From: Mark Dreyer
To: ROOTS
Sent: Saturday, September 05, 2009 4:37 AM
Subject: [roots] Cleanup on aisle 7

Last case of the day.  I took a few extra photos and spent some time labeling as I thought it represented
an interesting sequence of how to clean a chamber floor.

All of these photos are saved on my server as "web share" so the referring doc can see these.  We are not
printing near as many paper reports as we used to.  On slow days I have staff go to referring doc offices
and show their staff how to view this stuff on our website.

Finally have the kinks worked out of the photos on this particular scope.  The key to the better photos in
this room is the Canon MR 14-EX ring flash.  It is blindingly bright - Mark Dreyer, DMD





Mark thanks for share these pictures and your photo tips. Your pictures are cool -  Javier

astonishing images , mark which scope do you use ,? - sergio

Thanks.  Global G6 - Mark

Mark the foto’s where nice, but why did you do the endo? Was there an irreversible pulpitis?
When there wasn’t, you could make just a nice composite filling over the last caries and that
would heal as well. - Rob Kroese

I hadn't excavated all the caries when I took the photo.  I wanted to get a nice photo first.
Once I got rid of the rest of the caries, there was a pulpal exposure, so the preliminary dx was vital pulp
(no symptoms, wnl response to cold) and the working dx was IP due to the carious exposure of the pulp.
I do NOT believe in doing direct pulp caps on teeth like this on adult patients.  There are a small subset of
IP in which there are no symptoms.  I call this "assymptomatic IP" - Mark

Try a few on well selected case with MTA.  I have not purchased any of Brassler’s bioceramic material yet but am
going to.  It seems to have some science behind it.

I’m having very good success so far on direct caps on asymptomatic teeth that appear to be healthy on exposure.
I do not make the exposure larger as some recommend before capping.

You know that I was totally opposed to pulp capping and did not believe there was any successes.  Someone we both
respect told me that I should rethink that with MTA and try a few.  I have been a bit amazed with the results.
It takes a while to do one correctly but they seem to be working.  I’ve done well over a hundred with five failures
moving into endo.  Hell, Mark, you know how I love endo.  You think I’d be doing pulp caps if I could get into
those canals with a good conscience - Guy

Dear Mark, Very nice shots and work.

1.How did you clean the chamber of those small pulp stones  I find it hard to get rid of with US.
2.How did you hang the MR 14-EX on the scope ? Didn't it make your camera much heavier ? - Thomas

Thomas, I took a pointed u/s tip into the grooves around the stone and then criscrossed through the stone
with this same tip, reducing the stone down to the level of the grooves.  When you start doing this, bits
of the stone will chip off.  I then switch to a sanding type tip to smooth the floor.

The skinny tip I use is either one of the Carr tips, or one of the Tulsa Buc tips.  The sanding tips I use
are either the Carr small ball diamond tip or the Carr pear tip diamond.

As for attaching the ring flash to the scope, Global sells an adaptor for this.  It's about $60.  Once you
have that attached to the scope, the ring flash should screw onto that adaptor.  If it doesn't then you need
another adaptor and you can get this from a camera shop.  When I was first setting things up I took the lens
of the scope, the Global adaptor and the ring flash to a camera shop and they found the right ring to make it
all work for me - Mark

Mark, I think there is nothing wrong how you handled, but in a case like this, I think why wouldn’t you try to
safe the element without an endo.

When you just make a composite filling and there is later an irreversible pulpitis you have just to open occlusal
and you can do the endodontic treatment. But in many cases you don’t need the endo. And in the cases wich falled
and you informed the patient about the  risk the are all glad you tried

I am doing only endodontic treatments, but when I have my doubt’s I rather don’t do the endodontic treatment and
try it without. I do belief in direct pulp caps - Rob Kroese

Rob, I'm pretty conservative but not as much as you.  One thing that may be different in my situation is that
I practice on referral basis only.  Referring docs that send me a tooth like this are not going to be too happy
when I have to drill through their new crown a few months down the road to do a root canal on a tooth like this.
Now certainly there are a number of situations in which I won't do an rct just because the referring doc circled
rct on my referral slip.  However this is one of the situations in which I'll do it just about every time - Mark

Mark, I am working as well on referral basis only and I know the feeling and I think in practice a do indeed the
same as you would do.

I ask therefore, to the referral dentist, what he/she planned to do with the element after the rct.

When it is just a filling, in this situation I try it with a filling, when the dentist planned a crown I would do
the rct as well -  Rob

I have not found composite to bond well to caries.  I’ve also found that leaving caries under any restoration is a
pipe dream and only putting off the inevitable.  Remove the caries and if you have a healthy pulp, cap with MTA or
the new bioceramics from Brassler.  I’m going to try that for direct pulp caps since I’m running with about a 95%
success rate on MTA direct caps now…but time will tell.  I’ve done a few MTA indirects when I knew I was going to
expose.  They got a long sodium hypochlorite soak before capping - Guy

Rob, I’ve tried many of these things because John Kanca said they worked.  The simply did not in my hands.
I was working on a 100% failure rate If I knew there was going to be an exposure on removal of the caries.
Simply placing composite over the caries or placing amalgam over the caries (this was recommended when I
left school in the dark ages) does not work.  Everything leaks everything and you are only putting off the
inevitable using composite or alloy.  As I said, I’m having significant success with MTA.  Time will tell on that.

I think this is a personal thing.  Mark has not had success with pulp caps and that would have been me a year ago.
I was adamantly opposed to capping exposures.  I lean to the conservative side and hated exposures but I still did
pulp caps for many years using the recipe of the day.  They all failed and I realized all I was doing was setting
my patients up for pain later and it never happened at a convenient time for them or me.  Seeing patient on
Monday morning who has not slept in three nights because the  didn’t want to bother you  is no fun for patient
or dentist.

MTA is showing success.  But the minute those start failing is the minute I stop doing them.  I’d like to try the
bioceramics but Brassler seems to be very stingy with samples and trial packs.  I have MTA so I use it.
I think Mark did the only thing he could do considering his experience and it is huge experience.  Mark practice
general dentistry for a long time and moved to endo.  I’ve got two teeth right now that Mark is going to do endo
on and both are vital.  We’re doing endo because they both are near exposures and will be under crowns in a full
mouth reconstruction.  Cutting through zirconia is not easy and without fail fractures or crazes the porcelain.
Those things have to be considered when doing any type of pulp cap. - Guy