Source: "Roots"
From: Jerry Avillion
Sent: Wednesday, April 25, 2001 7:42 AM
This came up on another list...
Is there anyone out there that uses formocresol or any of that kinda stuff for
interappointment medicaments?
My contention is that calcium hydroxide is the current state of the art.
Jerry Avillion
From: BENJAMIN SCHEIN
Sent: Wednesday, April 25, 2001 8:49 PM
No.
Powerful and irritating stuff.
But that is not what worries me in necrotic cases my "theory" is:
That if you can not clean the root canal system the formocresol kills the bugs
and the endotoxins or other bacterial cell products from their "carcasses" can
be more irritating than the medicament or the bugs themselves.
I know some people that use it as holding up therapy after a pulpotomy
(vital pulp), but without entering the root canals. Many BU'ers use cresatin
for vital pulpotomies.
I think nothing beats calcium hydroxide at the present, but not for the reasons
postulated generally (antibacterial properties) but for other reasons we ignore.
Ben
From: "Mark Dreyer, DMD, PA"
Sent: Wednesday, April 25, 2001 9:05 PM
It is still state of the art for pulpotomies on deciduous teeth from what
I've heard talking to docs that work on kids.
I was finalizing a prep for a crown yesterday and I had an exposure. The
pulp was pretty hyperemic. I couldn't stop the bleeding to do a bonded pulp
cap. She told me her husband wouldn't approve of my doing any further work,
(The crown had already been charged out a couple months ago, and I had sent
her for crown lengthening surgery) since he wanted her to get any further
work done by her "plan doc". Thus, I opened the tooth, and did a
formocresol pulpotomy. In my experience, this is the next best thing to do
as far as keeping the patient comfortable, when you can't instrument the
canals right then and there. I called her last night, and she was doing
fine. - Mark Dreyer, DMD, PA
From: Jerry Avillion
Sent: Wednesday, April 25, 2001 10:57 PM
Fred, Something that I always wondered about...
When you do a study, how do you decide where to publish it? (which journal)
Jerry Avillion
From: Fred Barnett
Sent: Thursday, April 26, 2001 12:02 AM
Hi Jerry,
It is usually a good idea to spread it around, especially if you are a basic
scientist, which I am NOT. I am just a clinician who masquerades as a
researcher/educator.
Most American Endodontists read JOE. OOO, Dental Traumatology and Int.
Endod J are subscribed to, and read, less often. (I think).
Right now the JOE has a 14 month waiting list, whereas OOO's wait list is
considerably shorter. Therefore, I am sending a paper to OOO from my Temple
Univ. study. We have 2 studies from Einstein that were recently sent to JOE
(better exposure for the residents).
At the time when we did the controlled release paper, my Chairman,
Leif Tronstad was the Editor-in-Chief of Endod Dent Traumatol.....therefore.
At Penn (1981-1991) we did everything we could to support that journal....even
if it meant publishing my lousy research ;-) - Fred
From: John J. Stropko, D.D.S.
Sent: Wednesday, April 25, 2001 11:49 PM
Calcium Hydroxide is a "Gift from the EndoGod". I have that on good authority!
John Stropko
From: "John J. Stropko, D.D.S."
Sent: Wednesday, April 25, 2001 11:53 PM
According to Gordon Christiansen, March'01, bonded pulp caps don't work!
John Stropko
From: "Mark Dreyer, DMD, PA"
Sent: Thursday, April 26, 2001 12:16 AM
Well maybe Gordo needs to come over and take a hands on course at my
institute-maybe we could co-produce a video tape :-)))
My criteria for using a bonded pulp cap is the following:
If I can easily stop any bleeding at the site of a pinpoint exposure, using
a bleach soaked cotton pellet, and if the patient had no hx of symptoms, I
will offer the option of a bonded pulp cap to the patient with the
understanding that the tooth will probably be ok, but it also may need endo
down the road. Having done a ton of these pulp caps over the years, I can
tell you that using this criteria, and in my hands, bonded pulp caps do
work. Of all the endo I do, VERY little of it is done on teeth I had
previously restored using adhesive restorations-pulp capped or not.
Mark Dreyer, DMD, PA
From: "Fred Barnett"
Sent: Thursday, April 26, 2001 12:47 AM
Mark,
Do you take in to consideration the type of final restoration that will be
needed? For example, if it will be a crown, will you still pulp cap on a
fully developed permanent tooth? - Fred
From: "Mark Dreyer, DMD, PA"
Sent: Thursday, April 26, 2001 1:08 AM
Fred,
No I don't consider the type of restoration in determining whether or not to
recommend a pulp cap. (I do very few crowns by the way-mostly I do tooth
conserving adhesively bonded onlays/inlays.)
My main thing is if the pulp seems to be hemhorragic at the site of the
exposure and/or the patient tells me he/she had even the slightest symptoms,
I'll always strongly recommend the endo. Otherwise, I'm quite comfortable
recommending the pulp cap as an option, even on a fully developed permanent
tooth. Seems to work for me.
Mark Dreyer, DMD, PA
From: Fred Barnett
Sent: Wednesday, April 25, 2001 12:01 PM
Formo loses all of its antibacterial properties by 1 day exposure to the root
canal environment. Having a controlled release antibacterial drug within the
root canal system makes a lot of sense.If I may: "Controlled release of
medicaments in endodontic therapy". Tronstad, Yang, Trope, Barnett.
Endod Dent Traumatol 1985. Ben, please let me slide on this one ;-)
Fred Barnett
From: "Yosi Nahmias"
Sent: Thursday, April 26, 2001 12:54 AM
Federico! This is where the microscope comes in handy! If there is a
problem, viola, the endo can be done! If it were my tooth, do the cap, no
endo for me! If I need it later, I go to see an Ninja with a Scope!(and do
not mean the green liquid to rinse your mouth with!)
From: "Gary B. Carr"
Sent: Thursday, April 26, 2001 1:36 AM
But according to him, Sargenti is just as good as what we do........
Gary
From: "John J. Stropko, D.D.S."
Sent: Thursday, April 26, 2001 7:00 AM
........In his
hands, everything works!!! But, unfortunately when he talks, people listen.
as far as the bonded pulp caps, my experience is the referrals to me that
didn't work. - John
From: "Mark Dreyer"
Sent: Friday, April 27, 2001 12:48 AM
Adhesive dentistry is VERY technique sensitive. I much rather have a
mediocre amalgam placed in my tooth than a mediocre resin. Do your
referring docs use rubber dam isolation when doing their adhesive
restorations? I'd bet not.
Mark Dreyer, DMD, PA
From: "Fred Barnett"
Sent: Thursday, April 26, 2001 3:39 AM
I am concerned about the longer term prognosis...5 years. On incompletely
developed teeth, a "partial pulpotomy" a la Cvek, is definitely indicated.
For a fully developed tooth with an exposure after excavating caries (pulp
will be inflamed, regardless of symptoms), that will be restored with a
crown or is a bridge abutment, I would recommend endo therapy.
From: (John J. Stropko, D.D.S.)
Date: Wed, 25 Apr 2001 18:25:40 -0700
Mark, Why not use MTA? - John Stropko
From: "Mark Dreyer"
Sent: Friday, April 27, 2001 12:45 AM
Because in the situations in which I'm doing a bonded pulp cap, I am usually
placing some sort of adhesive resin restoration also. Thus, I want to use a
resin for my pulp cap in order to get the best seal to the subsequent
restoration.
Mark Dreyer, DMD, PA
MTA, and then what??? You can not bond ot top of MTA (doesn't bond)! - Mark
From: "John J. Stropko, D.D.S."
Sent: Thursday, April 26, 2001 9:17 PM
Seal with a sterile, wet cotton pellet/Cavit for 24-48 hrs, then place
base/bonding etc. - John Stropko
From: "Mark Dreyer"
Sent: Friday, April 27, 2001 1:13 AM
Better yet, seal with LinerBond 2V (my favorite dentin bonding agent) &
Starflow (a flowable composite) and you are done in two minutes. Then you
can restore the tooth with a direct or indirect restoration of your choice
at the same appointment if you'd like. The nice thing is you won't have to
see the patient again in 24-48 hours using this technique. And if you
choose your pulp cap candidate judiciously, (ie don't do this on a tooth
that has had symptoms, or in which you have a gross carious exposure) and
follow meticulous attention to detail in your adhesive restoration
placement, you probably won't touch the tooth again for many years.
Mark Dreyer, DMD, PA
From: "Richard Schwartz"
Sent: Thursday, April 26, 2001 9:08 AM
See: Pameijer and Stanley. The disastrous effects of the "total etch"
technique in vital pulp capping in Primates. Am J Dent 1998; 11(special issue):56-61.
From: "Mark Dreyer"
Sent: Friday, April 27, 2001 1:06 AM
I'm not familiar with this study. However, I am aware of research by
Fusiyama out of Japan which contradicts the above referenced study.
Fusiyama is the father of modern adhesive dentistry. I recall that in his
research, he placed phosphoric acid directly on the pulps, sealed the pulp
with dentin bonding agent and resin. If I recall the results of his
research correctly, he was able to show that this protocol did not result in
pulps blowing up.
Now of course, if you are doing pulp caps on pulps that are already
inflamed, or if you are doing the pulp caps with sloppy technique, I'm sure
you could show that vital pulp capping doesn't work.
If you want the references on the Fusiyama research, I'd be happy to look
for it.
Mark Dreyer, DMD, PA
From: "Richard Schwartz"
Sent: Friday, April 27, 2001 7:53 AM
Hi Mark,
The paper I referenced showed that if there was bacterial contamination
of the pulp exposure the success rate was about 20%. It was done with
healthy monkey pulps that were exposed and contaminated with saliva. Half
were etched and bonded and half received direct pulp caps with CaOH. Both
groups were restored. The animals were sacrificed at various periods of
time and the pulps were analyzed histologically. The CaOH group had a
success rate of greater than 80%. Similar studies with dogs by Charlie Cox
showed great success with adhesive pulp caps, pulp healing and dentin bridge
formation. The difference is that he used virtually sterile technique.
When the pulp gets contaminated, which is always when you are doing a tooth
preparation, the success rate of adhesive pulp caps is likely to be low.
The antibacterial effects of the CaOH bring the numbers up. If you have the
opportunity to follow some that you have done, perhaps you can report back
to this group. As for Fusiyama, he has certainly contributed to adhesive
dentistry, but he is not considered a scientist. If you ever hear him speak
or see one of his videos, you'll appreciate this fact. He does his adhesive
dentistry without a rubber dam, and does things like have the patient bite
into the soft composite to form the occlusion before light polymerization.
The paper I referenced is probably the best study on this topic.
I taught restorative dentistry at the dental school in San Antonio in
the early 90s when this was a hot topic. We tried about a dozen adhesive
pulp caps and followed the patients. Most of them failed. They didn't tend
to blow up, but rather, died a quiet death.
Rick
interappointment medicaments
