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Endo tips    Better Endo    Endo abstracts    Endo discussions

Tooth # 37 : Double curvature

The opinions and photographs within this web page are not ours. Authors have been credited
for the individual posts where they are. /font>
From: Patrick Baltieri
To: ROOTS
Sent: Wednesday, March 04, 2009 6:48 AM
Subject: [roots] Tooth 37 - double curvature

Attached is a clinical case, held in single session.

Description:

1 Patient reported that the tooth had "broken" some months ago and that
he  felt some discomfort in the region. However, a week before the pain
increased;
2 Tooth 37 showing extensive caries, pulp necrosis, pain in palpation and
percussion;
3 In the radiographic examination was the presence of chronic periapical
lesion and mesial root with double curvature;
4 Diagnosis: pulpal necrosis and pericementites due acute exacerbation of
periapical lesion;
5 Procedures performed:

* anesthesia in buccal region  using articaine 4% with epinephrine 1:200,000;
* removal of carious tissue;
* the location of the channel MB was made with the aid of ultrasound, since
  the two channels in this root is separated from the middle third;
* preparation with the Easy Prodesign system following the technique of
  UNICAMP (Brazil, Piracicaba-SP), with patency and enlargement of the
  apical foramen;
* chlorexidine 2% gel and EDTA 17% was used as chemical substancy, and
  irrigation was made with saline;
* Obturation by the technique of continuous wave of condensation, using
  cement and points of the mark Konne;
* Build up with the composite resin, using as the adhesive system
  ClearFill SEBond.

In the immediate postoperative period (2 days), the patient reported that
pain and discomfort had disappeared completely.  - Patrick Baltieri

tricky diagnosis

tricky diagnosis

tricky diagnosis

tricky diagnosis

tricky diagnosis Patrick, that is a fantastic case, very well documented - Jose Nice case Patrick, It'll be interesant to attached the cd Rx with the files 1mm beyond the apex as the Unicamp tecnique preconizes. It'll disturb some folks - Sergio. Well-done documentation and very beatiful case, Patrick. Congratulations.... But, just one point: No NaOOCl??? - Gustavo Thanks Gustavo... No hypochlorite... I only use chlorexidine 2% gel, in all cases! - Patrick Baltieri Edward, Yes, the Easy Prodesign system is a brazilian product, you can find more about and buy these files in this site: www.easy.odo.br The master apical files were #35 in mesials and #40 in distal (gauged with hand files). I never use Hypoclorito, all my treatments were performed with the aid of chlorexidine 2% gel, EDTA 17% and saline to irrigate - Patrick Baltieri Is that Henrique Bassi's technic? - Fred The instruments were developed by Henrique Bassi, however, his technic is adapted to our purpose (apical ampliation), following the phylosophy of FOP-UNICAMP (Piracicaba, SP, Brazil) - Patrick Baltieri Patrick, Please explain the advatage of the NaOCl non-use - Gustavo My answer will be summarized in one word: SECURITY! Especially, when it's made the ampliation of the apical foramen, that we do in ALL cases. - Patrick Baltieri 1: Motta MV, Chaves-Mendonca MA, Stirton CG, Cardozo HF. Accidental injection with sodium hypochlorite: report of a case. Int Endod J. 2009 Feb;42(2):175-82. PMID: 19134046 [PubMed - in process] 2: Kleier DJ, Averbach RE, Mehdipour O. The sodium hypochlorite accident: experience of diplomates of the American Board of Endodontics.J Endod. 2008 Nov;34(11):1346-50. Epub 2008 Aug 30. PMID: 18928844 [PubMed - indexed for MEDLINE] 3: Mehdipour O, Kleier DJ, Averbach RE. Anatomy of sodium hypochlorite accidents.Compend Contin Educ Dent. 2007 Oct;28(10):544-6, 548, 550. Review.PMID: 18018389 [PubMed - indexed for MEDLINE] 4: Sawalha AF. Storage and utilization patterns of cleaning products in the home: toxicityimplications.Accid Anal Prev. 2007 Nov;39(6):1186-91. Epub 2007 Apr 13.PMID: 17920842 [PubMed - indexed for MEDLINE] 5: Arévalo-Silva C, Eliashar R, Wohlgelernter J, Elidan J, Gross M. Ingestion of caustic substances: a 15-year experience.Laryngoscope. 2006 Aug;116(8):1422-6.PMID: 16885747 [PubMed - indexed for MEDLINE] 6: Gursoy UK, Bostanci V, Kosger HH. Palatal mucosa necrosis because of accidental sodium hypochlorite injectioninstead of anaesthetic solution. Int Endod J. 2006 Feb;39(2):157-61.PMID: 16454797 [PubMed - indexed for MEDLINE] 7: Gorguner M, Aslan S, Inandi T, Cakir Z. Reactive airways dysfunction syndrome in housewives due to a bleach-hydrochloric acid mixture.Inhal Toxicol. 2004 Feb;16(2):87-91.PMID: 15204781 [PubMed - indexed for MEDLINE] 8: Ziegler DS, Bent GP. Upper airway obstruction induced by a caustic substance found responsive tonebulised adrenaline.J Paediatr Child Health. 2001 Oct;37(5):524-5. No abstract available.PMID: 11885726 [PubMed - indexed for MEDLINE] 9: [No authors listed] Managing the NaOCl accident.Dent Today. 2001 Oct;20(10):44. No abstract available.PMID: 11665413 [PubMed - indexed for MEDLINE] 10: Hülsmann M, Schade M, Schäfers F. A comparative study of root canal preparation with HERO 642 and Quantec SC rotary Ni-Ti instruments. Int Endod J. 2001 Oct;34(7):538-46.PMID: 11601772 [PubMed - indexed for MEDLINE] 11: Kavanagh CP, Taylor J. Inadvertent injection of sodium hypochlorite into the maxillary sinus.Br Dent J. 1998 Oct 10;185(7):336-7. PMID: 9807916 [PubMed - indexed for MEDLINE] 12: Jakobsson SW, Rajs J, Jonsson JA, Persson H. Poisoning with sodium hypochlorite solution. Report of a fatal case, supplementedwith an experimental and clinico-epidemiological study. Am J Forensic Med Pathol. 1991 Dec;12(4):320-7.PMID: 1807142 [PubMed - indexed for MEDLINE] 13: Mühlendahl KE, Oberdisse U, Krienke EG. Local injuries by accidental ingestion of corrosive substances by children. Arch Toxicol. 1978 Feb 14;39(4):299-314.PMID: 25063 [PubMed - indexed for MEDLINE] 14: Hales JJ, Jackson CR, Everett AP, Moore SH. Treatment protocol for the management of a sodium hypochlorite accident during endodontic therapy.Gen Dent. 2001 May-Jun;49(3):278-81.PMID: 12004727 [PubMed - indexed for MEDLINE] 15: Ehrich DG, Brian JD Jr, Walker WA. Sodium hypochlorite accident: inadvertent injection into the maxillary sinus.J Endod. 1993 Apr;19(4):180-2. PMID: 8326264 [PubMed - indexed for MEDLINE] 16: Neaverth EJ, Swindle R. A serious complication following the inadvertent injection of sodium hypochloriteoutside the root canal system. Compendium. 1990 Aug;11(8):474, 476, 478-81.PMID: 2097052 [PubMed - indexed for MEDLINE] 17: Varela SG, Rábade LB, Lombardero PR, Sixto JM, Bahillo JD, Park SA. In vitro study of endodontic post cementation protocols that use resin cements. J Prosthet Dent. 2003 Feb;89(2):146-53.PMID: 12616234 [PubMed - indexed for MEDLINE] 18: Kaushik SP, Yim HB, Agasthian T. An unusual manifestation of severe caustic injury.Singapore Med J. 2000 Jan;41(1):39-40. PMID: 10783681 [PubMed - indexed for MEDLINE] My reply can be summarized in ONLY ONE POINT AS WELL: I have concern with the organic load missed into the root canal system. Moreover, luckily, NaOCl accident is relatively rare when well-trained hands are considered. It is a fact - GUstavo De-Deus I respect your views on this feature of hypochlorite (dissolve organic tissue), but I believe that the removal of the organic tissue shall be made with the instrumentation... The problem is not only well-trained dentists using NaOCl. I know of several accidents that were not published, occurred in my region... so these facts are not so rare - Patrick Baltieri .......I respect your views on this feature of hypochlorite (dissolve organic tissue), but I believe that the removal of the organic tissue shall be made with the instrumentation... if you consider the complex anatomy of root canal system, You will come to conclusion that instrumentation alone is not sufficient - Michal Jegier I was searching in PubMed at this moment and, as Patrick Wahl said, all papers that study hypochlorite tissue dissolution, are performed in conditions quite different from those in the root canal. I never said that hypochlorite is a bad substance, far from it, however, justify its use by ability to dissolve tissue, it´s complicated. Like you, I also treat patients, so try to employ what I believe to be the best for them. I don´t want that you stop use NaOCl, and do not have the intention that, only present a case of my pratice, that I did with the biggest care to my patients...Patrick Baltieri Thomas, This really summarized the whole issue: "we treat patients, not x-rays" - Gustavo If you want security, change your method of delivery, not your substance of irrigation. You won’t have any accidents using EndoVac. That way you can take advantage of the tissue dissolving properties of hypocloride (which chlorexidine simply can’t do) without any risks. Although in my humble 7 years of endodontics using 2,5% hypocloride, I’ve never had one single accident, and I didn’t even start to use EndoVac yet - Leo Leo, I’ve been using it over 35 years, early on with primitive delivery systems with no accidents. Had on small CHX but no consequences or unusual post op pain. Fear is what we have to fear in utilizing proper protocol for doing endo. It is seen in the fear of separation. How often does that happen and how often when it happens does it matter. Even a sodium hypochlorite is not the end of the world - Guy We meant safety - Leo Leo, In my 12 years of practice, Í've also never experianced no one even using full-strength NaOCl. - Gustavo Dear Patrick, Couldn't help myself but to respond. Removal of organic tissue with instrumentation only? I am sure you know what % of the canal you don't even touch with your files and I am not talking about the tissue in the fins, isthmuses, lateral canals whatever. I don't think anyone can justify not using NaOCl in endo. Look at Terry Pannkuk he even doesn't want to use apex locators in order not to miss 1 minute with NaOCl inside the canals. Your case is a work of beauty on the x-rays, but we also need to address the biology (there is someone on this forum that points this out all the time). We need to do as much cleaning as possibly we can. Sadly, without the NaOCl you don't. As Marga told me we treat patients, not x-rays - Thomas Excellent, Thomas. I had a case yesterday two cases point of fact that had POE and laterals that no file was going in consistently. I had to depend on sodium hypochlorite and irrigation to get access - Guy Dear Thomas, Like you, I use hypochlorite in every case. I'm looking for every little bit of help I can get. However, I wonder if we are attributing more to hypochlorite than it really delivers. If we're talking about tissue removal in a vital case, I have not seen literature that convinces me that hypochlorite does that significantly better than water. The literature that DOES show hypochlorite's tissue removal abilities are in no way clinically-relevant. They use hypochlorite in situations that just aren't the same as what we do. For example, some of these studies immerse necrotic tissue entirely on all sides in hypochlorite. That's nothing like a root canal system, and it's nothing like what we're able to do clinically. Is anyone aware of any literature that shows superior tissue removal of hypochlorite in a situation similar to what we do clinically? I don't do what Patrick does. But I'm not convinced he's wrong - Patrick Wahl Hi Pat,Nice to see you here. Pat, most the endo and dentistry studies are far away from the clinical situation. But, it not necessary means that they don’t have any value. Clinical recommendations based on such findings are deductive and, so need to be interpreted with care. However, individual problems can be singled out in these investigations and basic information can be gained. This is one of the science pathway. So far, NaOCl is irreplaceable as the main irrigant. The amount of residual organic tissue after cleaning and shaping procedures is also a universal concern. There is lot of evidences showing that even using full-strength solution, considerable amount of residual organic tissue remaining in the isthmus, irregularities and etc It’s obvious that with the non-use of only one biocide solution without tissue dissolution ability, the amount of residual organic tissue will be increased. In addition, Pat . See the below text remarkable review about irrigation (JoE, 2006) by friend Matty Zehnder. The concern is not only about tissue dissolution but also on the inability of CHX on Gram-negative bacteria which is abundante in the primary endo infections - Gustavo Despite its usefulness as a final irrigant (see Suggested Irrigation Regimen below), chlorhexidine cannot be advocated as the main irrigant in standard endodontic cases, because: (a) chlorhexidine is unable to dissolve necrotic tissue remnants (63), and (b) chlorhexidine is less effective on Gram-negative than on Gram-positive bacteria (74, 80, 81). This may explain why long-term application of chlorhexidine in dogs led to a domination in plaque samples of Gram-negative rods (82). It must be cautioned here that many ex vivo studies use extracted bovine or human teeth mono-infected with Enteroccous faecalis, a Grampositive facultative species associated with failed root canal treatments (83). However, in primary endodontic infections, which are usually poly-microbial, Gram-negative anaerobes predominate (20). Entero- cocci are rarely encountered in primary endodontic infections (84). The efficacy of chlorhexidine against Gram-positive taxa in laboratory experiments may thus cause an over-estimation of the clinical usefulness of this agent. In a randomized clinical trial on the reduction of intracanal microbiota by either 2.5% NaOCl or 0.2% chlorhexidine irrigation, it was found that hypochlorite was significantly more efficient than chlorhexidine in obtaining negative cultures (85). This was especially the case for anaerobic bacteria, while the difference for facultative taxa was less significant. Furthermore, more culture reversals from negative to positive were found with chlorhexidine than with hypochlorite. The authors attributed this phenomenon to the inability of chlorhexidine to dissolve necrotic tissue remnants and chemically clean the canal system. Dear Gustavo, I agree wholeheartedly that studies have value. That's why I read them. I am hoping and praying and crossing my fingers that hypochlorite has great value in removing tissue. But the studies supporting this idea I find to be remarkably weak. I use hypochlorite, but I am careful not to pretend that my irrigant is the only acceptable irrigant. There is wide disagreement among endodontists on this issue. I personally know two endodontists who use only saline. Clinical recommendations based on such findings are deductive and, so need to be interpreted with care. Exactly. However, individual problems can be singled out in these investigations and basic information can be gained. This is one of the science pathway. So far, NaOCl is irreplaceable as the main irrigant. Irreplaceable? I think that is too strong a word. Pretty soon, you're going to say that Resilon is "irreplaceable" as an obturant! The amount of residual organic tissue after cleaning and shaping procedures is also a universal concern. There is lot of evidences showing that even using full-strength solution, considerable amount of residual organic tissue remaining in the isthmus, irregularities and etc Exactly! As you say, even after using full-strength solution, the tissue remains! It’s obvious that with the non-use of only one biocide solution without tissue dissolution ability, the amount of residual organic tissue will be increased. When people use the word "obvious," it is usually because there is no literature to support the assertion they are about to make. It is not obvious to me that hypochlorite, whose tissue-dissolving abilities are suspect to me in a clinical situation, will do a better job clinically of tissue removal than water will in the same situtation. Yes, I use hypochlorite, but I'm crossing my fingers as I do. In addition, Pat . See the below text remarkable review about irrigation (JoE, 2006) by friend Matty Zehnder. The concern is not only about tissue dissolution but also on the inability of CHX on Gram-negative bacteria which is abundante in the primary endo infections. I've tried to separate the issue of tissue removal from bacteria fighting. I agree they are both important, but to have a clear and productive discussion, I think we should address them separately, and I was responding only to the assertion that hypochlorite does such a spectacular job of tissue removal that to forego its use would be to demonstrate a lack of concern for the patient - Patrick Wahl Here it is Pat... There are good papers about NaOCl. As a whole, irrigation is one of the better studied aspects of all Endo. The review that I quote do a nice job summarizing all the main background. Pat, with all respect that I have to you, but this not deserve a comment. < I was responding only to the assertion that hypochlorite does such a spectacular job of tissue removal >. I never said that NaOCl do a spectacular job in terms of tissue dissolution but, certainly, in a measure significantly better than CHX alone. At this moment, Yes! NaOCl is irreplaceable as the MAIN IRRIGANT. Moreover, improvements in the NaOCl properties are coming…..see recent paper about Chlor-XTRA (attached). You really don’t need that since NaOCl is better way, so far. On the other hand, undoubtedly, your ‘saline Endo colleagues’ really need that - Gustavo Gustavo, I’ve been using sodium hypochlorite years before we had the good delivery systems we have today. Early on in the 70s I was using it because Col. Cox in the US Army taught me to. This is totally 100% anecdotal but observable. In the mid 80s an new endodontist came to a nearby community and told me to stop and use anesthetic solution only…bleach was dangerous. My retreat rate ballooned to twice what I was having using bleach and some of those retreats were referrals to him. By the end the mid 90s he was using sodium hypochlorite. An excellent endodontist can get away with not using it. Pannkuk could have excellent results without it but that’s not what Terry is looking for. Terry is looking for absolute perfection thus bleach close to out the apex…and he’s right - Guy Chlor extra is NOT just hypochlorite, but has surfactants added to it that decrease the contact angle with dentin and make it much more effective. Haapasaalo has done a good deal of the research on this. Gary pond, feel free to jump in and fill in the blanks - gary Dear Gustavo, This will be my last post on this topic as I suspect many are tiring of it. Please know, however, that my love for you is always and forever. There are good papers about NaOCl. As a whole, irrigation is one of the better studied aspects of all Endo. The review that I quote do a nice job summarizing all the main background. Gustavo, the review you quoted said NOT A WORD about tissue dissolution. As I said, the literature that I have seen convinces me NOT AT ALL that tissue dissolution really occurs with live tissue in the clinical situation. Pat, with all respect that I have to you, but this not deserve a comment. Actually, after I posted that message, I realized -- I personally know THREE endodontists who use only saline. One of them was my instructor both during my dental school days at Temple as well as during my endodontic residency days at Penn. I do not agree with their choice, but I am not so convinced of the magic of hypochlorite as to be adamant about my own choice. I think irrigants work mainly mechanically in removing debris (as water would). The rest is a lick and a promise; a wing and a prayer. < I was responding only to the assertion that hypochlorite does such a spectacular job of tissue removal >. I never said that NaOCl do a spectacular job in terms of tissue dissolution but, certainly, in a measure significantly better than CHX alone. NaOCl has better tissue dissolution properties than CHX alone? In a petri dish, no doubt, because CHX has no tissue dissolution properties AT ALL. But in a clinical situation, I'm not so sure. And I don't think you can be so sure, either -- certainly not that the difference is significant, unless you can present to me the study performed under clinically-similar conditions. At this moment, Yes! NaOCl is irreplaceable as the MAIN IRRIGANT. Moreover, improvements in the NaOCl properties are coming…..see recent paper about Chlor-XTRA (attached). You'll be pleased to hear that I've been using Chlor-XTRA in every case since this product was mentioned on ROOTS years ago. Like I said, I'll do anything that might help within the confines of a single visit. But I'm not so adamant about my way as to think it is the only way. I've read the literature, and it is weak. You really don’t need that since NaOCl is better way, so far. On the other hand, undoubtedly, your ‘saline Endo colleagues’ really need that. I'm crossing my fingers that the magic attributed to NaOCl really occurs clinically. I know it occurs in a petri dish. - Pat Unfortunally we have a group of endodontics in Brazil that forget all the history of endodontic treatment and one of the most important basic principles of the irrigation solutions like organic tissue dissolving. In my 11 years of endodontics and 6 years of endodontic teaching using NaOCl, I've never had one single accident. It's absurde change the irrigation substance due to untrained dentists!!! The target is: Training, training, training, not change of substance. Everything should be as simple as it is, but not simpler. (Albert Einstein) - Leandro Fear breeding fear. Thanks, Leandro. Gustavo, there must be a lot of excellent dentists in Brazil. I meet them on restorative forums also - Guy Dr. Leandro, Sorry for disappointing you, but I am one of these endodontists... I don't forget the story, but don't get attached to it, so the changes are much easier to happen. Again and for the last time, I think that justify the use of NaOCl by its dissolution property is not the better approach, despite the fact that in vitro it dissolves. Antimicrobial property of NaOCl is another discussion - Patrick Baltieri Patrick, This has getting a bit out of hand. Every endodontist that has a scope can easily see the NaOCl working in the canals as it is BUBBLING. Do I need any more proof than that, that it is working ? Does Saline bubble as well ? Does it change color because it does anything ? Using saline is a waste of time as it doesn't do anything better then the NaOCl but the NaOCl is better then Saline in everything. Even if it's just 5% better my patients deserve it. That doesn't mean I would like to have something even better. Also if you use GEL, please tell me how you make it go to all those hidden places inside the canal like fins. Also are you sure at all you can remove it from the canal at all? Nuff said, - Thomas

Protaper flaring

6 yr old Empress

Cvek pulpotomy

Middle mesial

Endo misdiagnosis

MTA retrofill

Resin core

BW importance

Bicuspid tooth

Necrotic #8 treatment

Finding MB2 / MB3

Deep in a canal

Broken file retrieval

Molar cases

Pushed over apex

MB2 and palatal canal

Long lower third

Veneer cases

CT Implant surgury

Weird Anatomy

Apical trifurcation

Canal and Ultrasonics

Cotton stuffed chamber

Pulp floor sandblasting

Silver point removal

Difficult acute curve

Marked swelling

5 canaled premolar

Sealer overextension

Complex anatomy

Secondary caries

Zygomatic arch

Confluent mesials

LL 1st molar (#19)

Shaping vs Cleaning

First bicuspid

In Vivo mesial view

Inaccesible canals

Premolar 45

Ortho and implant

Radioluscency

Lateral incisor

Obturation

Churning irrigant

Cold lateral

Tipped to lingual

Acute pulpitis images

Middle distal canal

Silver point

Crown preparation

Epiphany healing

Weird anatomy

Dual Xenon

Looking for MB2

Upper molar resorption

Acute apical abcess

Finding MB2

Gingival inflammation

Irreversible pulpitis

AG BU ortho band

TF Files

using TF files

Broken bur

Warm technique

Restorative prognosis

Tooth # 20 and #30

Apical third

3 canal premolar

Severe curvature

Interesting anatomy

Chamber floor

Zirconia crown

Dycal matrix

Cracked tooth

Tooth structure loss

Multiplanar curves