Healing on a retreatment case


The opinions and photographs within this web page are not ours.
Authors have been credited  for the individual posts where they are.
Photos: Courtesy of Jorge Vera - www.rxroots.com
From: Jorge Vera
To: ROOTS
Sent: Tuesday, April 26, 2005 12:32 AM
Subject: [roots] HEALING ON A RETREATMENT CASE ( CORRECTED)

I sent this case earlier but my computer got crazy and attached another file that wasn´t mine. Hope it goes trough
this time - Jorge Vera

 



No patency, yet beautiful healing.

So how do we(you) explain these?  The biofilm, bioburden, is significantly reduced such that the balance of
disease/healing is tipped in the favor of the host?  The biofilm/infection in the uninstrumented areas is
disrupted by diffusion of Ca(OH)2?

I have a couple cases I'm trying to follow like this ( too recent for follow-up images as yet)
retreats without patency on one or more canals, yet symptoms resolved and apparent healing underway - Kendel

Yes Kendel, I would guess the medicaments have a lot to do with this, but, on the other hand, achieving patency
doesn´t guarantee elimination of Biofilm or bacterial flora like we proved on the study done with Nair in which every
case was kept patent but 88% of the canals remained infected, on the other hand, there´s no study that has proven
that patency increases bacterial reduction and/or success. I do however try to attain it in every case that I can and
I think it should remain a goal - Jorge

Let me play devil’s advocate.  If we have no evidence that patency increases success or even bacterial colonies, on
what are we basing the principal that attaining patency should be one of our goals.  What then is the justification
for doing so? - Gary

The same principal we use when we wash our dishes at home.   Intuitively we know it must be better when we leave
things cleaner - Mark

Isn't this an example of a situation where 'we don't have evidence' because thea ppropriate test (ie randomised
double-blinded trial) would be impossible to carry out, or ethically unacceptable?

I justify striving for patency on the basis that I want to give access to thee ntire canal system to my irrigants; if
there is a periapical radiolucency, then presumably the canal immediately adjacent to the p/a area is contaminated,
so I want to get into it.

An additional factor in my mind is that I cannot be certain about length control until I have achieved patency
- Simon, Oz

I agree completely, but, despite the fact that it hasn´t been proven to increase bacterial reduction (It probably
does), it has been proven to aid in maintaining working length and it aids in the cleaning of the apical third when
compared to those canals where patency was not achieved. So, I try to achieve patency but still can sleep very well
at night if forever reason I can´t on any given case - Jorge



You may be correct simon.  But we are an evidenced base profession.  How do we establish a protocol without hard
evidence it makes a difference.  I truthfully never did it until I joined roots.  I just finished a max bi two
minutes ago.  I instrumented a #20 hand file 2mm beyond the apex, finished to the apex locator reading, recapitulated
in between with the #20 in the m4, and obturated.  Does it make any difference I took the time to do it.  I hope so,
but I’m not sure.- Gary

Go to any endodontists office and ask him to show the last...Oh say 10Billion failures that came in.  Two will be
"long" i.e. overextended and underfilled.  The remaining 9,999,999,998 will be short.

I do not need a double blind, cohort bound, multi-location, cross-referenced, time trial controled, interdisclinary
study about dropping a hammer on my foot to know that it will hurt.  Every time.

What would such a study prove anyway?  If it said patency was not important, us barbarians would say "Methodological
problems"  If it said patency was important, the pulp lovers would say...."Methodological problems"

I trained at Iowa.  It was a major abandonment (I chose this word on purpose) of almost everything I was taught.  It
took a few years, and a very embarrassing question from Buchanan, but the bulb went off.

Again, paradigm effect.  The engineers, starring at the molten debris of Cherynobl knew from their construction of
the reactor core that it simply could not have blown up...

Speaking of Ruskies, why is is there are only defections from the pulp lovers side?

Ahhh ignorance is bliss.  I long for the good old days when I could be 1-2mm short.  Then I could do 10-15 cases/day
and get that e55 and new computer I have lusted after for years - John A Khademy

LOL..................the real bottom line is that we need to debride and especially disinfect to the foramen.
Patency will facilitate that as it helps to prevent ledging, blocking and transportation, all of which may compromise
the ability to properly disinfect - Fred

It obviously does not hurt.  We've been doing it accidentally for years with no ill effects whereas we do know that
there are ill effects from filling short.  I can see no down side to cleaning the entire canal and filling the entire
canal.  Can you?  - Guy W. Moorman, Jr. DDS

We are evidence based to a point and often scorn the statement, "it's worked well for years".  Truth be, "it's worked
well for years" is evidence based.   I remember when I was in the military they were going to put a warning against
using lidocaine in pregnant women on the package.  The basis of that was that lidocaine had come out since an
arbitrary date in the late thirties so it had to have that warning.  Is that evidence based or simply a crap shoot.
The dental profession was able to stop that warning from going on the package.  Lidocaine came out about 1 year after
the arbitrary date set by the FDA.

Evidence based CAN be a crap shoot when we have two or even three groups studying a material or technique and coming
out with differing positions or answers.  Sometimes, "it works well for me" is all the evidence base we need in some
cases.  We were getting patent for years without trying with no ill effects.  Now that we understand disinfection,
getting patent simply makes sense - Guy W. Moorman, Jr. DDS

How do we know that patency would effectively eliminate all the bugs?  But,I agree, that on teeth
with AP, patency is what I try to achieve and maintain.  But I have closets full of cases of AP that
never had patency and healed beautifully.  So what do we learn from this?

That patency is NOT the answer for enzootic success.  Please see the Hoskinson et al study and look
at their healing rates - Fred

Your comments please