Molar EICR treatment:Dycal isolation technique - Courtesy ROOTS
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From: Terry Pannkuk
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
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
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 Iíve 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 Pentronís
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. Iím 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