Long standing toothache
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From: ahmad tehrani
Sent: Monday, February 20, 2006 2:28 AM
Subject: [roots] long standing toothache
2 years old PVC...the tooth has been constantly hurting and lately
the pain had become spontaneous, unprovoked and lingering. Aspirin
and Tylenol not effective.
Thermal test and EPT zeroed on #19 and clinical/radiographic
examination confirmed LL 1st permanent molar: Irreversible pulpitis,
with normal peri-radicular perio. gingival bleeding , should be self
limiting with proper hygiene & when PVC removed.. distal wall of
2nd premolar looks prepared...patient informed of it before any
attempt was made to remove the crown. Amazingly he was never offered
any treatment other than occ. adjustments and occasional does of
antibiotics whenever he complained.
after PVC was cut out and caries control the distal pulp horn was
exposed. The coronal portion of the pulp looked necrotic(no bleeding)
until I was 8-10 mm deep in the canal. subsequent to initial appt of
total pulpectomy with CH dressing, his was symptom free. 2 mesial
canals and by the time the distal was accessed, cleaned and shaped
it was a continuous c-shaped canal. System S and build-up with tiny
incremental composite, trying to minimize the c-factor like Liviu,
Marga and many others do in their cases. - ahmad
A beauty Ahmad, this applies to the endo, the build-up and the
documentation !! - Marga Thanks for your comments. - ahmad
Ahmad, all of us have some of those out there. I shot a BWX on
all my crowns before seating them because I'm really anal retentive
about everything I do in dentistry. Still, occasionally, you'll
shoot a film and say, "who did this crap?". ME! We miss a few. Guy
Very nice case! Please tell me about "system s" John Anderson,
eager to do better endo - John Anderson
Hi John: System S or Squirt is the molted warm gutta percha heated
to 200 in Obtura gun and injected to the perfectly shaped, cleaned,
patent canal system after a thin layer of cement placed. Drs. Serota,
Dreyer, Dovgan are resident experts. I learned this technique at
Dr. Stropko's office and obturate 99% of my cases like that.
It is not an un-controlled obturation technique if every step is
meticulously performed to the conventional endodontic
principles with minor modifications to adapt for obtura squirt.- ahmad
Good Answer Ahmad....I would only add one more item.....Puffs make
NO difference in healing but are the result of
adequate preparation to the terminous. - Joseph Dovgan
How do you obtain apical control with this technique? I love my Obtura
but I place a .04 or .06 GP point and sizzle it with the Touch & Heat
first. I would be worried about blowing alot of GP out the apex without
a apical plug in place. I had that happen a few times years ago when
I tried the Phase II system. - Steve
Surprisingly, with system S the biggest worry is not the overfill
...it is the underfill. Think of System S as 100 people
trying to get of a room at the same time.Only a few can get through.
But all the shaping objectives must be in order for it to happen.
Phase II was a different beast than Obtura....I have looked at many
cases that Dr. McSpadden had obturated with his PhaseII and no one
can do it better than him. The Alpha phase is too sticky and runny
for me, so with an open or irregular apex, the chances of
extrusions are quite high. The PacMac is pushing the soft GP ahead of
the tip. So it becomes a forceful compaction of a runny material.
And it is harder to compact the GP with Phase II than Obtura since
it is too soft. After buttering the condenser with beta and alpha GP
it was too thick for inserting it in most canals with the way I was
shaping the canls ( that could be the answer to my frustration
with that technique)
But ad with any technique, the more practice you have the easier
it becomes. So my suggestion would be pick ONE technique and master
it. You would know the limitations and advantages so making
adjustments becomes easier. - Ahmad
Iím surprised to hear you say that. I am hardly an expert, perhaps
now having done 20 cases or so, but I have never been short.
My biggest fear has been apical control, but the more I do it the
less concern I have, unless I have a #80 apex or something
of that nature, then I still fit a cone. It seems if instrumentation
is done properly the only thing going beyond the apex is sealer,
and that can be limited by placing the proper amount of sealer,
which ainít much. I use joeyís condensors preset approx 4mm from fill
length and for proper diameter. I especially like squirting in
curvatures and where two canals have a common poe. - gary
Steve....does extrusion of GP bother you? If so, then System S is definatley
NOT for you. As for the apical control...it all has to do with creating an
orifice of a certain diameter at the terminous.- Joey D
Hi Joey, From what I understand you want to try and keep the GP inside the
root if at all possible. Is there any difference in success rates with slight
overfills? - Steve
Steve, Why do you want to keep the GP in the canal systems? Could the
research be flawed? does it represent clinical reality?
Steve, You know years ago...I was a Prove it to me kinda guy....it was
because of my graduate program..we had to justify everything we do with
literature with Rick Walton...lit for this, lit to pick your nose, lit for
everything ya know.
10 years ago, I was very fortunate to have a long conversation with Cliff
...asking him the literature (and I already knew the answer...I went to
lateral heaven at Iowa)...show me the proof...and he spent over an hour
with me...which I'm sure was very taxing to Cliff....because I can be
quite the debator...
In any case, his final response to me was "You just gotta believe"...
which I thought sounded more like religion then a proof. But the words
stuck with me.
They had to rattle in my brain for a few years...then I met Stropko and
he showed me the Squirt Technique aka System S...and while it's different
then the way Cliff does it....I'll never forget his words...because he
"broke me into the way of thinking about overfills...YOU JUST GOTTA BELIEVE"
Overfills and extursions are NOT bone magnets like some on the lecture
circuit will have you believe...but they are a marker that perhaps you
have shaped, cleaned and obturated to the terminous.
Endodontics is about biological control, removing substraites and antigens,
and obturating to keep some stuff out. - Joey D
How about this one, Joey? :-)Anyone worrying about overfill check out the
one year. Not as good a radiograph but adequate. We won't debate the
material but the fact is that this overfill was totally asymptomatic and
healed without a problem. I'm not posting this as a good thing.
As Bill Watson said, I had some pretty crappy apical control on this thing.
But the overfill did nothing negative...just looked scary. Guy
Guy...even I consider this one a little extreme. But ya gotta love it
working.- Joey D
Ruddle actually called it "surplus" ..... excess means too much
which is what GP out of the tooth is)
Any GP you put out into the periapical tissues is going to prevent complete
biological repair ..... isn't it?? A bit of sealer, maybe ... but GP?
That's an overfill - Simon Bender
"I'd rather have a little gp out in the bone than a bunch of bugs in the canal"
How's that for a quote...you can quote me on that. LOL - Mark
First and foremost Steve, this is a Canadian journal.we elected Steven
Harper so letís put things in perspective.
Second of all, neither example reflects a well sealed optimally sterilized
functional tooth residual gutta percha in an extraction site and a leaking
crownless bicuspid would be problematic regardless.these are isolated cases..
where in the case of the remaining gp, the tooth that was extracted could
have had a significant CAP and that was residual with bacterial content
after the extraction, the other one is a leaking root canal at best.again,
define excess itís the distinction between overfilled and sealed and over
extended and unsealed.- Ken Serota
So you mean I don't have to beat myself up when I push the GP a bit past
the apex (as long as the canal is properly shaped and cleaned that is)!
Never beat yourself up. Your presence here indicates you probably do it
better or will do it better than 95% of the tooth talking population.
Joey can clarify, but I believe he once told me he gets upset if he doesn'ít
have a puff of stuff on the film.- gary
I hope nobody is suggesting you can't seal a root canal without blowing
"excess" GP into the bone - SB
Joey D, "It's not about the overfills...it's about cleaning and shaping to the
terminous and then obturation to the terminous with a little extra squeezed out.
Cliff Ruddle once said "You can only fill a tooth 100%...everything else is just
excess" - Joey D
Beautiful case! Terrible PFM! - Steve
makes you wonder why no BW x-rays were exposed before seating the sombrero crown,
doesn't it??? Probably trying to spare the patient from excess radiation...))
I always try to expose at least a vertical BW and a PA before seating anything.
Thanks for your comments. - ahmad
Ahmad, In addition to totally missing it on the margins, the previous dentist
tapered the heck out of that tooth didn't he? Do you anticipate any challenges
related to the excess taper in making the new crown? - Mark
Mark, new porcelain margin crowns and all porcelain crowns require more
reduction and often you get more taper. They are retained very well with the
new GI cements and adhesion. The biggest problems my labs see is lack of sufficient
tooth to complete what the script calls for. Guy