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Treatment of multiple teeth

From: Terry Pannkuk To: ROOTS Sent: Wednesday, July 08, 2009 6:44 AM Subject: [roots] 22 year recall, multiple teeth treated I live for this information and feedback. This very petite woman with limited jaw opening and a narrow arch was very difficult to treat when I performed endo on #19 in 1987. I didn't do cores in those days naively thinking that my senior colleague referrals would elegantly isolate teeth aseptically and place meticulously designed cores. Remarkably many of these types of cases come back on recall with surprising success. Not predictable success, but surprise success of the anecdotal "Close Encounters of the Third Kind". :) In Paleozoic Era when I started endodontic practice I would simply send back teeth as requested with post space in mesial canals, distal canals, alimentary canals, ear canals, or etc. I literally "aimed" to please. These days I don't worry about pissing people off by doing what's best for the patient. For instance, I saw a consultation patient yesterday, the woman needed a simple molar endo with no ala carte complexity codes. She went home and her daughter talked her into requesting extraction. I frankly told her that I didn't feel comfortable extracting strategically important teeth that could be easily saved even though I was capable of extracting it and placing an implant for her. I sent her to an oral surgeon to do the dirty deed. This type of attitude is an evolution in confidence, or maybe an evolution of progressive arrogance. Whatever it is I don't care and I sleep well at night. The giant post in the distal root of #19 and the incompletely filled mesial core space would tend to suggest a problem with eventual percolation of contaminants over time, but it's "suspected to be healing". You can see the hint of an abrupt, tight, hidden apical curve on the distal. Over the years any over-filled material typically resorbs back to the root surface making it look short. Gutta percha resorbs just like sealer although much more slowly. Personally I don't like material resorbing which is why I don't use Kerr EWT which was brought up in a previous post. All these issues are favorite topic of argument and differing rationales. I also treated teeth #'s 20, 21, and 29 (not 22). They weren't as interesting. The patient moved to France for about a decade and returned a couple years ago. #18 had been treated while she was overseas and was giving her subtle symptoms (slight percussion sensitivity and awareness) for about a year until we decided last month to retreat it. I really didn't want to because her maximal incisal opening was now less than 30mm and her management was much more complex than it was 22 years ago when she was younger. I prescribed her 1mg of Xanax and performed some spray and stretch with a refrigerant. It was stressful for her but we managed. I placed the core on this one. It will be interesting to see if her symptoms subside now that the root canal systems were prepared with deeper shape and presumably better cleaning. The "apical splay" is the classic sign of appropriate deformation via multiple waves of compaction at an adequate heat carrier temp (Touch n Heat above 340C). You can see that the narrow "Rotary Shape" of the initial treatment radiograph belies the apical convergence that is demonstrated on the retreat - Terry multiple teeth treated

multiple teeth treated Dear Terry, Could you please give me some explanation about what you mean by spray and stretch? - Amir The classic text by Janet Travell and David Simons describes the technique ("Myofascial Pain and Dysfunction, The Trigger Point Manual"). I spent a week observership at the UCLA Pain Managment Center right after dental school and before I started my endo residency observing the multidisciplined approach to nondental pain; very insightful. Bernadette Jaeger and Stephen Graff Radford were the two specialists pretty much running the clinic at the time (1983-1984). The original technique was described by Hans Kraus in an article he published with Janet Travell in 1952. He discovered that spraying ethyl chloride on the skin relieves musculoskeletal pain. The refrigerant allows stretching and improvement in range of motion. If you freeze the specific muscle fibers that are undergoing maximal tension during passive stretch you will note remarkable improvment in range of motion. It is the standard Rx for myofascial therapy.....and another favorite tool used in amateur porn like the Canon Rebel, just ask Khademi. :):):):):):):) - Terry

DFDBA
Typical molar
Type II palatal
Canals
Deep split
Gold onlays
Cerec Onlay
Multiple access
MB root
Cavernous sinus
Apical in DB
Apical lesion
Resorption lacuna
Upper bicuspid
Pulpitis case
Multiple tooth isolation
Interdental molar bone
Dens invaginatus
Periapical healing
Microscope Zeiss
Calcific metamorphosis
Instrumentation protocol
Perforation case
Double curvature
Buccal sinus tract
Buccal swelling
Lingual version
Percussion
Tooth # 4
Dumbing down of dentistry
Evidence based dentistry
Upper incisor
MB and ML canal
apicoectomy
Furcal floor
Trauma case
Broken file cases
Large lesion
Flex post
MTA obturation