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From: Terry Pannkuk
To: ROOTS
Sent: Friday, July 10, 2009 4:28 AM
Subject: [roots] Why did I treat this one?
Here's a 9 year recall on a 3rd molar I treated. I don't treat
cases with lesions in one-visit anymore and this was probably
one of the last ones I did. The tooth was simply treated to
maintain the vertical dimension while the implants were planned
and placed. She needed to have her posterior occlusion maintained.
The tooth appears to be going strong although the distal crown
margin seems to be on the composite core and not dentin. :(
- Terry
Very nice healing Terry despite the questionable distal crown
margin! It looks like the most distal implant restoration has
lost some porcelain lingually?
Always good to see your cases - Stephen
Nice case. From the look of that beautiful healing, it seems you
didn’t need to change your single session protocol to a
two-visit one - Leo.
Single anecdotes don't count. :):):) - Terry
May I ask, would you know the % success difference between 2 visit
and 1 visit when you were doing them for these type of cases?
Do you think you were seeing the 10% difference that is reported?
And were these early or late failures? I guess if you're doing
1 or 2 of these a day an increased failure of 10% means an
additional failure every 1 or 2 weeks...
I've read where you've said that you're a strict 2 stepper, but is
that mainly to do with the complexity of cases you get referred?
ie. do you get many vital carious exposed teeth to treat, and
would you one step these? - Geoff
I don't see very many vital exposures at all, but I tend to one-step
vital cases with routine anatomy. The outcome studies are worthless
because of uncontrolled variables (mainly operatory skill and anatomical
variation).
I made that decision based my own recall patterns. I used to believe
that if I could "dry it I could pack it". If I continued to believe
that after what I've seen and observed, it would be disingenuous and a
rationalization to be more economically productive rather than truly a
better clinician. There were occasional patients I would see years later
on recall with a lesion still present. There is really no practical way
to quantitate how important it is to two-step unless a specific
practitioner runs a very controlled systematic study in their own
practice meticulously controlling technique and anatomy. It just can't
be reasonably done. The best we can do is observer our own patterns
diligently as long and as thoroughly as possible.
The way I practice, I'm convinced that it makes an important positive
difference regarding retreatments and necrotic cases because it's common
sensical and obvious to me that my spending the two visits with an
intracanal medicament creates a cleaner system regardless how long I
screw around on a first visit trying to one-step it.
We can argue literature all day long, but it's pointless. The studies
are poor.
Look at it this way:
1. If you perform cleaning and shaping poorly, the apical third is
still contamminated whether you perform two steps or a one-step, infact
it may be worse two-stepping since you'll stir up an apical titer and
let them grow until the second visit. Theoretically this might be worse.
One study may show this if the operators performing the study were
mediocre clinicians.
2. If you are perfect at cleaning and shaping and capable of wiping out
all pathogens from the root canal system, you can probably fill it in
one-vist. Again, it probably doesn't make any difference. No one is
perfect and this type of study is a fantasy given current available
techniques and materials.
3. If you're a conscientous clinician, clean and shape the root canal
system very well, you might still have a very small pool of apical
pathogens harboring in fins/tertiary anatomy, but placement of CH likely
creates enough of a pH gradient making the environment inhospitable to
microbial growth and clinical infection. It allows you to nail the bugs
down to an even smaller titer and in the best case maybe even eliminate
or entomb them from areas of that will communicate periradicularly.
Follow this up with a hyrdraulic deformation/injection of a
nonresorbable, dimensionally stable root canal filling material and
you've clearly performed the best you can clinically. It is my opinion
that we capable of achieving predictable success this way.
We're not perfect but we can be very good and create predictable root
canal treatment success validated on long term recalls.
The questions are, "How good do you want to be?" "Do your patients
deserve your effort?" "Does that effort matter?"
Too often the questions I hear from other dentists are, "How much are my
patients going to pay me to spend this extra time?" "Does the patient
know the difference between an 80% success rate and a 95% success rate?"
"If no one can tell the difference, why should I spend the extra time to
do it?".
If you look at your own work meticulously and look at your own long term
recalls, carefully and honestly observing patterns, you will simply
answer these questions for yourself, no one can answer them for you.
All I can tell you is what I believe and see for myself. This makes a
lot of people uncomfortable, especially scientists who do not understand
the highly nuanced art of endodontic treatment. Those who demand to
practice an evidence-based endodontic technique, use poor evidence and
typically rationalize their protocol based on the schizophrenic
literature of their choice. This is disingenuous and riddled with
self-deception. Let's face it if we don't have evidence, we don't have
evidence, some just have to get over it and not make science up. :)
With that said, I have a very strong opinion about what I see and what
I know to be true. Do not let others tell you that endodontic treatment
is simpler, easier, and works better than what you know to be true.
It is a specialty and requires special skill sets that cannot be
abbreviated in the ways that are popularly promoted.
Good luck, hope I don't get shot with too many bullets for saying
this. - Terry
Yep Terry, Tks for sharing your clever thoughts - Gustavo
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