From: Terry Pannkuk
To: ROOTS
Sent: Friday, February 12, 2010 4:48 AM
Subject: [roots] Molar EICR Treatment

This patient came in during the holidays for a second opinion looking for an endodontist to tell him he could
save his tooth. The previous one who took a CBCT said it was untreatable.  I looked at the CBCT he had in hand
and told him it looked complicated but was doable with a guarded-to-fair prognosis if I was allowed to take the
crown off, perform crown lengthening, and build-up and repair with amalgam; otherwise it would be best to have
the tooth extracted.

A month ago I extirpated the pulp leaving the crown  and at the end shelled out the resorbed area and treated it
with TCA then filled the canals with calcium hydroxide.

I continued on this morning. The Lava crown took forever to cut off which I did first thing. I then used a special
high-tech Parkell device to coag and cut the tissue away. If Glenn wants to email or call me I'll explain how
this really cool device works. I then prepped and smoothed the external resorption defect out (predetermined
to be supraosseous from the CT), isolated multiple teeth with the dam clamping the second molar and sealing the
holes, building up walls with Dycal, then performed the RCT, and at the end bonded with Amalgabond and built up
with amalgam.  The patient had unbeknownst to us today coordinated a visit with his dentist to the temp afterwards.
We immediately canned that idea since the amalgam would be fragile the fact that I had scheduled this as an
open-ended appointment which would have made him an hour late to see his dentist.

This is a perfect example of how I mismanage the Spa image of my practice.

1.  I didn't make things easy for my referral.
2.  The patient didn't get an immediate temp.
3.  I didn't have a cool laser.
4.  I used mercury.
5.  I spent 4 hours treating the case when the patient thought it was probaby going to take 2 1/2 and we didn't'
    give him any aromotherapy or foot massages.

I was happy with the result though. I prepped out all the minute resorption defects with a Munce bur feeling that
I was able to definitively manage the resorption and I don't think the restorative dentist will have a difficult
time prepping it and making a crown.  I'll get a CT in about 6 months after the tooth is restored.   Actually the
patient seemed very satisfied with the treatment even though it took extraordinarily long.  He seemed to be looking
for someone willing to spend the time to give this tooth the best chance possible.  With these questionable case,
the patient has to be on board, you have to be confident you can manage it, and then you have to spend all the time
it takes to not let any weak link compromise the result.  My assistants hate these cases. :):):) - Terry




Nice case.  How do you charge for this?  Same as your normal fee?  Assuming you could do 4 normal cases in 4 hours
do you charge 4 times as much?  How does this compare to an implant fee?

Not being critical, just wondering.  I struggle with these issues every day.   - Paul A Jones

What normal case gets done properly in one hour? :)  Tissue can't possibly be dissolved from a root canal system
that is performed in a single 1 hour visit.   I charged for crown lengthening, resorption management/TCA/CH,
a build-up, and a molar RCT.  It still wasn't nearly enough to make me as profitable as some guy who "machine-shops"
out 6 rotary-defiled one-shot cases a day, but it allows me to pay my overhead and keep my doors open. :) - Terry

great case  and great management - I love these open ended cases with a series of problems and possible solutions,
and nothing but time required to figure out how to get there.

I have never seen Dycal used to form a temporary  build up - but it obviously works for you.   My own solution to a
temporary build up - which I have used for many years, is to etch the tooth/root surface and place a build up using
flowable composite  - this is very stable and can be used to take length measurements. It can also be used to hold
the dam in place ( usually, but not always with a clamp on adjacent tooth also)  After RCT, the flowable  can be
snapped off because it has not been bonded, I use an ortho pliers -  Ken Heritage

Thanks Ken, Dycal is cheap, strong, and seals very well.  I use it primarily as a rubber dam seal on difficult teeth
to isolate but started expanding it's use as a matrix, to help enhance matrix band, copper band marginal contours
and support.

Here's a presentation I gave on the topic a couple years ago, various Copper Band, Dycal Isolation/Matrix techniques.
- Terry

The buildup Matrix and Endodontic Isolation maintenance
Focus on two techniques - 1. Dycal Isolation  2. Copper band Matrix support

Thanks for presentation - very neat

so, John Kanca is wrong after all, there is a use for Dycal, and what are we going to do when amalgam is gone!
- Ken Heritage

When amalgam is gone I'll just have to extract these teeth that could have been saved like he does now. :( - Terry

So very true Terry! So true! Nice solution to a tough issue we face daily - Sanjay Jamdade

TERRY I HAVE JUST DOWNLOADED AND SEEN YOU DYCAL AND COPPER BAND PRESENTATIOS IT HAS BEEN OF GREAT HELP TO ME.
THANK YOU VERY MUCH - Javier Pascual

I have tried Dycal several times to seal the rubber dam since Terry mentioned it last year.

There is no question that the Dycal works much better than Ultradent's OraSeal. The Dycal dries solidly in place,
and does not itself leak -- unlike OraSeal which does not dry, does not necessarily stay in place, and can itself
become soaked and useless due to the leaking dam.


I still use the OraSeal most of the time, simply because there is no mixing and no issue of working time --
it is easier to use. But when I need something that really works, I now use Dycal - Thanks, Terry!

I can't do the things you do, but I can use Dycal - Patty

Pat, this probably only happens with fools like me but I’ve found a simple way to really dam it up.  Take the
adhesive for PVA and a tiny mop used to apply bonding agent.  Paint the adhesive lightly around the area needing
sealed on the dam and the tooth and wipe a fast setting PVS material.  I use Pentron’s Correct Bite material.
It is hard also and stays put.  The material can be easily removed from the tooth with an abrasive cup.
You need only a small amount.  I found myself to be bad with the Dycal so I went looking.  I’m probably the only
idiot who does this but it works.  The adhesive goes in the mouth with impressions so it is not out of line to use
it lightly on a tooth.  It will dam like crazy.  You can even stick it to a clamp and polish it off later - Guy