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Endo tips    Better Endo    Endo abstracts    Endo discussions

Apex Locators in the diagnosis of perforations

  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 -

From: Jorge Vera
Sent: Tuesday, April 26, 2005 12:32 AM

I sent this case earlier but my computer got crazy and attached 
another file  that wasnīt 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 doesnīt 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, thereīs 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 entire canal system to my irrigants; if 
there is a peri apical 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 hasnīt 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 canīt 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
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