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Endo tips    Better Endo    Endo abstracts    Endo discussions

interappointment medicaments
The opinions within this web page are not ours.Authors have been credited
for the individual posts where they are. - www.rxroots.com


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

(But according to him, Sargenti is just as good as 
what we do)........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
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