Definitely something to learn from this thread.....................Ignorant underinformed me was not even aware of the silver oxide and its nasty tenacious behaviour and on top of it Randy really pointed out something informative about silver points and resorption. Thanks Ahmad...............Thanks Randy..............Thanks for sharing and teaching - Sachin
Dear Ahmad, Didn't most of the residue vanish after enlargment of the canals ? They seem much larger then in the pre-op. How does it look in the canals ? Black? - Thomas
Hang in there Thomas. I still struggle with mine after 2 years but I’m not going back. In fact, I’m taking my assistant with me next month for 2 days of nothing but scope training. Endo I can do under the scope, restorative and reconstructive I struggle with still. Look how much more you are seeing. It’s funny you pointed out those fins of gp. That’s one of the first things I noticed when I first got my scope. Wasn’t as clean as I thought it was. Still amazes me that I’ll find some debris the size of the state of new york in the field, and when I bring it out on an instrument it is hardly visible.
You will get it. Glenn can tell you there are still areas he struggles with, and he is about as good as there is with a scope. - Gary
Ahmad, I imagine the silver oxide was not just along the walls, but well into the dentinal tubules. Was your objective for removing the silver oxide primarily mechanical (ie wider canal shaping) or primarily chemical. I realize both are necessary, but with five C&S visits, it seems you were going for a lot of “chemical” time.
Can anyone answer what is the best chemical to remove this residue? I’ve played with chloroform and halothane. Anyone who’s done these knows about the pile of blackened paper points and has thought that there must be a better way to get this crud out. Are our standard irrigants – NaOCl, EDTA and CHX the best we’ve got for this?
Also, Ahmad, you say it’s “only a radiographic success”. Are you saying the pt still has clinical symptoms? Or are you implying that it may not be normal histologically? - Road Tataryn
Rod: Absolutely. The objective of multiple appts with CH dressing wasn't enlarging the canals to bigger and larger files as much as it was to chemically irrigate the canals with ult. sonic to remove debris. Ever since I started using the scope I haven't been able to finish many cases in just one visit. Also, as you know, in a case like this, it was very hard to keep the canals dry. Penetration of the Ag2O in the dentinal tubules is unquestionably a concern, hence the objective of multiple visits, primarily for chemical irrigation . CH uptake was another. When we started the tooth was extremely percussion sensitive. Her symptoms gradually went away from extreme to almost none.
My main irrigant is always NaOCL and couple of drops of H2O2 to lift up the debris by effervescent action. Dry the canals and ultrasonically activate EDTA to remove the smear layer, suction it out and start using NaOCl again. I did that for almost an hour in each subsequent visit. As far as enlarging the canals, I strive for wider taper in necrotic cases and not necessarily wider apices. In this case the foramen was ripped/ resorbed in the distal and the mesials though not as badly mangled, but not much better than distal.
Paper points are another one of my pet-peeves. I may use a few in each case. I am paranoid about the lint fibers remaining in a fin or anastomosis to disrupt the final fill. I rely heavily on micro suction tip and Stropko air needle to dry the canal. However once you look at the turbid fluid in canals after sonication ( under a scope ) ....you know you have a long way to go.
Radiographic success is the healing of cortical plates of bone with the lesion still intact ( Seltzer & Bender classic study). This patient never had any intra-appt pain, flare up or symptoms and remains asymptomatic that way up to now.
Histological success is our final destination and holy grail. Since it is an impracticality we rely on a poorly informative radiograph. My whole point about the short term success is never let your guards down and always be on the look out to do the best possible treatment from start to finish. Make sure each step is a stepping stone for the next and you have left no stone unturned.
Terry Pannkuk says that any recall less than 5 years is meaningless. It is a tough criteria to hold yourself too. But after seeing hundreds of his cases, it is hard to argue with his logic. There are days that I want to fire him and hire myself a new guru....))) - Ahmad
Thanks Ahmad – your thoroughness is inspiring. Great case. - Rod
