosophy
one or two visits modalities should be directed not only for the extra microbial control that may or may not
be derived from caoh and an extra flushing from your irrigants, whether the canals are dry or not, but also
from establishing a technical protocol for your cases i.e.,
1. Determination of apical length (where do oyu clean and shape to, I.E patency or no patency)
2. determination of apical width for that particular canal and achieving it
3. symptoms of the patient( I.E is the patient comfortable to go through the entire tx time of cleaning shaping and
obturation)
4. whether all the canals that could possibly exixt are found and treated ( do you routinely see more at a second visit?)
5. and a very important factor , whether the operator is feeling rushed to do the procedure or he/she has enough time to
do this well (see all the above)
and if all these criteria are met then atleast at present i dont have any problem finishing cases in one visit...
but alas i end up doing quite a few vital cases in 2 visits because i cannot achieve the outlined criteria which by the
way ,from literature, attracts lower success than when done in one vist ;-))
I have done about 20 max molar surgeries (including private practice) and 2 mand molar surgeries.
at school we always send for a biopsy , in my practice , i was guilty of being lenient... - Sashi Nallapati
Sashi:
Thanks for the detailed reply...Quite a few interesting points you brought on....
one or two visits modalities should be directed not only for the extra microbial control that may or may not be derived
from caoh and an extra flushing from your irrigants, whether the canals are dry or not, but also from establishing a
technical protocol for your cases i.e.,
but isn't the technical protocol objective the same as microbial control? IOW, don't we file, shape & irrigate for
reducing the bacterial population? and unfortunately the more sophisticated we become with our research and diagnostic
tools, such as, SEM, TEM and confocal microscopy...the more elementary our current methodology of treatment looks. We now
know there are bacterial colonies and biofilms that our irrigation doesn't even effect. It is also humbling to know that
our instrumentation may not anatomy of the root canal system as we think it does, So I agree with you that looking at CH
purely from a microbiological stand point may be skewed, but considering our less than perfect instrumentation perhaps the
use of CH may give us not only an added edge to bacterial control, but another chance to revisit the case with another
regimen of irrigations, instrumentation and disinfection.
1. Determination of apical length (where do you clean and shape to, I.E patency or no patency)
do you try to achieve patency in all cases right from the start?
or do you differentiate between cases with different diagnosis?
let me give you two examples....
1. Necrotic pulp, cellulitis and firm swelling....no sinus tract
and,
2. Necrotic pulpitis with sinus tract with AAP.
which case merits to obtain patency in the first visit? and why?
2. determination of apical width for that particular canal and achieving it
This without a doubt is the most misunderstood part of endodontics for me. Determining the apical diameter by successively
larger files, not only can move the foramen from its original location, but ellipticizing the foramen, hence creating an
added dimension of difficulty to achieve an apical seal.
I just can't understand why thinning the most delicate part of root (purposefully to ridiculous sizes ) can achieve, other
than zipping or cracking the root end. so what is the happy medium?
3. symptoms of the patient( I.E is the patient comfortable to go through the entire tx time of cleaning shaping and
obturation)
I agree..excellent point.
4. whether all the canals that could possibly exixt are found and treated ( do you routinely see more at a second visit?)
Well how would a one-shot endodontist know what they may find the 2nd time around, if they never take a 2nd look? It may
not necessarily be a missed anatomy..it could be a tissue tag, or an incompletely cleaned canal wall, or even finding
another POE of the same canal that can effect the outcome of the case.
5. and a very important factor , whether the operator is feeling rushed to do the procedure or he/she has enough time to
do this well (see all the above)
and that goes back to #4...the one shot endodontist believes s/he does..and the Ca(OH)2, multiple visit endodontist thinks
s/he doesn't. "One shot"er, says CH blocks all POE and smudges the pristine canal walls they just shaped, cleaned and
irrigated...
and the CH aficionado claims that there is enough real estate left untouched that they need a disinfectant like CH.
e feacalis has been increasingly being shown not that significant in endodontic failures. its importance in biofilm
formation as a monoinfection and its role in creating an ideal environment for biofilm formation in a polymicrobial
infection has been implied in tx resistant periodontitis but current lit in the last few months seem to think the
pathogenecity of these bacteria may not have anything to do with the symptomatic AP and they may be just innocent
bystanders..
Now i saved my favorite part for last.
For those who have been on ROOTS for a while, remember that Dr. Schein has been preaching the same thing about the
e.feacalis.
"An innocent bystander"....It was only after listening to Dr. Costerton, that it finally clicked in what Ben has been
saying all along. Endodontic microbiology has relied on a planktonic model which in reality is not only inaccurate, it is
far from what really happens naturally, The single bacteria theory is as solid as the lone gunman on grassy knoll in
Dallas...
with all that said and done, Thank goodness, we can still provides a very predictable outcome for our patients despite all
the mental gymnastics of debates in Endodontics. - ahmad
Ahmad,
Thanks for the detailed response to Sashi's case. It is very stimulating and hopefully is causing a lot of thought. I
would like to explore your comments under #2 , determination of apical width. I agree that apical width or apical
preparation diameter is a very misunderstood and more commonly overlooked factor in debridement. I am a LightSpeed user
for over 13 years and I would like to explore the basis for your statement of concern about larger apical preparation
sizes. I would also like to post a copy of a recent review article in the Journal of Endodontics on apical preparation
size for others to review as this discussion proceeds.
When you made the statement about transporting and elipiticizing the foramen with progressively larger instruments were
you referring to tapered instruments only or were you including non-tapered LightSpeed instruments also? If you were
referring only to tapered instruments I would have to agree with most of your statement. Tapered rotary NiTi instrument
are indeed very stiff, especially with larger tapers such including .04 tapered instruments and larger tapers.
I would also like to ask how you determine the final apical preparation diameter in your cases? There is quite an
accumulation of anatomic, SEM, microbiologic culturing studies that support larger apical preparations for better
debridement. Studies using the Bramanti sectional method and other methods to evaluate canal transportation clearly
indicate that larger apical preparation sizes can be achieved with the more flexible LightSpeed with little or no
transportation.
There are others on ROOTS who base this critical part of the endodontic procedure on opinion and ignore research. They
want to dismiss established, confirmed research yet offer no legitimate reason for doing so. There was a time when the
literature was weak and very thin on this subject and small apical preparations could be defended but that is no longer
the case. Proper defense of this position requires scientific substantiation. I think the review article makes that
point very well.
Finally I am enclosing a case I just completed an hour ago. It's #18 please look at the pre-op distal canal, it is very
large even before I initiated the endo treatment. My final preparation was 45 on the mesials and 80 on the distal.
Notice the wide funnel shaped anatomy of the distal canal orifice also. It is still in it's original position. When
using instruments larger than #60 LightSpeed they too become stiffer and can cause some transportation. Yet even though
it was necessary to enlarge this to a #80 to properly debride this large canal, there is minimal transportation.
Ultrasonics were used to insure that the B & L of the distal canal was properly debrided also
Finally I am enclosing a case I just completed an hour ago. It's #18 please look at the pre-op distal canal, it is very
large even before I initiated the endo treatment. My final preparation was 45 on the mesials and 80 on the distal.
Notice the wide funnel shaped anatomy of the distal canal orifice also. It is still in it's original position. When
using instruments larger than #60 LightSpeed they too become stiffer and can cause some transportation. Yet even though
it was necessary to enlarge this to a #80 to properly debride this large canal, there is minimal transportation.
Ultrasonics were used to insure that the B & L of the distal canal was properly debrided also - Randy Hedrick
Dear Randy , I have enjoyed the article you have posted. It doesn't show a solution to the problem and doesn't discuss
LightSpeed. I am not a LightSpeed user, but I can understand the rationale behind it. Your clinical case is also very
nicely done. A great service to the patient - Thomas
Thanks Thomas for the compliment. Just trying to add another piece to the endodontic puzzle we try to put together
everyday in practice. - Randy Hedrick
