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Tooth # 32: Third molar: Lesions
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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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