Retreatment case

The opinions  within this web page are not ours.Authors have been credited  for the individual posts
where they are. - www.rxroots.com  photographs courtesy: Mark Dreyer, Oliver Jones
From: Mark Dreyer
To: ROOTS
Sent: Wednesday, April 16, 2008 6:03 AM
Subject: [roots] Retreatment case

Case done less than a year ago by an endodontist out of the area.  Patient never had the tooth restored since
it never felt comfortable.  According to the patient the endodontist referred her to a pain clinic.
The GP knew of me, so the patient drove a couple hours to my office.

In defense of the endodontist, some of her symptoms could have been unrelated to a less than ideal rct and
thus I can see how he might have seen the pain as unrelated.  My criticism though is that he wasn't willing
to go back into the tooth and try to improve his result.

One of the interesting aspects of the case was in the dx testing.   I was able to duplicate some of her
symptoms by running an explorer over the root surface of this tooth.  It just about made her come out of
the chair.  I thought this was pretty unusual, and probably related to some vital tissue in the missed mb2.

I'm hoping the improved treatment result will give her relief of her symptoms.  A call the next day said that
the original pain is gone and now she has a different pain.  I hope the "different pain" is normal post-op
inflammation related to my apical barbarism.  :-))

I don't think this endodontist will be sending me any Holiday goodies since the patients want the records
so they can go have a followup conversation.

Thanks to all for their sentiments of condolences about my Dad.  I'm going to try to post some more now - Mark



beautiful case Mark, and welcome back - Sergiu Nicola

Local endodontist treated this a couple years ago.  I retreated it today and figure with the
independant mb2 canal now treated it has a decent chance of working out. - Mark



man what is with your local endodontist???

Nice job! You thinned out the mesial wall a lot... but we can all see the consequences of not finding the MB2
and not shaping enough from the preop - Oliver Jones

Oliver,

I took from the mesial wall what I need to take to find that mb2.  It took about twice as long to find and
shape that silly canal as it took to remove the obturant and reshape the other 3 canals combined.

I would maintain that while preservation of tooth structure is a nice goal, there are way more untoward
consequences seen from conservative endo access/undiscovered anatomy than there are from teeth like this
one in which there is a restorative failure down the road due to an aggressive endo access.

Thanks for your comments - Mark

That’s not even close to thinned out.  Imho, you had a failing endo, public enemy #1 is an undetected mb2 on
a max molar,  not much point in doing the retreat if you do not do what you have to do to find it.
Tooth is failing anyhow.  I’ve completely destroyed the mesial aspect in search of anatomy.
Patient’s understand the alternative if explained to them.

I still maintain my membership in mark’s fan club on this one  -  gary

Mark... this has been an awesome watching your day to day work, you are a force and for sure i would not do any
more endo if you worked down the street from me and would accept my work.

Gary im certainly not disputing finding an mb2, thats game over for me even if its a first time round treatment.
It has to be found. I was just thinking of the straight line access coronally. As it turns out i had another
look  - Oliver Jones



It looks fine and as you say not even close to thinned out now that i look again. I think just recently ive been
spoiled with a few that were miles from the mesial marginal ridge - Oliver Jones




But as it happens i did one on tuesday where i just went ahead and icecream scooped the furcal aspect in search of the anatomy (no perf, but thinned)... i was looking far too distal - Oliver Jones




Oliver,

You said "we can all see the consequences of not finding the MB2 and not shaping enough"

See my other reply to Mark---I contend that we can all see the consequences of coronal leakage.
Bacteria is the problem, and a root filling is not the end all and be all.

If Mark had done the original treatment, with the same level of expertise with which he did the retreatment,
then the restorative dentist cracked open the coronal seal with a post prep and missed a margin, do you think
the disease would not have recurred?

Rhetorical question of course, just trying to redirect the focus a bit.- Kendel

Funny thing, i did this case on Tuesday. I used to mock people who said they could smell infection,
but you could on this one.

This one, the composite was brown through and through, so clearly coronal seal was the issue.
The RCT was 13 years old with a big lesion. Upon access though, the DB did not smell bad on removing the GP,
the P did not smell bad. The MB had a smell that would outlast religion!! And there was obviously, the missing MB2.

So 13 years... i dunno. Does the biological burden reach a certain level then it blows up.
Could it have gone 20 years with the MB II treated? I agree failure is inevitable with poor coronal seal - Oliver Jones



an untreated mb2 would provide a nice source of nutrient and significant volume of space for bugs to colonize,
set up a bar and disco, and invite the family, once they had a way in thru the wondeful composite 'seal'
arf arf and the smell----sometimes I can smell them just looking at the rads ;-) - Kendel

Yup, I posted a case last week to another forum, and Kendel said he could smell it.
We are separated by the Gulf of Mexico, so that was one smelly tooth!  LOL - Mark

"......See my other reply to Mark---I contend that we can all see the consequences of coronal leakage.
Bacteria is the problem, and a root filling is not the end all and be all...........Oliver Jones"

Should have used Epiphany/Resilon.  Fred’s shown resistance to leakage and so have I.- Guy W. Moorman, Jr. DDS

From: Mark Dreyer
To: ROOTS
Sent: Thursday, April 24, 2008 5:49 PM
Subject: [roots] Retreatment

I don't routinely 2 step all necrotic/re-tx cases.  I evaluate each case and make a decision based on the individual situation.

In this case I did a multi-visit approach because his symptoms were no reproduceable.  Although there was a
large lesion and the initial tx didn't look too good, I still wanted to have some reassurance that the symptoms
were related to the poor initial treatment.  My rationale is that although the root canal obviously needs
to be retreated, it's also nice to know that you are addressing the problem that is causing the symptoms.
The two visit model is nice for these situations since you can verify improvement of symptoms prior to
completion.  After 30 days of caoh, the sympotms had resolved so we completed tx - Mark



Mark, had the symptoms no resolved, what would have been your course of treatment.  I’ve had the unenviable
privilege of being able to deal with many of my old early failures.  Many were just total incompetence on my
part but many were a total mystery.  Some of these responded immediately to CaOH but others continued to persist
with symptoms and drainage.  It is always nice to have a fistulation heal after CaOH but then it can be extremely
depressing to see that fistula reappear from completing what you assume was ideal retx.  I wondered if you had an
particular protocol IF you see response to CaOH other than simply retreating.

Biofilms are becoming a growing explanation for a lot of our unexplained problems with endo and, heck, all of
dentistry.  It seems that the litter beggars have minds of their own and are often smarter than we are.
Example: the case of the cuspid ending up as an implant virgin tooth, no visible crack under stain and
SMS zilch but massively unbearable symptoms.  Periradicular biofilm is as good a response or guess as any.
I truly wish I’d know about Gary’s work on this type of biofilm.

Thankfully, the majority of the retreatment of my old stuff (which has been a tremendous learning experience
more valuable than hours of CE) has been explainable by missed canals, cracks, leaking coronal restorations,
and most commonly a poorly finished apex (crud left where it counts most).  Then I have those cases like
the cuspid.that humble me and several other clinicians.   -  Guy W. Moorman, Jr. DDS

	Guy,  I would have probably re-irrigated and repacked the caoh, temporized and brought him back a third time.
	If no resolution at that point I probably would have recommended extraction.

	In these type cases I present the case at the consultation visit as a phased treatment in terms of the fees.
	One fee if we find a crack and give up on the case in the first visit, a second fee if we disassemble,
	reshape the case and do a caoh phase, and a final fee if it looks like it's working and we complete tx
	at some subsequent visit.

	These type cases aren't often really profitable but doing things this way is part of being a doctor and
	not an accountant or lawyer like we are sometimes tempted to approach things in our practice.   - Mark

You could rot and burn in endo hell for that attitude mark J.  Are you a through the crown guy or a let me
tap/metalift/whatever to get it off guy?  I’m guessing you went through the top from the rad. - Gary

Gary,

LOL, I'm waiting for the 2-visit police to crush me.  I have my bullet proof vest on.
I go through the crowns most of the time.

BTW, if the evidence surfaces some day that proves there is a higher success rate doing these type cases
in 2 visits I will become a dedicated 2 visit guy also.  However, somehow that study will have to control
for the one variable that is most important:  doctor skill.  I think the TDO outcomes study will be a
great step in that direction.

My point is that until proven otherwise, I think the issue which is more important than how many visits is
did you find all the anatomy and how well did you clean what you found?  For some doctors this takes more
than one visit, and for other doctors, who can manage their schedule appropriately, this can be done in a
single long appointment.  (for many but not all cases-I still do my share of 2 visit cases, much to the
chagrin of my scheduling gal).

Ok, I have the fire proof vest on top of the bullet proof one.  LOL - Mark

Strictly evidence based, no one can disagree with your approach. - gary

Mark,

You said you "wanted to be sure the symptoms were related to the poor initial treatment".
I assume you are referring to the initial endodontic treatment?

If so, I would say maybe, maybe not.

When I look at all of the recent retreatment cases you posted, I see one thing they all have in common-----
the appearance of inadequate (coronal endodontics)/build-up/crowns.

All of the cases you have shown demonstrate technical excellence on your part when doing the retreatment
that is unmatched by the previous operator.  However, while your white line are definitely easy on the eyes ;-),
and technical excellence should never be downplayed, let's not miss this point.

Biology rules the day, and your beautiful works of art will suffer the same fate as the 'poor initial treatment'
cases if the coronal endodontics/build-ups/crowns are done in a similar manner to the original - Kendel

	Ken, I think this is the sign of an excellent clinician in the field of restorative dentistry, which I’m sure Mark
	was.  I keep seeing cases from endodontists who were straight out of dental school or from 15 years of periodontal
	practice…they are missing the experience that Mark shows with his cases.  Someone who produces nice white lines can
	also produce nice composite bonded build ups.   - 	Guy

Kendel, Yup, and the quandry is that if/when my tx fails, I will take the fall.  And if I try to take control of the
situation by doing the buildup myself, I lose business.  I tried to start doing buildups and this move didn't
receive rave reviews from the referring docs.  I do have a couple docs that let me do the buildups.
Frankly the biology of the situation and the welfare of the patient take second place to the economics
of the situation.  :-((  - Mark

I hear ya Mark, I just get tired of folks saying "the endo didn't work"   when it's the dang restorative that is,
at the least!, a major player - Kendel

Mark,
(Givin' it the ol' college try...)

At the AAE meeting a few weeks ago Ralan Wong delivered an outstanding presentation about the coronal seal and he
addressed this very topic--GP's who don't want the endo to do the core.  He's a big proponent of glass ionomers
(so am I) and he seals the coronal 2-3 mm's of the canals with Fuji IX (correct me if I'm wrong).
He even places Fuji Triage over the gutta percha at the base of a post prep (in case the GP decides not
to place a post and leave it full of air ;-)).

He uses the centric syringe to to which he transfers the mixed glass ionomer.  That way he can carefully syringe
it into the canals while minimizing air entrapment.

Overall I think it's a great solution to enhance the coronal seal.

My solution is to do all my own cores because I can-and mostly with amalgam ;-))  R/ - Scott

	Scott my man, great to see you.  Let’s just assume that Ralan’s cores are solid and yours are leaking.  J Personally,
	I have an affinity for bonding resin.  I know that bonds.  I’ve had too many crowns come off with Unicem in the crown
	and not on the tooth.  Bond one on with Cement It and the Cement It is one the tooth and the crown is empty.  Get a
	good composite resin and build up with it after placing flowable in the canal orifices.  I like purple Permaflow.  I
	am backing away from the buildup materials that flow out of a mixing tube.  I question their approximation to chamber
	walls.  I like packing to the walls.   - 	Guy

			Guy,

			The question is not which material to use, but WHEN to use each material.  I place composite cores from
			time to time, but nothing beats the adaptation of amalgam.  You and I both see patients walk in with
			the core in the crown and the patient asking you to "recement" the crown.  This isn't a material failure--
			it's an engineering failure.  It's like pouring a 2" slab of concrete upon which to park your Winnebego
			and then crying when it cracks.  It's not the concrete...

			Granted, the high copper alloys of today corrode less than those when you got out of school ;-)),
			but they still corrode.  And creep has also been proposed as a method for self-seal.

			Suffice it to say that my cores get better with age and yours get worse....

			Hope it ain't too buggy in the Swamp, - 			Scott

			(p.s. Still gettin' used to this format--I'll try to make it work).

	I am a GP that a would that would rather have the Endodontist do the buildup--at least most of the time.
	Unfortunechatally, the Endodontists usually do not in my area. One in particular will not do any--
	he is an instructor at Pitt Dental School.

	Last Wednesday I had to do a buildup on My sister-in-law on tooth # 14, done by the instructor.
	She has had a lot of postop problems so(I am betting on a MB2 but I am just a GP) I put off the
	permanent buildup off for several months but did seal the  occlusal openning wiith composite.

	When I did do the buildup, he had removed so much gutta percha that it looked like post preps!
	I use a Centrix syringe with a needle point and Absolute Dentin but the buildup had so many voids,
	it looked like hell.

	How can I get to his depth or do I ask him to not prep them as deep? - 	Jim Rathfon

	ps:  About the same time her sister needed an RCT on #14 also, I do very few one appointment RCTs.  The first sister- the important one had five apointments at the Endo guy and two at my office.  Sister-in-law # 2 had four appointments-including a separate appointment for the buildup and one to recondence the palatal, damn Resilon sure is tenacious
	- Jim Rathfon

			Jim, That is a tragedy that an endodontist would refuse to do a build-up.
			This is the HEART of the whole implant issue.

			AS LONG AS ENDODONTISTS ARE THE COTTON/CAVIT "WHITE STRIPE GUYS"--WHO LOOK AT WHAT'S CIRCLED ON THE FORM
			AND "TREAT IT"--THE GENERAL DENTAL COMMUNITY WILL NOT GIVE THEM THE DUE RESPECT OF BEING RESTORATIVE EXPERTS.

			As the endodontist becomes the bona fide expert in restoring endodontically treated teeth,
			he/she will regain the rightful place of "GATEKEEPER" of the natural dentition.  Implants need to be
			used where appropriate, and natural teeth need to be saved when appropriate.  Proper diagnosis and
			identification of etiology will increase the success rate of retreatment endodontics and refer
			those cases with poor prognoses to the implantologist. - Scott

	Not sure EXACTLY why, but this post really seems out of line to me.

	As a general dentist that refers out about 25% of my endo, it blows me away that any gp wouldn't want their
	endodontist to do the buildup at the time of finishing the RCT.  It makes no sense outside of monetary gain
	for the gp to have the endodontist put in a temporary restoration.

	With that being said, I don't see endodontists being any more qualified to restore endodontically treated
	teeth than the general dentists.  There are crappy restorers of teeth at all levels- both endodontists and
	gp's alike.  Just as there are practitioners from both areas that are great at it.

	What makes a dentist a restorative expert is being diligent in the details of their work and continuing
	their education constantly so that they are aware of the best, most successful modalities of treatment.
	Just being a gp or an endodontist doesn't make one better at restoring teeth than the other.

	What really bothers me is the thought that a specialist of any kind is the "gatekeeper of the natural
	dentition."  Huh?  How many dental patients are seen by endodontists each year vs. how many are seen
	multiple times each year by the general practitioner?  Its my job as the gp to be the "gatekeeper".
	Its my job to step back and punt to the specialist when appropriate.  I'll see the failures of my decision
	making and the specialists long before the specialist does.  Its my job to meet with the specialist and
	talk about those failures and try to figure out how to better take care of our patients in the future.

	I have great respect for the restorative capabilities of my endodontist.  If I didn't, then
	as the "gatekeeper" it would be my responsibility to find one that could handle that aspect of
	endodontic care. 	Respectfully, - Craig Harder

		I would rather have the endodontist place the core at the time of the obutration before the
		rubber damn is removed! - Jim Rathfon

			Craig,

			I appreciate your perspective. I'm a GP too.  I also understand your point that there are crappy
			practitioners on both sides.  I'm saying that  the endodontist should be a restorative expert for
			endodontically treated teeth. He should be more familiar with the lit in that arena than the GP.

			Sure, you're the gatekeeper for  the hopeless teeth, but we need more "expert" endodontists
			to raise the trust of  the GP in retreatment endodontics.  Too many teeth are needlessly
			extracted in favor of implants when simple correction of deficient original treatment
			or even a good initial treatment will retain the tooth.

			When guys like Gordon Christensen make statements that seem to convey a slipping trust in endodontic
			it spreads like wildfire into the mindset of the GP.  There was even a panel discussion at the AAE
			a few weeks ago about this.

			Sorry Craig if I came across out of line.  I don't believe I am.  I have 6 endodontists in my area
			and I've been impressed with none of  their work.  I'm not saying it's all bad--I just want them
			to spend more than one hour on a molar.  And I know not all endodontists are like  this--
			but we need to continue to raise the bar of excellence. - R/ Scott Weed

			Scott,

			Maybe I'm not understanding your use of the term gatekeeper.  I feel that we are the gatekeepers of
			all the teeth, healthy or not.  We ultimately answer to our patients whether we send them to a
			fantastically skilled specialist or the crappy one we know will see them right away.  They look
			to us to coordinate their care, and they usually look to us for the second opinion on what
			the specialist tells them.

			I agree that many teeth are needlessly extracted when they could have been saved with expert care,
			but many patients are also put through heroic and expensive treatment that eventually fails as well.
			That's where the gp really earns his keep.  When he can navigate the options and help the patient
			decide what is in their best interest long term.- Craig

					Craig, i think the term gatekeeper comes from the fact that when push comes to shove,
					Gary Carr or Khademi have a better idea if you can get success on a tough tough endodontic
					case. We simply cant locate the same anatomy, have the same follow ups.

					We guide choices very strongly and 90 percent of the cases we may well know whats up, but
					the rest of the cases we honestly dont have to the capactiy to know. The implant algorithms
					etc will help, but we still see some cases posted that healed where most Gp's will go wow
					and still see anatomy that weve never located.

					Now for someone like you who is willing to let the endodontist acheive the basic coronal
					seal, you are truly the gatekeeper for 75 percent of the teeth and he is for 25 percent.
					Those guys who dont let the endodntist seal his work, when its human nature for patients
					to postpone appointments and walk around with cw and cavit, they are ticket booth
					administrators :-) - Oliver Jones

I agree we should be able to assess restorability of any tooth, but the complete endodontists like i mentioned above can do that, and do the basic restorative.. making them gatekeepers ultimately. Do i trust the average endodntist i get to refer to to be gatekeeper in my area? No way... what sort of gatekeeper would stuff some cotton over GP with some Fuji II LC over the top :-)) i get caries free and do pre endo build up if i refer. Jeez some endodntists dont even want to restore after the endo. If they dont know how to do it or want to do it, i think they are a different type of endodontist. That is O.K though. But those guys arent qualified to be the expert on save or lose.

			Craig,

			We're on the same page.  It was my use of the term that threw things off.  We need to be able to rely on
			specialists to give us superb treatment and know when not to do heroics when there are other viable alternatives.

			I guess what I'm saying is that endodontists need to be experts in restoration of endodontically treated
			teeth.  Then they can place buildups that minimize coronal leakage.  They can know when to throw in the
			towel.  GP's will trust those kinds of endodontists with those questionable teeth.  The GP can know
			that the endoodontist will do what's in the best interest of the patient.

			Another issue, Craig, is that guys like you and me are above the average.  We care about our patients
			and try to do great work all the time.  What about everyone below the mean?  What about those guys one
			standard deviation below the mean?  For those kinds of practitioners a well-versed specialist could
			be a lifesaver to the patient.  Thanks for your thoughts, - Scott

			Good discussion Scott.  Thanks for clarifying your thoughts.  I know I'm lucky in practicing in a small
			community with great dentists and specialists.  Its not that way every where so I tend to forget that.
			- Craig


You are right... the problem here is the GP who believes in posting every molar (then removing
restorative from the canals), or the GP referrer actually doesnt really believe in the "immediate coronal seal"
- but does believe he is doing he isonly doing a good job with the core build if he removes ALL the restorative
and then has to do the core himself. What happens is this type of GP sometimes goes and perfs the pulpal floor!
- Oliver Jones

don't know how I got on this, but I will try to remove myself, but does
anyone know of someone in the CA area that uses epiphany resilon, it is
for a pt.  She is going to relocate to the Los Angeles area.
thank you. - Spray