From: ahmad tehrani
To: ROOTS
Sent: Tuesday, February 21, 2006 10:43 PM
Subject: [roots] Anterior MTA case

just the garden variety recurrent decay around the crown's margin with un-esthetic appearance of the crown #9.
PA radiolucency because of poorly sealed apex.
No pain or sinus tract present...... goes to show what the body is capable of handling.
cognitive dissonance at work.
Planned on orthograde retreatment of the case.
1st appt:
Removed the crown and the laterally condensed GP.
NaOCl, EDTA, Anolyte, Ethanol and COX used for irrigation with proper sequence for effectiveness.
CHX ( CHX = Chlorohexidine) dressing and cemented the provisional crown for one month.

2nd appt:
irrigated and cleaned the CH dressing....verified the apical diameter to be a MAF= size 100.
I placed an apical MTA plug & indirectly sonicated it with Joey's pluggers in to place.
Injected Ultracal *Ca(OH)2* over the MTA mass closed with a moist cotton pellet/cavit and the provisional crown
so MTA set could be verified before closure.

3rd appt....MTA was rock hard...post & core composite buildup.... ahmad





Nice case, Ahmad

I like the idea of putting Ca(OH)2 directly over the MTA ... and you really got it nicely into place and well packed
Simon Bender

Thanks, Simon...somehow I knew you will like the 120th use for Ca(OH)2...)))
My rational for using it over MTA cases is:
CH high PH is bactericidal, making it a great holding medium....
it also hydrates the MTA to help in setting.

You can always use CHX gel too... I prefer the CH for its simplicity, ease of use and is mixed with H2O.
Plus, MTA releases CH during its setting expansion, so I don't worry as much about the probable chemical
cross-reaction like I do with CHX + MTA. - ahmad

Ahmad, Lovely apical control on the MTA without a barrier.  Did you use a Lee block to make the plug,
or just rely on the plugger plunger to estimate the size of plug? - Bill

Hi Billy: I measured the canal it with the biggest Dovgan MTA carriers to make sure it binds short of the apex.....
Then I used the biggest plugger ( Orange) pre-measured to that point.

I put the apical plug wet and follow up with dry MTA packed with an amalgam carrier....All of these are easily managed
under a microscope.

After the apical plug is in place, I slightly wet the dry MTA bulk and ult. sonicate it to place.  - ahmad

Ahmad: Excellent apical control on the mta.  Did you pack an apical barrier to condense against? - gary

No Barrier. Just the usual obligatory 30 day CH. - ahmad

Excellent case and documentation Ahmad.
Any scientific reason to wait 1month with CH dressing?
Are there any studies in LIT to show that CH bacteriostatic potential would last one month in the root canal ? -Venkat

No literature that I am aware of ( but I know very little literature ) indicates the antibacterial properties of CH last more than 7-10 days.
30 days would be a dream....But I defer to Fred or other lit. mavens to answer that question.

CH acts as a holding medium ( As Dr. Schein refers to it)....I let it sit for a month because:
1. I like to see some resolution of symptoms, if the tooth is symptomatic.
2. To cauterize the apical tissue enough to stop exudates and bleeding ( like a barrier )
3. Allow the immune system to get involved.
4. Give the patient and myself a break.
5. Scheduling conflicts.

so my reasons for 30 days is not exactly evidence based, but if I err, I like to be on the side of caution. - ahmad