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Necrotic case - Courtesy ROOTS
From: "Ahmad Tehrani"
To: "ROOTS"
Sent: 09 June 2007 21:43
Subject: [roots] Last week's memorable consult

18 year old football player, whom is drafted to play for one the top notch football programs in the nation.
His UL central (#9) started darkening about 3 years ago when he was elbowed in the face. No pain, just discoloration.
His UR lateral (#7) had a sinus tract associated with it that he was completely unaware of. Hard to believe, but I had to literally show
him the GP in the tract to make my point.Both teeth were necrotic and didn't respond to ice stick or
EPT.....and both teeth were percussion sensitive.

Anyway since he is too busy and had to leave in 3 days his mother insisted that we do these RCT right away so he can go to college. We
discussed the necessity of multiple appointments specially for #7 and wait for closure of ST before final obturation. Not to mention the
multitude of cases I showed her from other patients. I drew and doodled and colored on the computer monitor like a chalk board,,,,,
She wouldn't hear of it and demanded, and I mean DEMANDED, that I refer them to another endodontist who would do this in one visit! I
asked her why not let an endodontist in Ohio treat him since he is going to be living there anyway?? she said she has to meet the doctor
herself before anyone touch her baby. BTW, the "baby" is 6'8" weighing close to 200 lbs! but to a mother he'll always be a baby.

Since I am such a gentle, calm, cool and collected push over, I let her have the phone book after she paid for today's visit.

You can take a dead horse to water, but you have to beat the crap out of him to drink the water...)))...Ahmad

Dear Ahmad, Fascinating case you are discussing. I do most everything in a single visit, and would love to read a fuller discussion by those of you who don't. I'm open to anything! One thing I wish you or someone would address ... No one talks about what they might do differently if a flare-up occurs and the case is not obturated versus a case where a flare-up occurs and the case is already obturated. That is, if the case is finished and a flare-up occurs, you might adjust the bite, you might prescribe something. If the case is finished already, what will you do differently? Are you going to open it back up again? Why? To do what? To get drainage? How often are you going to get drainage in such a case? In the very few cases in which I did not finish in one visit, and there was a flare-up, I was never able to get drainage at that point. Flare-ups are never a good thing and we all want to prevent and avoid them, but I don't think finishing the case makes them more difficult to treat. On the contrary, we can allow the body to heal without going back in. I may be all wrong, and I hope you can address it! I promise to read with great interest. Pat Patrick Wahl
Ahmad, I would have treated this in one appointment. But I do admire you for sticking to what you obviously so fervently believe.- DanS Hi Dan: I am very surprised to hear you treat this in one visit and aren't scared of Philly mob?...))) Kidding aside, tell me why? Is it because pt asked you to do it? or do you treat all necrotic cases in one shot? - Ahmad I will treat some necrotic cases in one shot, if I can meet my goals. That almost never happens on molars. I also think I try so hard on the first appointment that I wear myself out and it is good to come back with a fresher state of mind on the second appointment and have an easier time getting to where I want. The literature is a little confusing, since there are good studies that make a case for success rates either better or unaffected by a second appointment. I prepfer to think a second appointment is usually an advantage so I am likely to use one on most of my cases. This case you described is easier to reach cleaning and disinfecting goals, although I do like to confirm that a fistula has gone away. I still remember Paul Abbot treating cases for months, and avoiding surgery on many of his cases. I would have informed the patient of the possible slightly higher success rate with a second appointment, and then done what the mother wanted. - DanS am always amazed how many more answers I get the next day doing the crossword puzzle when I was stuck the previous day. The same is true with C & B. Had I taken my impression the same day, I may have left some decay, not taken off enough, ended a margin on some composite, etc. A second appointment I think is good. By that time, at the very least we know the patient should be feeling better and asymptomatic before we complete the case. - DCO Ahmad, I admire you for this. Most dentists I know would do as the mother has asked for. On the other hand - why not do one step endo on a single rooted tooth ? - Thomas One step a necrotic tooth with sinus tract and PARL ? you must be joking....)) - ahmad Not really Ahmad, My long time conclusion is that on simple teeth if you have a scope and can use ultrasonic cleaning the result of one and two visits is exactly the same. I two step everything necrotic and feel like a clown when my USA friends tell me they can't justify two visit's with only 1500$ per tooth ;-) My tendency is towards one step in single canaled teeth. Ask Marga and her Dutch collegues....Thomas Ahmad, It's good to see you stood up for what you believe for...most folks would have caved.- Joey D Joe: Actually it was a no brainer. Sinus tract, necrotic teeth,asymptomatic, been discolored for years, lackadaisical attitude, demanding parents, pt leaving town in 3 days..it is all recipe for disaster....sometimes we ask God to give us signs and he is waving all these red flags lit up by neon lights "DON"T DO IT" before our eyes....)) I am glad not to do this case, because it goes against everything I believe in.- ahmad Ahmad, You know you did the right thing and were not bullied into doing something you didn't believe was in the best interest of the patient. It would be too easy to take the single visit route with the better productivity etc. I'm glad that people still stand up for these things, well done. Just think, in a few years when he's at the Superbowl and getting his ring, with his gappy smile, you will think how he would still have the teeth had he seen you :-) - Bill Depends how you look at it. Sinus tract = guaranteed no acute blow up after treatment pt leaving town in 3 days = guaranteed "geographic" success ;-) I think the chances for "disaster" as you call it (in terms of acute post op discomfort and problems) are virtually nil. But I can see your point in not wanting to get involved with the case. However, having done a bazillion (Ok, not a bazillion - but probably 5-10,000) nonvital single appointment cases, I have to strongly disagree that single appointment treatment is associated with hugely different rates of failure. Yes, there is literature to support the premise that multiple appointment treatment (when done by certain individuals) has a higher success rate. But I submit that a lot of that research has more to do with WHO and HOW the endo was done. ( Sjogrem 97 is a great example). We have argued about that for years and there's no point in going over the problems with the research. There are a LOT of clinicians out there doing single appointment endo and very successfully. I have my share of failures and the literature mavens out there will scream and holler that I have no idea of my true success rate - but I'll tell you one thing - If the %s were so different than vital teeth - I'd be doing a lot more SRCTs and ReTx on them than I now do. Yes, I do have more failures with nonvital teeth - that is a fact and it makes sense that it would happen. They do fail more frequently. After 21 years its amazing how that 10 or 15 year old case will come back to haunt you. But of those that I suspect are "failures" - a very high % are VRFs - not true endo failures, I am now more careful about beating myself up when I see a "possible endo failure" recall name like that on my daysheet. BTW - I DO NOT charge for retreatments of my cases if I suspect they are true endo failures. If my nonvital failures were that bad, after 20 years I would be retreating them by the bushels. I would have a big $ incentive NOT to do one shots. It just isn't there. I wish to add one personal observation. I have been paying much closer attention to the failures that I have been getting lately and one thing has become abundantly clear. In those seemingly "easy" anterior teeth with chronic LEOs that don't heal, ( upper laterals especially) it doesn't matter how many times I place CaOH - the sucker simply will not heal. ( This is at odds with my BU training.) Invariably I end up surgerizing the case and the biopsy frequently comes back cystic in a higher % of cases than I would have guessed. I must agree with our esteemed Dr.Barnett ( and the Biofilm theory) that a very high % of these failures are probably due to extraradicular factors or what is known as apical plaque. And that means you can place CaOH til the cows come home and it won't help. BTW- I've never mentioned it to Fred but I find it ironic that ( being such a staunch proponent of CaOH use that he is ) he helped identify a clinical situation where CaOH really is ineffective. I suppose the real question Fred must ask himself is how accommodating will the patient be when after th 4th or 5th application of CaOH the lesion remains the same or the sinus doesn't close. How "patient" is the patient!?! (vbg) Here are some responses from the recent survey I did: Endodontists Outside Canada: 98 responses Do you routinely perform single appointment treatment on: Vital (non-infected) cases? 92.9% Teeth with necrotic pulps without radiographic periapical lesions? 67.4% Teeth with necrotic pulps with radiographic periapical lesions? 46.9% "Oher" responses which were added by clinicians: 1.Not routinely, but vital cases where all favorable factors line up 2.If I can get the canals clean and dry, I fill, in the absence of swelling. 3.The only cases I see for multiple Appts. are silver point retreats and cases that will not stop draining. 4.as rime permits 5.If I can dry the case I usually fill it. 6.Single visit for all necrotic teeth with a fistula. 7.Never on Retreatment cases. 8.depends on the case 9.Never 10.when the time is not limited Endodontists in Canada - 27 responses Do you routinely perform single appointment treatment on: Vital (non-infected) cases? 92.6% Teeth with necrotic pulps without radiographic periapical lesions? 70.4% Teeth with necrotic pulps with radiographic periapical lesions? 66.7% "Oher" responses which were added by clinicians: 1. As far as necrotic pulps with lesions, the tooth must be "dryable". 2. Only if canals dry consistantly. 3. If patient asks me to 4. Always unless i can't dry the case 5. Depends on the case 6. Too case restrictive to answer. For instance , what of sinus tracts being present etc.???7. General Practitioners: - 84 reponses Do you routinely perform single appointment treatment on: Vital (non-infected) cases? 85.7% Teeth with necrotic pulps without radiographic periapical lesions? 39.3% Teeth with necrotic pulps with radiographic periapical lesions? 25% "Oher" responses which were added by clinicians: 1. Depends on how much time I have available, patient availability, and clinical status 2. Having done single and multiple for many years, and looking at the evidence for single visit, I now routinely do single visit where time allows. 3. If I have the time I always try to perform in every case single appointment treatment 4. VERY RARE 5. I perform one-visit treatment of vital teeth if i have sufficient time to do this. Unfortunately, most of the time i see vital teeth needing endo is emergency and most often i do not have that time... 6.. Generally my cases have been seen on an emergency visit and a pulpotomy or pulpectomy has been done. So all my cases are one vist cases, exluding the emergency visit. 8.depends on the case 7. Not always. If it's a really hot tooth I'll try to calm it down first 8. Rarely do single visit endodontics. 9. It depends on the case 10.If time permits I try to do one visit if canal not draining 11. Teeth with one or two canals easy to negotiate if I can dry the canals. It was very interesting to see that Endodontists agreed ( almost to the exact %) on frequency of treating vital and "non LEO" cases in a single appointment. Canadians were more likely to treat cases with LEOs in a single appt ( 67 vs 47%). When comparing this to general practitioners ( where the single appointment procedure numbers are much smaller ) I suppose you could interpret this as them being more "careful" or feel that they need more time. On the other hand, you could say that while the Endo specialist may feel more confident in his single appointment cleaning and shaping skills - he should "KNOW BETTER" and we would expect him to use CaOH for most infected cases. The responses do not support this. As the costs for procedures go up ( scopes, Ni-Ti, expensive irrigants, single use instruments etc.) one can only assume that there will be more pressure to complete treatment in a single appointment. Call it "wrong" if you will but that philosophy is what is being implemented in the trenches - as the survey clearly shows. And as much as I like the literature - I find what people are actually doing in their practices to be far more interesting (and relevant) reading. At the AAE meeting in Phila , Gary Carr was kind enough to invite me to his TDO group meeting and I was interested to see that the they are now undertaking a VERY serious controlled study to address the very question of single vs. multiple appointment success rates. Because of the very stringent controls, I expect those results to be very interesting readings as well. If all goes as planned , I hope to be involved with that when I migrate to the Canadian version of TDO in the next few months - Rob Kauffman Rob ! geographic success I LOVE IT - Dennhardt H, LA Thanks for the reply and writing such a detailed descriptive post.....all we have is basically our perception. Your perception is that these teeth rarely flare up & heal in one visit per your experience and mine is the opposite. In spirit of debate only, I will give you my perspective about CH and later on about 2 or more visit endodontics. Facts we know about CH: 1. Necrotic cases with apical lesions have a higher success rate when treated in 2 appointments with CH medication ( for at least one week). 2. Microbial culturing studies demonstrate that canals treated with CH for one week have significantly lower bacterial contamination levels. 3. CH inactivates bacterial LPS (endotoxin), it kills bacteria, and it dissolves pulp tissue. There is little arguement that CH reduces or neutralizes the bacteria it comes in to contact with. The pH of ~11 is incompatible with most organisms encountered in endodontics. It certainly doesn't last forever, but it is the best we have as a dressing..... We have beaten the Sjogren study to a bloody pulp, but one glaring fact of his study is " reduce the bacterial count and obtain a higher success rate"......forget the concentration of hypo used or who did the root canal, did they pre-curve files, or used EOM,,,,it is all about bugs...It has always been and always will be...This is our goal, every single day , in every single case. Does hypo inactivate every single bug in a "canal system"? Is CHX the answer? how about CH? smear clear? MTAD? Negative suction devices? Whipping plastic sonic brushes? We all agree that there is not one modality that works by itself or is considered the silver bullet. It is all in a successive chain of steps collectively known as endodontic procedure. Now what if we added a step that not only is another antimicrobial disinfectant, it does no harm and increases our odds for success in necrotic cases based upon mounds of evidence. When a single visit doesn't heal we are still faced with what could have been done differently. Do ALL 2,3,4,5 step cases heal? No, but bet you a cup of tea, the percentage is much higher than one shot. In multi step cases you aren't left scratching your head and asking what ifs.....why? You have left no stone unturned and revisited the case in at least 2 separate occasions. You re-measure the length, refile the canal, plane the wails again, irrigate, re-irrigate.....repack CH....allow the immune system to recharge...etc....so even if you go to surgery it is done with confidence IOW, The "perception" is replaced by evidence. Your evidence. Now as you mentioned ( which was also shared by Gilberto Debellian in Monterrey) exceptions are the sulfur granules, extra radicular infection, extra canal plaque formation, root deposit of bio film......all not disturbed by what is done inside the root canal system.....but even then you still have to do what you can to minimize the bacterial population and minimize their occupying space by obturating the entire canal system...or simply not placing a lid on a garbage can....but whose garbage can is cleaner??? We all think we irrigate the best and clean better than anybody else, but unfortunately the science is not our side. They all point to what a terrible job we do of it. Dr. Carr's SEM are fascinating to look at it and very humbling to say the least.....another reason I like to give myself a choice to clean a system twice or trice..... Lets look at another scenario: ....how many times you get a case from another practitioner that you go straight to surgery without ortho-grade endo retreat? How many times you say the previous endodontist did the best job possible and only SRT will help? It is the old dogma of " retreat cases done by others and surgerize your own". The answer and opinions are too complex....and biases aplenty. We all make decisions based on our knowledge and our perceptions. It would be great to have concrete evidence, SCIENTIFIC evidence, for what we do for our patients. OK here is another scenario.....lets suppose you get a flare up after you one step a case...I know you said you NEVER do and the chances are nil when there is a ST, but for the sake of discussion what do you do? Do you retreat the GP filled canal or do you prescribe NSAID or Cortisone instead? how about AB?? how about the patients perception of endodontics after the treatment was "finished" and root canal was done? Now what do you think a 2 stepper would do? replace the CH , re-irrigate the canal, re-instrument the canal, repack and close the case. The pre-endodontic consultation is important to address the possible flare up and in either case the patient is upset, concerned and inquisitive as to the cause....However, in multi visit cases, they know the treatment is ongoing and not completed yet.....they know it is a process and we specifically tell them about possibility of swelling and intra -appoitment complication.. It is nice to have the option of revisiting the case once more before it is closed, obturated and sealed. But then it could just be me. I don't even want to discus the economics implications of multi step endodontics, because it is frankly ridiculous and has no place in our discussion. Soon it is extrapolated to scope, files, rubber dam and so on......Let me tell you endododntics is not for the faint of hearts where they skip a beat every time they have to throw away a NiTi file....We are physicians of oral cavity and not actuary insurance bean counters. Our responsibility and obligations is toward our patients who place their trust in us. So our decision to do a case in one or more visit is solely a patient based decision, and not what's good for us and our wallet. Although I can promise you, regardless of what part of world you live in, even in a multi step endodontic cases we make more money than a dish-washer, a garbage collector or an asphalt layer working for minimum wage. So who is right? the one steppers or the multi-step believers? No thanks to AEE, Dr. Carr and some 50+ other endodontists are funding their own study to address this very controversial issue puzzling and polarizing endodontists all over the world for decades. We shall see for the first time in a very deliberate, careful and controlled study what the answer is. Congratulations on getting TDO...there are many international users who are very happy with it - ahmad
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