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Trauma slow burn :skeletal maturity

From: Terry Pannkuk To: ROOTS Sent: Thursday, July 09, 2009 5:57 AM Subject: [roots] Trauma Slow Burn Here's a 10 year old boy that saw me 2/15/2008 when he avulsed this tooth on the playground. The prognosis was poor because the extraoral time was judged to be well over 45 minutes and the tooth had not been placed in a suitable storage medium. The pulp was removed and Ledermix placed 10 days later after initial stabilization with a splint. After one month the Ledermix was replaced with CH, then one month later obturated with MTA, a fiber post placed with core filling the access. On 8/25/2008 he was recalled and no root changes were noted radiographically. When he was recalled on 10/26/2008 you can start to see an incipient crater on the middle portion, mesial aspect of the root. This was a bit more pronounced today when I examned him after he had chipped the incisal third of the crown diving into the shallow end of a pool hitting the bottom with his tooth. He was due for a recall and this incident assured us of his returning. :) My guess is that we might get 2 more years out of this treatment at best. The root is clearly losing width and resorbing. I doubt his hyperactivity is helping our odds. Sometimes I've noticed that resorption goes through periods of quiescence, hopefully we'll get lucky, I doubt it. He will probably lose this tooth before skeletal maturity. Any evidence that triple antibiotic paste used for revascularization helps prevent replacement resorption in these cases? My current protocol is to use Ledermix as suggested by Paul Abbott and others... .didn't place it for 3-4 months like the dogs and monkeys though. Tetracycline staining/maintaining tooth in an imcomplete weakened state might have been problematic for this kid - Terry
J Endod. 2009 May;35(5):663-7. Links Effect of intracanal corticosteroids on healing of replanted dog teeth after extended dry times. Kirakozova A, Teixeira FB, Curran AE, Gu F, Tawil PZ, Trope M. Department of Endodontics, University of North Carolina, Chapel Hill, North Carolina 28211, USA. anna.endo@gmail.com This study investigated the effect of potent intracanal corticosteroids on periodontal healing of replanted avulsed teeth and evaluated the systemic absorption of these corticosteroids. Sixty-seven extracted dog premolar roots were randomly assigned to one of the following groups: groups 1-3 filled with gutta-percha and replanted immediately and after 40 and 60 minutes, respectively; groups 4 and 5 filled with 0.05% clobetasol; and groups 6 and 7 filled with 0.05 % fluocinonide. Groups 4 and 6 were replanted after 40 minutes and groups 5 and 7 after 60 minutes. After 4 months, roots were evaluated histologically for signs of periodontal healing. Roots treated with clobetasol and fluocinonide healed more favorably than roots filled with gutta-percha and were different from each other at 60 minutes. No change in the systemic corticosteroid blood concentration was observed in any group. Corticosteroids were efficacious in the beagle model as intracanal medicaments for promoting favorable postavulsion periodontal healing. On Thu, Jul 9, 2009 at 3:05 PM, Fred Barnett wrote: I don't believe we can undo the damage of extended dry times with topical or intracanal drugs at this time..... unfortunately. Fred Dent Traumatol. 2002 Dec;18(6):316-21. Links Effect of immediate intracanal placement of Ledermix Paste(R) on healing of replanted dog teeth after extended dry times. Bryson EC, Levin L, Banchs F, Abbott PV, Trope M. Department of Endodontics, School of Dentistry, UNC at Chapel Hill, Chapel Hill, NC 27955, USA; Oral Health Centre of WA and School of Dentistry, The University of Western Australia, Perth, Australia. Ledermix Paste is a paste containing triamcinolone and demeclocycline with demonstrated anti-inflammatory activity that may slow down resorptive processes after severe traumatic injuries to the dentition. A total of 29 premolar roots of six mongrel dogs were extracted and instrumented with rotary nickel titanium files. Fifteen of these roots were then filled with a calcium hydroxide (Ca(OH)2) slurry and 14 roots were filled with Ledermix Paste paste. All accesses were sealed with glass ionomer and the roots replanted after an extraoral dry time of 60 min. After 4 months, the dogs were killed and the roots prepared for histological evaluation. Five-micrometer thick cross-sections of the root and surrounding tissue taken every 90 micro m were evaluated for healing. In addition, residual root mass was also measured to determine the extent of root structure loss for each treatment method. The Ledermix Paste-treated roots had statistically significantly more healing and less resorption than the roots treated with Ca(OH)2. Root filling with Ledermix Paste also resulted in significantly less loss in root mass due to resorption compared to those roots filled with Ca(OH)2. Immediate intracanal placement of Ledermix Paste at the emergency visit after an avulsion injury appears to decrease resorption and increase favorable healing. PMID: 12656865 [PubMed - indexed for MEDLI 1: Dent Traumatol. 2001 Dec;17(6):254-9. Links Periodontal response to two intracanal medicaments in replanted monkey incisors. Thong YL, Messer HH, Siar CH, Saw LH. Faculty of Dentistry, University of Malaya, Kuala Lumpur, Malaysia. Intracanal medicaments are recommended for use in replanted teeth to inhibit inflammatory root resorption. This study compared the effect of calcium hydroxide (Pulpdent) and a corticosteroid-antibiotic paste (Ledermix) on periodontal healing and root resorption following replantation. Incisors of eight Macaca fascicularis monkeys were extracted, stored dry for 15 min and replanted. After 11 days, root canals in two adjacent maxillary incisors were treated with one medicament and contralateral incisors with the other medicament, or left as untreated controls. Animals were sacrificed 8 weeks later and the teeth prepared for histomorphometric evaluation of periodontal ligament inflammation and root resorption. Periodontal ligament inflammation and inflammatory root resorption were markedly inhibited by both calcium hydroxide and corticosteroid-antibiotic relative to untreated controls. Replacement resorption was lowest in the corticosteroid-antibiotic group, and significantly (P<0.05) more normal periodontal ligament was present in this group (79.6%) than in calcium hydroxide and control groups (64.6% and 62.7%, respectively). Treatment with the corticosteroid-antibiotic inhibited inflammatory resorption and was slightly more effective than calcium hydroxide in producing a periodontal healing response. PMID: 11766092 [PubMed - indexed for MEDLINE So what's your impression of leaving Ledermix in the canal space for 1 month versus 4 months. Was there a reason animals were sacrificed at 3-4 months versus 1 month in all these studies, or is it pretty much arbitrary? I'm starting to wonder if it would make sense to leave Ledermix in the canal system indefintiely and just place a final restoration over the top of it and let it go. Clearly the AB/Steroid efficacy must wear off at some point, but why not just make sure the root canal system has a good seal and run out the complete efficacy life of the mix? As far as I know there is no evidence showing Ledermix weakens the root like CH does, so shouldn't this theoretically be better? 1. It gets the maximum life out of the Ledermix 2. Prevents the CH root weakening effect 3. Simple and efficient. No? - Terry Hello Terry. As consequence you will force Long discussions about the negative effects of Corticostereorides and the abuse of antibiotics in medicine - Stefan Someone's going to argue that it's an issue if left intracanal? ......maybe for Lance Armstrong or Alberto Contador if the French police have steroid sniffing poodles. right? :):):) - Terry Someone argued, that mercury is bondet in amalgam fillings. That Mercury Level in the human Body is also caused of eating seafish etc. Etc. Anybody says: Hey did you Know? Terry Pannkuk use dangerous antibiotics and corticostereorides to treat teeth. And you are in hell. :-) Sure, thats the humour with the rumor - Stefan In Addition. Why not use Ledermix As Sealer in cases with periapical inflammation. Wouldn't we have faster healing? If it Works in replantet teeth , Why Not in regular cases? The seek of materials which are biocompatible , biotolerant or whatever would have been senseless. Why not do research for ledermix cement as permanent Root filling material? Endo could Be so easy, and nobody needs endodontists anymore. :-))))))) - Stefan Beautiful, and well documented. Does your protocol include decoronation...down the road ? - Ygal excellent case to show that it is still better to replant teeth even if the dry and extra-oral time is much more than optimal. especially in countries where the options of implants are not really a possibility, and in young patients where implants cannot be done immediately. thanks for sharing & also pointing out such a possibility. - viji
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