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Tooth # 37 : Double curvature

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Authors have been credited  for the individual posts where they are.
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From:
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







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
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[PubMed - indexed for MEDLINE]
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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