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Endo tips    Better Endo    Endo abstracts    Endo discussions

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

There should be no difference to use CaOH or not

From: Roberto Cristescu To: ROOTS Sent: Saturday, September 03, 2011 5:15 AM Subject: [roots] CaOH redux Hard to make my final email about this issue here, as it's exactly how I predicted, endless discussion.... 1. - I attach here the meta-analysis of Sathorn and Figini, showing no benefit in using it. Science is far from what we want, but we have to deal with what we have, if we don't stick with the idea of "in my hands works". And here a lot of studies have been thrown apart because of poor quality. So far, a meta-analysis is the top of the pyramid of evidence based dentistry. I saw here written that meta-analysis are weak, by the principle Garbage In Garbage Out. Than, on which evidence the use of CaOH is based if everything is garbage ? 2. - A lot of "old" studies like Sjogren, or Nair don't use a control group. Sjogren 97 does single visit and state that we cannot eliminate bacteria so we need to medicate. But they don't do a second group with medication to see the results. Nair 2005 the same. He just "assumes" that if single visit leaves bacteria, than we need to medicate. A lot of "classical" studies, if they use a control, is usually another medication (like CMCP) and from those comparisons they end up with CaOH is the best (see Brystrom 1985 - actually there is even more fun, they use in CaOH group irrigation with 5 % NaOCL and in CMCP group irrigation with 0,5 % NaOCl, they keep CaOH 1 month and CMCP just 2 weeks, they have absolutely no statistical test to see any difference between groups BUT : they state that CaOH is better and we should do endo treatments in 2 visits). 3. - Not everything that is "common sense" or adds a "benefit" leads defintely to a better outcome for the tooth: let's assume after CaOH you will have less bacteria than after single visit.. This doesn't imply that Apical periodontitis will heal in a bigger percent. Another example: making an access cavity in a "classical" way, or how Terry is doing a SEE access, removes little bit more dentin than a mouse hole cavity that John Khademi is doing. "The common sense" says that yes, if you can leave more dentin would be better. But there is no data to prove that teeth survive more in the mouth if you do those tiny access cavities compared to the normal ones. While if you do the normal access cavities the survival rate at 10 years is around 90 %. Is quite hard to understand the passion about this issue. If we leave on normal ground, and we look at the available data, there should be no difference in outcome (use CaOH or not). So each one of us can chose his/her best way to treat the patients and should not impose on others their way of treatment. If the available data will support a CLEAR better outcome for one method, I would understand that those doing that method will try to convince the others, for the benefit of the patients all the world, to apply the better method. Of course we have also people that don't believe in anything because nothing in endo is Bayesian, so probably they should stop treating patients, as everything they actually do AT THIS MOMENT is violating the Bayesian inference. Maybe by stopping treating patients and having more time to study and apply the bayesian thinking into our science, in few years we will have some nice data and outcomes that we can happily apply. I am interested how the data will look like, and how endodontists around the world with the patients in their chair instead of saying WE CAN TREAT or WE CANNOT TREAT, will tell the patients: LIKELY TO MOST LIKELY WE WILL TREAT or MOST PROBABLY WILL NO TREAT.... Roberto

Weiger et al and Peters et al placed Ca(OH)2 with paper absolutely inferior method of placing the white stuff. Peters et al even had bacterial growth in Ca(OH)2......really???? I truly wonder what that white stuff was. It certainly wasn't Ca(OH)2 ;-)) with a pH of 12. Roberto, It was really fine your analysis of the "famous" Sjogren study. Very true points. But, really good was the phrase: "Is quite hard to understand the passion about this issue. Recently, I did a literature review on that to try to determine the Strength of Recommendation for Single-visit Root Canal Treatment using the SORT grade. I could find 39 articles after the first-step screening. Of the 39 articles, only 6 were classified as RCT. The interesting point is that among these 6 RTC only Trope (1999) found better results for the CaOH2 group. Find attached some further studies on that. One good is the Ng paper (2008). - Gustavo GIGO!! And to think that people base a philosophy on such "papers". - Fred Fred, You are right. But the point is that ALL of these studies have methodological limitations. So, GIGO for both sides and so, each one choose yours! - Gustavo I know what Peters wrote on the second paper, but how it was done on paper #1 described her methods. Think about it. She had bacteria grow in Ca(OH)2.... that should speak to the methodology or lack there of. Also, look at how Weiger placed Ca(OH)2 in his paper......only using paper points if I remember correctly. Also, I spoke with Orstavik several years ago about his treatment protocols, and lentulos were always the method. Why the method wasn't described in the paper is a serious omission, especially since they did it the right way. And, it allows some to negate the results of the paper. Perhaps Gustavo's point of pick your garbage is correct. But just think about the meta-analysis that you quote about Ca(OH)2 and one-visit versus two.... I said previously. - Fred Dear Fred, 1. Look at double standard here: A. LB Peters writes DOWN in her clinical OUTCOME study how they placed the Calcium Hydroxide,with lentullo and than packed with paper points. And we say it's not true. B. Trope et al FORGET completely to write down how they placed it, but because we talked with Dag Orstavik it means is ok. ( I also think in Trope 1999 they used lentullo, and that's why I didn't even comment this). 2. I see a trend of moving the discussion from outcome to bacteria count, because with outcome is obvious nobody proved one is better than the other. If in 2011 we go back to discuss paper point sampling and culture of bacteria is a huge way back. But it was mentioned here the idea of having bacteria growing back in the canals as a huge drawback of LB Peters study, and I saw it questioned what kind of CaOH treatment is this ? Probably we all know, and audience of Roots might be also interested to find out that bacteria regrew in the canals also in WALTIMO study and also in KVIST study ( I attach here the slides with the comments). And what is interesting is to find out, was the WALTIMO study done with the same group of patients as Trope 1999 ? ;-) 3. Double standard again: - if Garbage in, how can we say one method is better than the other. Logically I see just 1 option to say if we don't believe in anything: - I DON'T KNOW WHICH IS BETTER -- Roberto Double standard and excuses..... 1. Peters writes down that she used only paper points in the first study which later became the follow-up study. WHO IS MAKING EXCUSES NOW? Please have Prof Wesselink come on Roots and verify how the Ca(OH)2 was placed in the first study, and I will ask Trope to do the same for his study. I have some colleagues who were present when Peters presented her work for her PhD defense. Game on! - Fred Dear Fred, 1. We started with outcome studies discussions - there was no proof that one technique is better. 2. Than we tried to move the discussion into placement methods of CaOH - we ended up showing that even others didn't mentioned their technique, while the ones blamed not to describe, were writing it down. So no proof. 3. We tried to move the discussion into growth of bacteria or re-growth, using studies which were done with paper point sampling, which we know nowadays how useful is (see attached paper). And we discovered re-growth in more studies, not just in one. So no proof. 4. Now we try to move the discussion in even more ridiculous details like who is knowing who,and what gossip heard each one at a coffee....This far I cannot go.... Let's look at the brighter side of the future: 1. I hope Terry will provide you with as much recalls of his AP cases done with single visit approach so that you can manage even with CBCT study to see if there is any difference in outcome. Let's hope he will manage to get as many recalls as possible. 2. I know you have and will have brilliant clinicians as residents, you have CBCT machine available,and there is a super post-graduate program at Einstein. Design a RCT study and see both the degree of healing of AP and also if there is any difference in healing , 1 visit vs 2 visits. It will be your center study, so nothing will be questioned. I have fully trust in a study coming from you,designed nowadays after the rules of the evidence based dentistry. warm regards,, Roberto How Useful Is Root Canal Culturing in Predicting Treatment Outcome? Chankhrit Sathorn, DClinDent, Peter Parashos, PhD, and Harold H. Messer, PhD The paper you posted is another GIGO.....don't you see that? And do you know how many cases it would take to show a 10% difference between 2 treatment modalities? I learned that with a 2x4 ;-)) - Fred Dear Roberto, A conversation to clear up misunderstanding between Wesselink and Trope on methodologies of their respective studies would be highly educational. That is all I asked for. Not looking for coffee talk.....just an honest conversation between colleagues. I hope you can see the difference. - Fred Fred, Personally, I like much more the scientific message from Prof. Wesselink than Trope. Even more after Resilon/Epiphany ... ... But, I need to say that I really appreciate your cordial style in conducting a debate ... and always looking for the better scientific approach. Nowadays, more than ever, this is an important feature to be followed. Gustavo I appreciate that Gustavo! Thank you. - Fred

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