Revascularization case - Courtesy ROOTS
From: Fred Barnett To: ROOTS Sent: Monday, June 11, 2007 5:42 AM Subject: [roots] revascularization case Here is a revascularization case that one of my 2nd year postdocs started last September. First visit, light instrumentation and irrigation with full strength NaOCl, EDTA, and CHX. Placed BiMix (Cipro and Metronidizol). At 2 week follow up, sinus tract closed, and asymptomatic. At that visit, opened tooth, re-irrigated, and initiated bleeding into canal. Placed Collaplug over blood clot and to help to keep the MTA at the CEJ. Then restored with composite. Radiographs: 1. Pre-op and Day of blood clot/MTA placement and 2. 4 month recall and 9 month recall. The tooth is undergoing apical development, the walls are thickening, and a hard-tissue barrier has formed under the MTA. Better than apexification!! - FredBiMix.....Cipro and Metro...I take it no staining or darkeing of the tooth? - Joseph Dovgan Hello Fred, First of all, nice case. But I have two little questions. Does the tooth reacts to warm/cold, EPT? Are you sure this is revascularisation and not obliteration? - Rafaël Hi Fred...................what does light instrumentation mean? Does it mean only coronal instrumentation or does it mean instrumentation till the apex ? Also what is the material for temp. closure after placing the BiMix - Sachin Hi all: Apparently Fred hijacked my case and posted it- I'll have to have words with him... (just kidding- he told me to say that). I'll try to answer all the questions: 1. The BiMix is prepared by taking a 500mg Cipro tablet and 500mg metronidizol tablet and smashing them together with a mortar and pestle. This powder is mixed with a little anesthetic solution. Haven't found a really great way to get it into the canal- it's really sticky (I think because of the coating on the outside of the tablets) 2. "Light" instrumentation meant using rotary files that didn't bind or plane the walls of the tooth. Didn't want to thin the walls any more than they already were, just wanted to try to agitate the irrigants and get as much infected tissue out as possible. I filled the canal with full strength NaOCl, and used ultrasonic files to agitate the solution. Also, used the ultradent purple tip on a suction to pull NaOCl down the canal and back out (poor man's EndoVac). 3. Tooth was temporized the usual way when the BiMix was in place- with cavit. 4. The tooth does not respond to cold or sensitivity testing. And I fully expect that PCO is the probable endpoint. The key thing is that the root walls are thickening (added strength), and that a calcified bridge is forming under the MTA (odontoblasts, cementoblasts, or osteoblasts are at work- but we really don't know what the histology of the new "pulp" is...) Hope this helps... David Prusakowski For those with access to JOE - pg 680 Pulp Revascularization article...Dr Ken Dave: You’ve got me confused. Obviously you folks have deviated substantially from the initial Japanese protocol and even from trope’s rendition. are you actually removing the trimix at the second visit and then placing mta and restoring? you are not using any solvent or vehicle with the bimix, just grinding up processed tablets? Fyi, both of these are available in powder form, used by compounding pharmacies where I’ve had the trimix compounded (reed’s in Arizona), and might eliminate the stickiness. Problem I’ve had with our compounded version is getting a decent seal over the top of the stuff - gary We eliminated the Minocycline due to the dentin staining that occurs. There are some ways to prevent or eliminate the staining, but I don't really see the need for the tetracycline when you consider the flora that we are dealing with. Perhaps cleocin would be a better substitute, but htis would need to be looked at. At the second visit, we irrigate the canal system to remove the BiMix and any remaining tissue, exudate, etc. Bleeding is stimulated and a Collaplug was placed as a barrier to prevent the MTA from "falling down" the canal space. Then restore - Fred Hi, I have a question regarding the bimix. > 1. The BiMix is prepared by taking a 500mg Cipro tablet and 500mg > metronidizol tablet and smashing them together with a mortar and pestle. > This powder is mixed with a little anesthetic solution. Haven't found a > really great way to get it into the canal- it's really sticky (I think > because of the coating on the outside of the tablets) Can I use glicerine as a vehicle? I don't know what the coating of the tablets is made from. But if it's sugar, you can try to dip them in some water until the coating dissolves - Andreea I would like to understand more about the staining that occurs due to locally used Minocycline. I had the ideea that we do not prescribe tetracycline to infants and children because we try to avoid enamel staining which occurs during the enamel mineralization process and is more dose/blood level dependent than the duration of treatment. I thought that dentin staining could not be an issue. When we apply the trimix, enamel is already mineralized and should have a normal color. A layer of dentin is also present. This dentin is also mineralized and should have a normal color. The only dentin that gets stained is the one in direct contact with the paste and the one, down the root, that forms during the two weeks in which the mix stays in a part of the canal. Is this true? > We eliminated the Minocycline due to the dentin staining that occurs. There > are some ways to prevent or eliminate the staining, but I don't really see > the need for the tetracycline when you consider the flora that we are > dealing with. Perhaps cleocin would be a better substitute, but htis would > need to be looked at. Andreea Andreea, The TriMix paste is applied into the root canal and will severely stain the dentin. There are ways to prevent or minimize this complication, but if the minocycline is not needed, It can be removed from the formula. - Fred If I remember correctly, Dr. Martin Trope at the AAE Philadelphia suggested using Arestin gel ( minocycline HCl as a replacement for the minocycline ( generic), and their preliminary research suggested "no staining", I agree with Fred - Is there any added advantage of mixing 2 bactericidals ( Ciprofloxacin + Metronidazole) with a Bacteriostatic ( Minocycline)? Even pharmacologically it does not seem right? " If you need to cut vegetables you do not need a sword, sometimes knives can suffice!!" - Rajiv Patel OK, I agree! How about using glicerine for the bimix. Any counter indication? - Andreea Glycerine is fine.......I just asked Dr. Trope as he is 2 ft from me ;-)) - Fred I don't see any interactions with with the meds. So if Trope sez it's OK...it's gotta be OK - Joey D When I had my stuff compounded by reeds, they consulted with the pharmacy school at usc about what vehicles to use with the 3 antibiotics, and we ended up having a glycerin based ointment product they loaded into tuberculin like syringes for me. Very easy to deliver - gary hi, I am using distilled water, and the paste i am having is very consistent. I had some swelling cases in post op cases, maybe the glycerin is a little bit agressive for the pdl.- Philippe The vehicle should be easily removed by irrigation.- Fred Dave, That is a very nice case, you really can be proud of it! Can you tell us what the tooth looks like clinically? Are there signs of grey discoloration? Any pictures? Did you use white or grey MTA? May I use this for a presentation, of course with full attribution? - Marga
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