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Two visit retreat with CaOH - Courtesy ROOTS

The opinions and photographs within this web page are not ours. Authors have been
credited for the individual posts where they are - www.rxroots.com
From: sashi nallapati
To: ROOTS
Sent: Sunday, February 26, 2006 5:05 AM
Subject: [roots] recall this week

Only one recall from this week.......
6 month and 15 months recalls  19  AP, two visit retreat, with Caoh , HEALING IN PROGRESS..
its taking longer than i expected...  sashi nallapati

Itīs looking nice at 6 months - Jorge Sashi: The distal canal is definitely healing...just look at the floating gp hugging the apex while the lesion is shrinking....)) did you use CHX as part of your irrigation? Do you BELIEVE that CHX or Steriolox has any merit upon healing lesions of this size? MTAD is sold at 1 million dollars a gallons, but there are studies indicating not much better than EDTA+CHX rinse? So much of what we do is working so perfectly despite of imperfect technique for addressing the apical 1/3. and if you happen to see this in 4-5 years (with incomplete osseous repair) what do you think you could improve internally by NSRT? I am not saying it will fail as I think it has an excellent chance to heal,,,but since it is quiet around here, I was hoping to drag you in to a discussion,,,)) - ahmad ahmad, I may have used chlorhexidine in this case but i am not 100% certain. my experience with MTAD ,chlorox and chlorhexidine on the rate of healing is none and the literature that I have read so far has not mentioned any thing on the rate of healing. caoh has been associated with faster healing rates though...... I think lesions of this size in retreatments may take a longer time than in initial treatments as the microflora is shown to be different and more resistant perhaps??? if I see this treatment fail in a few years and if I rule out coronal leakage, then I do surgery... I am not sure if I can improve this result by going back again nonsurgically - Sashi Nallapati Interesting, that the best intra-canal irrigant is still hypochlorite....and the rate of healing is overwhelming when utilized liberally. As you pointed out, the change of microflora to more anaerobic strains makes control of the bacteria even more difficult in AP cases. Perhaps that's why we try different solutions to kill all. CHX is also a very effective against E.facealis, if you believe it has anything with endodontic failure....do you? and what about CH? I remember you did many single visit and 2 visits w/ CH cases? what was your recall results like? which regimen are you going to partake in private practice? Sashi, I don't think anyone can improve what you have done. How many apical surgeries on molars have you done? and do you submit all lesions for a histology report? - ahmad e feacalis has been increasingly being shown not that significant in endodontic failures. its importance in biofilm formation as a monoinfection and its role in creating an ideal environment for biofilm formation in a polymicrobial infection has been implied in tx resisitant periodontitis but current lit in the last few months seem to think the pathogenecity of these bacteria may not have anything to do with the symptomatic AP and they may be just innocent bystanders.. atleast that's my take on this caoh is a good meidcament but not perfect. Clinical trials looking at the efficacy of this drug have been equivocal and there seem to be evidence supporting both one visit and two visit with caoh tx modalities. my recall rate is minimal and so far I am yet to see a failure in any of these categories, but the recall number and the recall period are too short for any valid conclusions. I presented a topic presentation to my faculty and residnets on one vs two visit endo and my conclusions are: IN my treatment philosophy one or two visits modalities should be directed not only for the extra microbial control that may or may not be derived from caoh and an extra flushing from your irrigants, whether the canals are dry or not, but also from establishing a technical protocol for your cases i.e., 1. Determination of apical length (where do oyu clean and shape to, I.E patency or no patency) 2. determination of apical width for that particular canal and achieving it 3. symptoms of the patient( I.E is the patient comfortable to go through the entire tx time of cleaning shaping and obturation) 4. whether all the canals that could possibly exixt are found and treated ( do you routinely see more at a second visit?) 5. and a very important factor , whether the operator is feeling rushed to do the procedure or he/she has enough time to do this well (see all the above) and if all these criteria are met then atleast at present I dont have any problem finishing cases in one visit... but alas i end up doing quite a few vital cases in 2 visits because I cannot achieve the outlined criteria which by the way ,from literature, attracts lower success than when done in one vist ;-)) I have done about 20 max molar surgeries (including private practice) and 2 mand molar surgeries. at school we always send for a biopsy , in my practice , I was guilty of being lenient... - Sashi Nallapati Sashi: Thanks for the detailed reply...Quite a few interesting points you brought on.... one or two visits modalities should be directed not only for the extra microbial control that may or may not be derived from caoh and an extra flushing from your irrigants, whether the canals are dry or not, but also from establishing a technical protocol for your cases i.e., but isn't the technical protocol objective the same as microbial control? IOW, don't we file, shape & irrigate for reducing the bacterial population? and unfortunately the more sophisticated we become with our research and diagnostic tools, such as, SEM, TEM and confocal microscopy...the more elementary our current methodology of treatment looks. We now know there are bacterial colonies and biofilms that our irrigation doesn't even effect. It is also humbling to know that our instrumentation may not anatomy of the root canal system as we think it does, So I agree with you that looking at CH purely from a microbiological stand point may be skewed, but considering our less than perfect instrumentation perhaps the use of CH may give us not only an added edge to bacterial control, but another chance to revisit the case with another regimen of irrigations, instrumentation and disinfection. 1. Determination of apical length (where do you clean and shape to, I.E patency or no patency) do you try to achieve patency in all cases right from the start? or do you differentiate between cases with different diagnosis? let me give you two examples.... 1. Necrotic pulp, cellulitis and firm swelling....no sinus tract and, 2. Necrotic pulpitis with sinus tract with AAP. which case merits to obtain patency in the first visit? and why? 2. determination of apical width for that particular canal and achieving it This without a doubt is the most misunderstood part of endodontics for me. Determining the apical diameter by successively larger files, not only can move the foramen from its original location, but ellipticizing the foramen, hence creating an added dimension of difficulty to achieve an apical seal. I just can't understand why thinning the most delicate part of root (purposefully to ridiculous sizes ) can achieve, other than zipping or cracking the root end. so what is the happy medium? 3. symptoms of the patient( I.E is the patient comfortable to go through the entire tx time of cleaning shaping and obturation) I agree..excellent point. 4. whether all the canals that could possibly exixt are found and treated ( do you routinely see more at a second visit?) Well how would a one-shot endodontist know what they may find the 2nd time around, if they never take a 2nd look? It may not necessarily be a missed anatomy..it could be a tissue tag, or an incompletely cleaned canal wall, or even finding another POE of the same canal that can effect the outcome of the case. 5. and a very important factor , whether the operator is feeling rushed to do the procedure or he/she has enough time to do this well (see all the above) and that goes back to #4...the one shot endodontist believes s/he does..and the Ca(OH)2, multiple visit endodontist thinks s/he doesn't. "One shot"er, says CH blocks all POE and smudges the pristine canal walls they just shaped, cleaned and irrigated...and the CH aficionado claims that there is enough real estate left untouched that they need a disinfectant like CH. e feacalis has been increasingly being shown not that significant in endodontic failures. its importance in biofilm formation as a monoinfection and its role in creating an ideal environment for biofilm formation in a polymicrobial infection has been implied in tx resistant periodontitis but current lit in the last few months seem to think the pathogenecity of these bacteria may not have anything to do with the symptomatic AP and they may be just innocent bystanders.. Now i saved my favorite part for last. For those who have been on ROOTS for a while, remember that Dr. Schein has been preaching the same thing about the e.feacalis. "An innocent bystander"....It was only after listening to Dr. Costerton, that it finally clicked in what Ben has been saying all along. Endodontic microbiology has relied on a planktonic model which in reality is not only inaccurate, it is far from what really happens naturally, The single bacteria theory is as solid as the lone gunman on grassy knoll in Dallas... with all that said and done, Thank goodness, we can still provides a very predictable outcome for our patients despite all the mental gymnastics of debates in Endodontics - ahmad Ahmad, Thanks for the detailed response to Sashi's case. It is very stimulating and hopefully is causing a lot of thought. I would like to explore your comments under #2 , determination of apical width. I agree that apical width or apical preparation diameter is a very misunderstood and more commonly overlooked factor in debridement. I am a LightSpeed user for over 13 years and I would like to explore the basis for your statement of concern about larger apical preparation sizes. I would also like to post a copy of a recent review article in the Journal of Endodontics on apical preparation size for others to review as this discussion proceeds. When you made the statement about transporting and elipiticizing the foramen with progressively larger instruments were you referring to tapered instruments only or were you including non-tapered LightSpeed instruments also? If you were referring only to tapered instruments I would have to agree with most of your statement. Tapered rotary NiTi instrument are indeed very stiff, especially with larger tapers such including .04 tapered instruments and larger tapers. I would also like to ask how you determine the final apical preparation diameter in your cases? There is quite an accumulation of anatomic, SEM, microbiologic culturing studies that support larger apical preparations for better debridement. Studies using the Bramanti sectional method and other methods to evaluate canal transportation clearly indicate that larger apical preparation sizes can be achieved with the more flexible LightSpeed with little or no transportation. There are others on ROOTS who base this critical part of the endodontic procedure on opinion and ignore research. They want to dismiss established, confirmed research yet offer no legitimate reason for doing so. There was a time when the literature was weak and very thin on this subject and small apical preparations could be defended but that is no longer the case. Proper defense of this position requires scientific substantiation. I think the review article makes that point very well. Finally I am enclosing a case I just completed an hour ago. It's #18 please look at the pre-op distal canal, it is very large even before I initiated the endo treatment. My final preparation was 45 on the mesials and 80 on the distal. Notice the wide funnel shaped anatomy of the distal canal orifice also. It is still in it's original position. When using instruments larger than #60 LightSpeed they too become stiffer and can cause some transportation. Yet even though it was necessary to enlarge this to a #80 to properly debride this large canal, there is minimal transportation. Ultrasonics were used to insure that the B & L of the distal canal was properly debrided also. - Randy Hadrick

I ask these questions in the spirit of scientific debate for the benefit of the members of ROOTS. I'm not looking for a testosterone charged conflict - Randy Hedrick Dear Randy ! I have enjoyed the article you have posted. It doesn't show a solution to the problem and doesn't discuss LightSpeed. I am not a LightSpeed user, but I can understand the rationale behind it. Your clinical case is also very nicely done. A great service to the patient - Thomas Thanks Thomas for the compliment. Just trying to add another piece to the endodontic puzzle we try to put together everyday in practice - Randy Hedrick Hi Randy: sorry for the late reply. But, I wanted to read the pdf you attached and be able to respond intelligently. It is hard for anyone who does clinical endodontics and recall his patients to believe : "....mechanical instrumentation in presence of irrigants doesn't reliably disinfect an infected system." and yet they concluded with some obvious notions : "However, these studies are often retrospective or have other factors (e.g. sample size) Moreover, many of these studies do not specifically evaluate the impact of a significant enlargement of the canal or of apical region with regards to clinical success. They have also shown that larger apical sizes yield cleaner canals that may promote further success. Failing to clean canals, especially in the apical region, can result in treatment failure. ".... no disagreement here... My opinion about the bigger and bigger apical diameter is the lack of consensus as to what size is actually produces more healing, and more importantly if it does actually promote healing. Again the quality of seal in such big sizes is a concern for me. Yes we can take apical diameter to a size 100 and remove all the substrate infected dentin from the canal walls apically, but shouldn't we concerned what's happening to the delicate root as we take more and more dentin away? and when do we stop? Reducing the bacterial count is only one dimension.... blocking, sealing & preventing their re-occupation of the system is another. and what about those cases that fail to heal despite our best effort? how big should we make those apices at retreatment??? Some jokingly say : we might as well take the tooth out for 100% success.....)) A series of carefully bent ss files, 1-2 mm from the tip, in presence of copious solutions can be quite effective to prep the apical area too....and there is an added advantage........not only it can be bent to follow the natural curvature of the canal...it can be effective to look for extra POE and accessory canals and basically scout the canal. But I like the LS files as an adjunct to our armamentariums..... I use it by hand to clear the apical area. I don't dream of spinning it at 2000 rpm (2500 rpm for LSX) at the apex. Bill Watson, whom I consider one of the best endodontists in the world, utilizes LS files for determining apical constriction size, apical diameter, and master LS binding file in his "Plains Technique" by hand. In summary, I am not defending a passive # 20 to apex and proceed to obturation protocol. I never met anyone who does either. Just stating the obvious, that each case is unique and should be addressed as it own. some require a size 80 and some a size 35. But my goal is not to take every apex to size 60 and above. However, preparing a canal with ss file as mentioned, takes time and patience, requires deliberate attempts to recapitulate the apical area through a well shaped & tapered canal to introduce irrigating solutions and removing debris. Randy, my knowledge of endodontics is miniscule compared to a Board certified endodontist such as yourself, but in the spirit of learning and debate, thanks for allowing me to trespass in your neighborhood - ahmad PS. Very nice case. Ahmad, Thanks for responding. And don't feel like you are trespassing, ROOTS is everybody's neighborhood who is looking for ways to improve their endodontic technique and understanding. You are a special person indeed because you are a teacher and also because you took the time to read the review article with an open mind instead of simply reciting tired old opinions. Endodontics can advance and improve only when we realize that we have not reached the end of the evolution of instrumentation, disinfection and obturation. New instruments, obturation techniques and materials will continue to come forth. The question remains will we be able to objectively consider new innovations or remain locked into the dogma of the past. I have attached 3 Powerpoint slides that powerfully demonstrate the importance of proper apical preparation size. It is an incisor that had been retreated once and was failing again. The patient had enough and wanted an extraction when another retreatment was recommended. Bill Wildey extracted the incisor and then sectioned it 1mm from the apex to uncover the problem. Notice the radiographic length of the obturation is correct and it is nicely flared. It is a very straight, easy canal to instrument yet the canal has been transported and is horribly underprepared in the apex. The final slide is of a typical LightSpeed preparation and Simplifil obturation. The difference is obvious, no transportation, no overpreparation, the entire circumference of the canal has been cleaned and obturated. I agree with you that each case is unique and should be prepared to an apical diameter that matches the size of the preexisting canal anatomy. Sometime if you get a chance practice with a LightSpeed at 2000rpm in an extracted tooth and then do a cross section to see if the canal is still centered and very clean. You might even try another tooth and try to intentionally transport the canal by lingering with the rotating LS instrument in the apex and see if you can detect any transportation. I bet you won't see much transportation unless it is with instruments larger than a #50 and in a significantly curved canal. Use a watch to record the amount of time the instrument was rotating at length and remember that the LS technique does not require you to be at the apex with the rotating instrument more than a second or two. We did a lot of cross-sectional analysis of various techniques in our preclinical endo lab and no matter who did the preparation, no matter what technique was used, nothing cleaned the canal more thoroughly and with less transportation than LightSpeed. I appreciate the quote you have included and would place equal or greater emphasis on the first part of the quotation since debridement is all about achieving cleaner canals. The second sentence is also very important. They have also shown that larger apical sizes yield cleaner canals that may promote further success. Failing to clean canals, especially in the apical region, can result in treatment failure. ".... Thanks again for your comments and dedication to endodontics. It is my hope that this kind of professional debate will help the many interested dentists who come to ROOTS improve their technique. In my opinion more good can be done by helping larger numbers of dentists improve their endo success rates from 70 to 80 or even 90% than can be done by helping a few excellent endodontists raise their success rate from 94 to 95%. They are already doing a good job! - Randy Hedrick

Randy: you may end up replacing terry as our ambassador of goodwill and fellowship . Love your cases and your communication skills - gary Randy: great discussion...I have nothing to add to your assertion about the need to completely and meticulously cleaning a canal system. Be it with LS, ss files, NiTi, whatever. There is no doubt the cleaning a system will lead to healing. LS files are great for apical clearing. I have seen Bill's central case many times and each time I wonder what went through the mind of the dentists who treated this case......twice! ...lousy length , short anemic preparation and fill....crud at end of the apex ..etc.. Isn't this Endodontic Insanity? Trying the same crappy technique over again, expecting a different result. Good solid debate is helpful and very conducive, yet we occasionally need Attila the Hun or Terry :-) to enforce the law. Randy, you are a wonderful addition to ROOTS and I sincerely hope you continue to post cases to stimulate debates in the hope of being able to serve our patients and our profession at the highest level of care possible. Thank you - ahmad Ahmad, I agree, this was a great discussion. I think it is the type of high level, professional debate that Ken is trying to achieve on ROOTS. No abrasiveness, no insults. Just a thoughtful debate on the issues with the intent of education and raising the bar! - Randy Hedrick
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