CaOH therapy after RCT failure

From: "René Stevens " To: "ROOTS" Sent: Saturday, June 28, 2008 3:44 AM Subject: [roots] my fist roots post, Ca(OH)2 therapy after RCT failure Trauma at approximate age of 9, RCT, US rinse NaHypo, obturation thermafill, no second canals found 31 and 41 Failure, growing p-a lesion, after a time i was allowed to do the retreat, Ca(OH)2 therapy, after 6 weeks changed the Ca(OH)2 (ultracal) Positions of 31 and 41 became normal, obturation with hybride technique. With regards René Stevens Netherlands.

René, Great case. Why do you think the first effort failed? I always try to answer this question when I retreat. I suspect the case had wither two canals or a wide canal that was not fully instrumented the first time. Maybe the first access was too far lingual and all instruments were directed to the facial? Anyway, this is the question you must answer yourself because this is a great learning opportunity when you do a retreat. - Dan Shalkey Thanx Dan, The first time i think i was maybe a bit to conservative with the canal preparation, also thermafill may have been a small part in the failure. Before the retreat i changed my irrigation protocol, i now rinse longer with NaHypo with UltraSonic aggitation and in case of retreat or necrotic tissue i also use 2% ChlX, of course EDTA is used in all cases. During the retreat i did not have a scope (have one now) but could not find second canals. Failure: underinstrumenting in combination with not enough NaHypo, maybe just more time for dissolving issue by the NaHypo wold have worked also in the first RCT. Missed canal/fin? - René ´Stevens Dan, I always try and do the same. I'm curious as to your conclusions, in general. Most of the time I come to the conclusion that the case fails due to coronal bacterial leakage. After all, persisting or recurring infection is the reason for disease. Many cases I retreat do have concerns with the original therapy, yet they are free of signs and symptoms for years before presenting with disease. Attached is a case with apical perforations in the mesial canals, and a perforation in the floor from the initial therapy. The referring dentist and I tried to persuade the patient to have the tooth removed, but she is strong willed and has a good dental IQ, so she insisted we roll the dice. I could not improve on the mesial root shapes, other than to disinfect and debride them more thoroughly after removing metal carriers. The floor perforation was repaired with MTA. She presented with pain, and symptoms were resolved during the CaOH phase. The initial therapy on this tooth was completed more than twelve years ago. My point is this: how long would this tooth have remained free of signs and symptoms if the coronal restoration was adequate to prevent micro leakage? I do not like the term "failure". It's not good for the soul ;-)) , and I do not intend to diminish the importance of quality endodontic treatment. I just want to emphasize that we often say the words "this root canal failed", when it is clearly a case of restorative breakdown leading to contamination. If you like the term "failure", let's say that the "restorative failure" led to contamination of the root canal system, requiring revision of the treatment. In such infected cases, the technical bar is now raised, and untreated, unfilled space will prevent healing. I feel it is important to place the emphasis on the restorative treatment. We are entering a time where we understand that teeth with lesions have not only internal, but extraradicular biofilm. Chronic low grade infection and inflammation may be present, the systemic effects of which are yet to be fully understood. New 3-D imaging systems are going to change the way we see these lesions, literally and figuratively. In this environment, I think it is critically important not only for the patient, but for the sake of endodontics, to emphasize the critical role that the definitive restoration will play in prevention of disease in root filled teeth. - Kendel

René, Great case. Why do you think the first effort failed? I always try to answer this question when I retreat. - G K Garretson I guess there was coronal leakage and / or undetected canal which led to failure. Two canals in lower anteriors is quite common. Thermafil probably doesn't have much to do with it. Possibility of missed canal is higher though. - S D Jamdade Hi René, Indeed a nice healing. I have some remarks though. How long ago was the initial treatment done by yourself? On your initial radiograph, there is no lesion present. So, the AP is likely due to ingress of bugs during or after finishing treatment. I don't think you can blame thermafil, but maybe the quality of the coronal restorations may have play a role here. Are there temporary restorations in place? I am not sure what you mean with underinstrumentation, but in my opinion, both teeth seem overprepared after the retreatment. I don't mean the apical part, but I am referring to the coronal third, there has been a significant reduction of sound tooth structure, which in turn will weaken the teeth considerably. I agree that there must be enough room to have the irrigation solutions work effectively, but that is never a problem in the coronal part. - Marga Marga, in the initial RCT the coronal seal was done with the RD on. it could be that the seal was not good enough, all i can say is that i really tried to make a good seal. The first control x-ray was made one year after RCT, The father at that point did not go along with a retreat, so i followed the progression of the lession. After that i could explain that not only the x-ray showed a problem but that the displacement of the lower incisors was also caused bij the prei-apical lession i was allowed to do the retreat. I will take your comment of an to agressive instrumentation of the coronal part to heart. (is this correct english?? dutch: ter harte nemen). - Thanx for your input. - René Hoi Rene, Looks great, the puff will resolve. - Drs. J.W.J. Spaargaren hi Rene, wellcome and keep posting excelent cases like this - Dr. Sergiu Nicola,