From: Ahmad Tehrani
Sent: Friday, August 25, 2006 12:10 PM
To: ROOTS
Subject: [roots] Silver Point short term recall

5 appointments spent C& S,  2 appointments for obturation.
NaOCl, EDTA , CHX by gallons irrigated these canals.
Getting all the silver oxide residues from the walls was a laborious task. It is a nasty and very tenacious residue.
Each appointment was finished with dressing the canals with mixture of Ca(OH)2 + CHX.
I don't know what possessed me to pack the distal canal with GP at first, but I came to my senses quickly.
Removed it and placed MTA apically like I should have done to begin with, until next visit.

Clinical success would be a 5 year recall when all the Strindberg criteria's are met.
So far it is only a "radiographic" success. Even that is debatable. but I digress..... ahmad







Many are speechless at the sheer quality of your results.  you and your patient worked your rear end's off on this one,
and it looks like it paid off.  good decision on the mta!   can't have 5 year success on a case a year out.  so as of
this moment in team, successful until proven otherwise.  excellent! - gary

I believe everything is a failure until proven otherwise. but that's the pessimist in me.
Thanks for the nice words and ego stroking.....)) - ahmad

Are there specific steps you take to remove this residue that differ from other treatments/retreatments?
Is your Ca(OH)/CHX mixture simply Ca(OH)2 powder and 2%CHX in a slurry? - KendelG

Kenny G:
Really the only way to remove the Ag2O is time and contact...and the only difference between the AG and other re-tx
procedures is the color of the crud you keep getting out. Also Ag2O is notorious for post-op flare ups.
Ult. sonic agitation of irrigants, scouting files, and repeating the process again.
Mix it to a paste-like consistency and lentulo the bad boy to length.
You can use the slurry mix to flush out a ST for instance ( away from vital structures like Mental F. or IAN )....
these days I mix it with Anolyte solution and flush with it as well....ahmad

Ahmad, Nice case!  For those of you who noticed the short distal root, realize that the root originally extended
to the tip of the silver cone.  The silver oxide, probably in conjunction with bacterial contamination, causes
root end resorption and loss of any chance of establishing an apical capture zone or an apical stop.  Once the
silver cone is exposed to the periapical tissues the resorption begins to advance.  Notice how there is a lesion
on the mesial but no extensive resorption because the silver cone is well short of the periapical tissues
minimizing the exposure of the periapical tissues to silver oxide (the black stuff on the silver point).

Nice teaching case Ahmad - Randy

Thanks so much for looking at the case with such keen eyes. I like this type of discussions.
I will try to post cases trying to learn something that I might have missed or can do it better next time.
as long as patients are paying, that's the least we can do for them.  - ahmad

I learned something here.  Thanks Randy, and thanks for posting the cool case Ahmad! - Mark

I agree with you Mark. Randy packed a fistful of pearls in his reply - ahmad

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, Great to see you back on track :). 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

P.S I got my scope running, it's great ! But the learning curve is quite hard. Didn't use a scope in 4 years :(

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

Dear Gary, Of course I will hang in there. I am not going back either. It's going to be hard work, but it's worth it.
My endo just got better :) - Thomas

P.S Those gp remnants are probably a good reason for some failures I have. I will be very happy to have less of those. Just this is worth using the scope.

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? - Rod 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