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Endo tips    Better Endo    Endo abstracts    Endo discussions

19 AP : two visit retreat with Caoh - Courtesy ROOTS
The opinions within this web page are not ours. Authors have been credited
for the individual posts where they are. 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

Nice curves in mesial canal

Apical periodontits

Type III dens case

5 canaled molar

necrosis periradicular..

Triple paste pulpectomy

Endo cases - Marcia

"C" shaped canal anatomy

Psycho molar

routine case

straight lingual

Doomed tooth

another molar

Tooth #36

Instrument removal

Tooth #27

Mark Dreyer cases

Troughing case

6 year recall

9 clinical cases

Flareup after best treatment

Fred Barnett cases

Cases by Marga Ree

Glenn Van As cases

Sashi Nallapati cases

Cases by Jorg

Terry Pannkuk cases

New dental products II

New dental products

Difficult retreatment

Canal anatomy 46

Freak case

huge lateral canal

Separate MB canal

Crown infraction

5 year recall

Palatal canals

TF retreatment

Fiber cone

Bio race cases