Sensitive Tooth
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From: "BENJAMIN SCHEIN" Sent: Saturday, May 19, 2001 9:58 AM Rick: I love this forum. I've had two cases in my 30 years of endo in which the tooth was sensitive to heat despite acceptable endodontic treatment. In each one of those two I discovered a fourth canal. Never seen one cold sensitive. I wonder who else has had your experience (cold... not heat). What brand cold spray do you use? Have you compared it to CO2 snow (Moyco device). Was the referror satisfied with "I couldn't help myself" or you had to go into deeper explanation? Pretty decent prior endo... no? Lightspeed case probably.... being in SA. Or wasn't it? Again...you are always teaching us something...Thanks. Ben
From: Fred Barnett Sent: Saturday, May 19, 2001 12:26 PM Subject:Sensitive tooth Regarding the use of Endo Ice and CO2 snow: there is NO difference in reliability between them when used to test the sensitivity of teeth in adult patients. However, in young patients, the EPT was shown to be less reliable than Endo Ice and CO2 snow. Assessment of reliability of electrical and thermal pulp testing agents. Fuss Z, Trowbridge H, Bender IB, Rickoff B, Sorin S. J Endod 1986 Jul;12(7):301-5.
From: The Janians Sent: Sat., May. 19, 2001 2:35 PM Hi Fred, In my experience CO2 snow is more reliable in certain cases. The teeth I am talking about are PFM crowns, and very old, calcified pulps, or a combination of both! (I see tons of these at the VA Hospital) When testing teeth like these with Endo Ice, I have gotten no response. Then I go get the CO2 stick, press it on the tooth, and about 20 seconds or so later the patient will feel it. This has happened so often on these types of teeth, I go straight to the CO2 snow and bypass the Endo Ice. The CO2 stick is colder (-78 degrees centigrade, vs -30 degrees centigrade for Endo Ice) and it's sustainable for much longer. Of course when using Endo Ice it will be coldest when on a large satruated cotton pellet, not a q-tip, or small cotton pellet. For most normal teeth, the Endo Ice works well for me. -Jeffrey H. Janian, DDS
From: The Janians Sent: Sat., May. 19, 2001 4:24 PM Fred, The EPT does work more often for me than CO2 snow. Usually it's on those patients that I put the CO2 on all or most of their teeth, and they still feel nothing. That may sound hard to believe, and I would have thought so before my residency, but I've layed the CO2 stick on multiple teeth on some of these old veterans, and they just feel nothing. But the EPT works. I usually feel better with a positive cold test than with a postive EPT test. Not a lot of science there, as both can give false positives, but I think EPT will give more false positives. (Liquifactive necrosis, etc) Cold of any sort will give more false negatives, especially with those old teeth I was talking about. (agian, no scientific back-up here) I haven't tried the bridging technique you describe, but I think it should work... In those PFM cases I have either used the little EPT tip for the Analytic unit, or have given up. I'll have to try it out. About the temperature of Endo Ice, I got my info from Spangberg's chapter in Pathways 7th ed. Whether -30 degrees centigrade or -50, it's really cold stuff! I think the CO2 snow gives me more positive results maybe because not from the colder temperature, but because it will stay that same temperature for a long, sustained time, vs. the Endo Ice where I suspect it peters-out when evaporation is complete.... Also I figure it is the same temperature every time for every tooth. While on the subject, one of my instructors recommends the rubber dam and ice water test for those diagnostic dilemmas where the patient has the chief complaint of cold , but the endodontist can't reproduce it (thanks Peter) . It sounds like the way to go, but I haven't needed it yet. I probably will when I enter the real world in a couple of months and I'm getting referred these cases. Right now we just see any endo that comes to the VA, not necessarily those that someone couldn't figure out. Anyone else have experience with this technique? Good discussion, -Jeff
From: Joseph Dovgan Sent: Saturday, May 19, 2001 4:37 PM Jeff While on the subject, one of my instructors recommends the rubber dam and ice water test for those diagnostic >dilemmas where the patient has the chief complaint of cold , but the endodontist can't reproduce it (thanks >Peter) . It sounds like the way to go, but I haven't needed it yet. I probably will when I enter the real world in a >couple of months and I'm getting referred these cases. Right now we just see any endo that comes to the VA, >not necessarily those that someone couldn't figure out. Anyone else have experience with this technique? It works well. I've been doing it for 12 years. Learned it from Rick walton in my residency. Only a couple of caveats. If the rubber dam leaks, sometimes you will get a false postive. That is, you get a reaction, but it may be comming from an adjacent tooth. If you use, RD sealing materials, sometimes you can't reproduce the symptoms since now you've added an insulator over the area that was giving the response. Second, it's very time intensive. I have 2 DA's when I do it, one assisting with the procedure and another getting ready the next RD with clamp. It goes much faster. Finally, I would suggest doing both Hot and Cold once the RD is placed on each tooth, it's much more efficient. Joey D, I've done boatloads of these and diagnosed cases that had seen several endodontists. If I can't reproduce the symptoms that day, I have'm back in a month and retest.
From: Fred Barnett Sent: Saturday, May 19, 2001 5:12 PM Jeff, See below. It's good to see your interest!! From: The Janians Sent: Saturday, May 19, 2001 7:24 PM Fred, The EPT does work more often for me than CO2 snow. Usually it's on those patients that I put the CO2 on all or most of their teeth, and they still feel nothing. That may sound hard to believe, and I would have thought so before my residency, but I've layed the CO2 stick on multiple teeth on some of these old veterans, and they just feel nothing. But the EPT works. Yes, for me as well. The EPT often neglected ;-( You should do a clinical study on patients with radiographic evidence of marked root canal calcification, and compare the EPT to CO2 snow, and perhaps Endo Ice. I'll assist you with the protocol if you need help. I usually feel better with a positive cold test than with a postive EPT test. Not a lot of science there, as both can give false positives, but I think EPT will give more false positives. (Liquifactive necrosis, etc) Cold of any sort will give more false negatives, especially with those old teeth I was talking about. (agian, no scientific back-up here). Check out this paper: Evaluation of the ability of thermal and electrical tests to register pulp vitality. Petersson K, Soderstrom C, Kiani-Anaraki M, Levy G. Endod Dent Traumatol 1999 Jun;15(3):127-31 Department of Endodontics, Malmo University, Sweden. kerstin.petersson@od.mah.se The aim of the present study was to evaluate the ability of thermal and electrical tests to register pulp vitality. Sensitivity, specificity, negative predictive value and positive predictive value were calculated by comparing the test results with a "gold standard". The thermal tests studied were a cold test (ethyl chloride) and a heat test (hot gutta-percha). For the electrical test, the Analytic Technology Pulp Tester was used. The examined teeth were 59 teeth with unknown pulpal status in need of endodontic treatment and 16 intact teeth, all with radiographically normal periapical bone structures. In total 46 teeth with vital pulps and 29 teeth with necrotic pulps were tested. This gave a disease prevalence of 39%. The gold standard was established by direct pulp inspection of the 59 teeth in need of endodontic treatment. In the 16 intact teeth the pulp was judged as vital. The number of true positive (TP), false positive (FP), true negative (TN) and false negative (FN) test results was calculated for each method as compared to the gold standard. Based on this, the sensitivity, specificity, positive predictive value and negative predictive value were calculated for each method. The sensitivity was 0.83 for the cold test, 0.86 for the heat test and 0.72 for the electrical test. The specificity was 0.93 for the cold test, 0.41 for the heat test and 0.93 for the electrical test. The positive predictive value was 0.89 for the cold test, 0.48 for the heat test and 0.88 for the electrical test, and the negative predictive value was 0.90 for the cold test, 0.83 for the heat test and 0.84 for the electrical test. This indicated that the probability of a non-sensitive reaction representing a necrotic pulp was 89% with the cold test, 48% with the heat test and 88% with the electrical test. It also indicated that the probability of a sensitive reaction representing a vital pulp was 90% with the cold test, 83% with the heat test and 84% with the electrical test. While on the subject, one of my instructors recommends the rubber dam and ice water test for those diagnostic dilemmas where the patient has the chief complaint of cold , but the endodontist can't reproduce it (thanks Peter) . It sounds like the way to go, but I haven't needed it yet. I probably will when I enter the real world in a couple of months and I'm getting referred these cases. Right now we just see any endo that comes to the VA, not necessarily those that someone couldn't figure out. Anyone else have experience with this technique? This works well for discomfort to hot that cannot be localized. Place the dam, tooth by tooth, fill a curved Monoject syringe with hot water, then flood the tooth (keep the suction handy). Give it a little bit of time, then repeat on another tooth. Thank goodness this does not have to be done often!! Fred
From: Joseph Dovgan Sent: Saturday, May 19, 2001 6:21 PM Fred, Buy an Odontotester. I'm sure you can work a deal :) Hurry now before they sell the company, due on May 25th. I've used CO2 snow for 12 years. Nothing like it and I consider it the Gold standard for point cold responsiveness testing. Over time, you will spend more for Endo-Ice then the cost of the Odontotester and renting the H size CO2 tank. We go through about 1 H size tank per 2 months at a cost of 25 bucks delivered. Make sure you get the CO2 with a dip or syphon tube. Keep one tank as a back up for when you run out cuz the DA left it on over nite! Some patients hate it. DA's hate it cuz it's more work for them. I love it because the response is quite definative! Just like Jeff sez, nothing goes through a PFM or one of these new all ceramic restorations like this stuff. Don't use the odontotestors ice holder cuz it ain't easy to disinfect/sterilize, put it a 2X2 gauze and roll up so the Ice is sticking out of the folded end. See my lecture I gave you for a picture. Joey D, the only way to make this product better is if it were plumbed into my OP! Just place a disposable tip and be on my merry way testing. Wow, would'nt that be great!
From: Richard Schwartz Sent: Saturday, May 19, 2001 9:14 PM Can either of you tell me where to get the CO2 snow and exactly how it is used? I'd like to try it. Thanks. Rick Schwartz
From: Fred Barnett Jeff, Thanks for the good info!! In the Fuss et al study, they used dichloro-difluoro-methane (DDM), which is -50*C. In your experience, does the EPT work better for the more calcified teeth than CO2 snow? Have you tried the "bridging" technic (place explorer on tooth structure below crown margins, and place the EPT probe on the explorer) for using EPT on teeth with crowns? Fred
From: BENJAMIN SCHEIN Sent: Sunday, May 20, 2001 2:22 AM Fred, Jeff, et al. The Malmo paper below is excellent. But as a clinician it does not help me to determine if the patient needs treatment or not. At chairside ( not as an academic) I am more interested in the clinical symptoms of pulp inflammation not in specificity, probability, and predictive value. For clinicians not academics I would recommend Bob Rosenberg's clinical paper in JADA. Rosenberg RJ Using heat to assess pulp inflammation. J Am Dent Assoc (1991 Feb) 122(2):77-8 The heat test is the "ugly duckling" of our tests. I've heard endodontists say it is not useful. Bob's paper is a clinical gem. it should be required reading for dentists. That reminds me ... L. Meskin (JADA) is a great editor...despite his academic credentials :-)....he will be a hard act to follow. Ben
From: "I. Blake McKinley, Jr." Sent: Sunday, May 20, 2001 2:31 AM Rick, I had the same situation on a #15. The referring dentist did a reasonable looking RCT and placed an alloy buildup directly over the floor of the pulp chamber. The only time the patient felt it when were testing was when the occlusal was thermal tested. I removed the alloy build up and found an MB2. Like you I also retreated the other three canals, told the GP that if I was taking responsibility for the case, I was taking it for the whole case not just the MB2. He understood and has referred many cases. Including himself, for a retreatment of two RCTs his son did for (to) him where the DB and MB2 canals had not been located on a #15 and 16. To his son's credit the teeth were not perforated as the DB canals were only found after intense microscopic exploration. Again, I discussed with him retreating vs not retreating the previously treated canals, he simply said to treat it the right way. Certainly a potentially dicey situation. Blake McKinley, Jr., DDS
From: The Janians Sent: Sunday, May 20, 2001 3:05 AM Hi Fred, In my experience CO2 snow is more reliable in certain cases. The teeth I am talking about are PFM crowns, and very old, calcified pulps, or a combination of both! (I see tons of these at the VA Hospital) When testing teeth like these with Endo Ice, I have gotten no response. Then I go get the CO2 stick, press it on the tooth, and about 20 seconds or so later the patient will feel it. This has happened so often on these types of teeth, I go straight to the CO2 snow and bypass the Endo Ice. The CO2 stick is colder (-78 degrees centigrade, vs -30 degrees centigrade for Endo Ice) and it's sustainable for much longer. Of course when using Endo Ice it will be coldest when on a large satruated cotton pellet, not a q-tip, or small cotton pellet. For most normal teeth, the Endo Ice works well for me. -Jeff Jeffrey H. Janian, DDS
From: Fred Barnett Sent: Sunday, May 20, 2001 4:07 AM Jeff, Thanks for the good info!! In the Fuss et al study, they used dichloro-difluoro-methane (DDM), which is -50*C. In your experience, does the EPT work better for the more calcified teeth than CO2 snow? Have you tried the "bridging" technic (place explorer on tooth structure below crown margins, and place the EPT probe on the explorer) for using EPT on teeth with crowns? - Fred
From: Joseph Dovgan Sent: Sunday, May 20, 2001 4:51 AM Fred, Buy an Odontotester. I'm sure you can work a deal :) Hurry now before they sell the company, due on May 25th. I've used CO2 snow for 12 years. Nothing like it and I consider it the Gold standard for point cold responsiveness testing. Over time, you will spend more for Endo-Ice then the cost of the Odontotester and renting the H size CO2 tank. We go through about 1 H size tank per 2 months at a cost of 25 bucks delivered. Make sure you get the CO2 with a dip or syphon tube. Keep one tank as a back up for when you run out cuz the DA left it on over nite! Some patients hate it. DA's hate it cuz it's more work for them. I love it because the response is quite definative! Just like Jeff sez, nothing goes through a PFM or one of these new all ceramic restorations like this stuff. Don't use the odontotestors ice holder cuz it ain't easy to disinfect/sterilize, put it a 2X2 gauze and roll up so the Ice is sticking out of the folded end. See my lecture I gave you for a picture. Joey D, the only way to make this product better is if it were plumbed into my OP! Just place a disposable tip and be on my merry way testing. Wow, would'nt that be great!
From: The Janians Sent: Sunday, May 20, 2001 4:54 AM Fred, The EPT does work more often for me than CO2 snow. Usually it's on those patients that I put the CO2 on all or most of their teeth, and they still feel nothing. That may sound hard to believe, and I would have thought so before my residency, but I've layed the CO2 stick on multiple teeth on some of these old veterans, and they just feel nothing. But the EPT works. I usually feel better with a positive cold test than with a postive EPT test. Not a lot of science there, as both can give false positives, but I think EPT will give more false positives. (Liquifactive necrosis, etc) Cold of any sort will give more false negatives, especially with those old teeth I was talking about. (again, no scientific back-up here) I haven't tried the bridging technique you describe, but I think it should work... In those PFM cases I have either used the little EPT tip for the Analytic unit, or have given up. I'll have to try it out. About the temperature of Endo Ice, I got my info from Spangberg's chapter in Pathways 7th ed. Whether -30 degrees centigrade or -50, it's really cold stuff! I think the CO2 snow gives me more positive results maybe because not from the colder temperature, but because it will stay that same temperature for a long, sustained time, vs. the Endo Ice where I suspect it peters-out when evaporation is complete.... Also I figure it is the same temperature every time for every tooth. While on the subject, one of my instructors recommends the rubber dam and ice water test for those diagnostic dilemmas where the patient has the chief complaint of cold , but the endodontist can't reproduce it (thanks Peter) . It sounds like the way to go, but I haven't needed it yet. I probably will when I enter the real world in a couple of months and I'm getting referred these cases. Right now we just see any endo that comes to the VA, not necessarily those that someone couldn't figure out. Anyone else have experience with this technique? Good discussion, -Jeff
From: Joseph Dovgan Sent: Sunday, May 20, 2001 5:07 AM Jeff It works well. I've been doing it for 12 years. Learned it from Rick walton in my residency. Only a couple of caveats. If the rubber dam leaks, sometimes you will get a false postive. That is, you get a reaction, but it may be comming from an adjacent tooth. If you use, RD sealing materials, sometimes you can't reproduce the symptoms since now you've added an insulator over the area that was giving the response. Second, it's very time intensive. I have 2 DA's when I do it, one assisting with the procedure and another getting ready the next RD with clamp. It goes much faster. Finally, I would suggest doing both Hot and Cold once the RD is placed on each tooth, it's much more efficient. Joey D, I've done boatloads of these and diagnosed cases that had seen several endodontists. If I can't reproduce the symptoms that day, I have'm back in a month and retest.
From: "Robin Hinrichs" Sent: Sunday, May 20, 2001 7:36 AM I use the rubber dam ice/hot water technique fairly often. I use either a 2, 3, or 7 clamp, single hole punch. If the patients cc is hot sensitivity, we use hot water, about coffee (NOT McDonalds) temperature. Or Ice water if cold is cc. I usually start anterior to the tooth & work back. Place RD, floss between contacts, & poor water in. Have assistant ready to suction quickly!! You can really light some of these folks up. Often this works really well if the culprit has a PFM & cold testing ( I use Endo Ice) hasn't worked. I also try & space testing each tooth, in case there is a delayed response. Sometimes that deep C fiber ache takes 30+ seconds to get going. I like this technique a lot, & patients that can't tell where the pain is coming from feel better about the diagnosis also. Hope this helps. Robin
Robin, good,good Post - Ben
From: Fred Barnett Sent: Sunday, May 20, 2001 8:08 AM Ben, Knowing if and when a patient needs endo tx comes from the integration of the literature with clinical signs and symptoms. Having the knowledge from the Malmo paper -- the probability of a non-sensitive reaction representing a necrotic pulp was 89% with the cold test, 48% with the heat test and 88% with the electrical test. It also indicated that the probability of a sensitive reaction representing a vital pulp was 90% with the cold test, 83% with the heat test and 84% with the electrical test" will make us better clinicians, especially in the more difficult to diagnose cases. The best example of this would be the lack of pulp responses following traumatic injuries; we need to know from the literature that these teeth can continue to have a blood flow throughout the pulp and yet give NO response to cold, hot or EPT for extended periods of time. The laser Doppler is the only "true" pulp vitality testing device, as vitality comes from blood flow. Fred
From: The Janians Sent: Sunday, May 20, 2001 10:10 AM Endoco sells it: 1-800-388-7868
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Photos courtesy of Janian - www.rxroots.com |
From: Benjamin Schein Sent: Sunday, May 20, 2001 10:24 AM Rick: See above Joe Dovgan's Message it is called the Odontotest. It is marketed by Moyco. You need a little CO2 tank from a local gas distributor. RDA's hate it with a passion......"Why don't you use regular ice, I made for you in the freezer doctor? Isn't it the same?" It is not the same as Jeff wonderfully explained. If I recall correctly the original was invented by Prof.Obweggesser a famous German Oral Surgeon long time ago. He was also the first one that put Calcium Sulfate in the bony crypts after curreting a lession. See, I am the endo-trivia maven. Maybe Ken wants to add a endotrivia.com? :-) Li'l Ben
From: "Richard Schwartz" Sent: Sunday, May 20, 2001 12:05 AM Ben, I use Endo Ice. I've not compared it to CO2 snow, but it is pretty cold. I've had the retreatment discussion with this referrer and others before. I tell them that once I enter a tooth it becomes my root canal and so I want to make sure all the canals are cleaned and packed well, or at least as well as I can do it. The original root canal was done in Kansas. I'm not sure of the technique. Funny thing about Lightspeed, it doesn't have much market penetration in San Antonio, even though the company is based here. To my knowledge, I'm the only private practice endodontist in town who uses them (another did, but he recently move away), and I use them mostly for guaging. Some of the GPs use them. They are being taught to undergraduates at the dental school now, so local usage will probably go up. They are good instruments, but some of the guys from the company have a way of antagonizing potential users. Rick
From: Fred Barnett Sent: Sunday, May 20, 2001 12:56 AM Regarding the use of Endo Ice and CO2 snow: there is NO difference in reliability between them when used to test the sensitivity of teeth in adult patients. However, in young patients, the EPT was shown to be less reliable than Endo Ice and CO2 snow. Assessment of reliability of electrical and thermal pulp testing agents. Fuss Z, Trowbridge H, Bender IB, Rickoff B, Sorin S. J Endod 1986 Jul;12(7):301-5.
From: B. Harvey Wiener, DDS Sent: Sunday, May 20, 2001 5:17 PM Fred, To me as a clinician, the malmo paper confirmed what I already figured out after 32 years of clinical experience. The part about culturing being analagous to the microscope is a bit (if not a lot) of a major stretch for me. I wish we lived in an ideal world but we don't. I respect you for sticking to your guns but personally I think you'll be very lonely on this one. I always believed that cultures were a waste of time for the Endodontic Clinician and I still do. Especially now that we do such a wonderful job cleansing and shaping under the scope, I would only culture if I had a very unusual or stubborn case that was reacting contrary to the clinical norm. When I have done that, it usually resulted in my changing the antibiotic used which I would do anyway if an infection persisted, or hospitalizing the patient for treatment of a major way out infection. So far this has happened 3 times in 32 years with only 1 hospitalization of the 3. To me those are important and relevant stats even if the only reference is moi. In no way do I find a problem with anyone choosing the culture route. There is no speed limit on that highway in this country. Regards Harv B.Harvey Wiener, DDS, MScD, FRCD(C)
From: Fred Barnett Sent: Sunday, May 20, 2001 6:07 PM Harv, I certainly don't mind being alone on the highway of science versus joining the party of clinical perceptions. Please don't misunderstand, I do not culture as a routine; but if there is refractory case, failing surgery, etc., having the knowledge of how to culture, may be quite advantageous for the patient and practitioner. As for your wonderful job of C&S with the scope, please let us know how you see past the curves and into fins and cul-de-sacs and into the dentinal tubules. If you think your 5.25% bleach and puffs do it for you, then you should tell us all how to achieve 100% success. Oh my, more ammo for my dear friend Ben. Respectfully, Fred
From: "Uziel Blumenkranz" Sent: Sunday, May 20, 2001 9:54 PM Dear Rick: Coming back from playing golf this morning I went mentally again through some of the postings, specially this one by you. Last week I saw a patient who is referring pain upon heat stimulation in a lower first bicuspid. told her maybe there is a second canal somewhere. however, then it struck me, yes some two years ago i had a patient come to the office and referring pain from a lower right second molar, which had been treated and retreated endodontically. Patient was complaining upon COLD, and when I tested the first molar, second bicuspid was not able to elicit any response. tested the upper teeth, no response. went to the second molar and yes, had the same experience you had. Patient more or less levitated in the chair. Could not believe it. Asked him if he would mind coming back on Monday, gave him my home phone number in case he had any emergency during the weekend, saw him again in Monday and the tooth kept hurting. redid the case. I will try to send you the images from the office tomorrow with a recall. - uzi
From: "B. Harvey Wiener, DDS" Sent: Monday, May 21, 2001 3:00 AM Robin, I always test from the Posterior to the anterior since my patients are usually lying back a bit. However I have not used the rubber dam for pulp testing so perhaps that would eliminate the problem of obtaining false positives as we move backwards. Harv B.Harvey Wiener, DDS, MScD, FRCD(C)
From: B. Harvey Wiener, DDS Sent: Monday, May 21, 2001 4:34 AM Fred, Thanks for your reply. I never claimed i could get 100% success. No one I know has. But the ammo is great fodder for us BU folks. Now go and watch the 2nd half. B.Harvey Wiener, DDS, MScD, FRCD(C)
From: Bill Watson Sent: Monday, May 21, 2001 4:35 PM ...Odontotester. ......Nothing like it and I consider it the Gold standard for point cold responsiveness testing. I also consider it to be the gold standard of vitality testing to cold responsiveness. I cannot imagine not having it my office. As has already been pointed out, the ability to maintain a -68° sustained application of much longer than 30 seconds is very helpful in calcified teeth and ones that may have PFMs. The CO2 ice stick can be made to be over 0.5 inches long. The advantages over water ice are easily understood, although there are certain types of cases in which water ice is preferable. I could truly not do without my CO2 ice test. If you are not familiar with the device, please see the attachment.
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Photos courtesy of Bill Watson - www.rxroots.com |
From: Bill Watson Sent: Monday, May 21, 2001 4:42 PM .....haven't tried the bridging technique .... Analytic makes a microtip that I have found to be very helpful when there is a small amount of exposed tooth btwn the gingiva and the crown. >While on the subject, one of my instructors recommends the rubber dam and ice water test for those >diagnostic dilemmas where the patient has the chief complaint of cold , but the endodontist can't >reproduce it (thanks Peter) . It sounds like the way to go, but I haven't needed it yet. I probably >will when I enter the real world in a couple of months and I'm getting referred these cases. Right now >we just see any endo that comes to the VA, not necessarily those that someone couldn't figure out. >Anyone else have experience with this technique? In my previous post concerning the Odontotester, when I mentioned that there were some cases that H20 ice worked better, you have mentioned the very situation and technique in which it is very helpful. Everyone should file your above-mentioned tip away for future reference. You will definitely have cases in which it will be useful. bill
