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Endo tips    Better Endo    Endo abstracts    Endo discussions

Tooth # 32: Third molar: Lesions

The opinions within this web page are not ours. Authors have been credited
for the individual posts where they are

From: Terry Pannkuk
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 

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 didnít 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.

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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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