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Testing temperatures of heat carriers for accuracy You can go on and on
about obturation being unimportant and if you’re only worried about
following your cases for a couple of years; you’re right obturation
probably isn’t that important for short term success. If you don’t
want your cases to become as septic and a Shell gas station toilet in a few
years you have to worry about the obturation and the coronal restoration.
For years I’ve suspected that the System B is a terrible heat delivery device.
The temp always seems inconsistent and I only used it because it was the only
device with a temp gauge supposedly telling me what the tip temp was. This is
important to for heat transference through the gutta percha as the material
appropriately deforms apically within the desired temperature range to affect
deformation but not overheat cause molecular phase transformation, excessive
shrinkage, and leakage.
A few weeks ago I finally decided to get a heat calibrator/measuring device
with a K-Type thermocouple (info gained from Khademi) and actually test
whether the temps were the same as on the digital display.
THEY ARE NOT!
I’m putting my System BS devices on Ebay for sale and buying the
Kerr Touch n Heat . The tip temps were no where close to where they were
supposed to be even testing with several different tips. The Touch n Heat was
the only device that got the tip to the desired 330 degree level. - Terry
Terry, Was there any correlation between the gauge an the real temp? As the
Sys B goes up to the 600s on the gauge,and starts at 100,then surely it must be
330 somewhere in between? Did tip size make a difference in your test?- Bill
Tip size didn’t seem to make a difference and the results were the same.
I just go off the phone with Khademi and we brainstormed some ideas to verify
that my results were an accurate reflection. I’m going out to get some copper
wire to really wrap these things and see if the results change.
The feeling is that the System B’s were only made to be accurate up to
200-250 degrees centigrade which really sucks if you understand rheology and
know what you should be doing - Terry
Terry, Does the heat carrier need to be at 330 degree to transfert heat
through gutta percha and softened it enough to get proper deformation apically?
Any danger to the PDL? Any research to support it? I have touch & heat units
which I use at level 6 usually... what is the temperature then?? Is it enough?
Thank you - Vince
This has been extensively studied at Boston U. The science has been there for
years. No one pays attention to it and yes it needs to be up to 330 and it
won’t be deformed adequately otherwise. I’ve posted my arguments against the
scientific validity of the continuous wave technique in the past. There have
been countless bastardizations of the vertical compaction of warmed gutta percha
technique described by Schilder. Schilder’s technique was studied thoroughly.
The polymer chemistry of gutta percha was meticulously analyzed through heating
cycles by Alvin Goodman. The external root temperatures were not at a level
that would harm the PDL. Jim Stephens wrote an excellent thesis describing
adaptations and settings required of the Touch n Heat to reproduce the Goodman
thermal profiles and yet 20 years later we have dumbed-down ineffective copy-cat
techniques promoted to sell profits and speed at the expense of a quality result.
Even I’ve been duped by the faulty digital temperature display. If the science
isn’t paid attention to you are only getting a single cone stuck in a pool of
sealer at the apex.
Now that I’m extracting quite a few teeth for implants, I get a chance to look
at the forensics. Below is one I believe represents something like the continuous
wave technique. Radiographically, you have what would be viewed by many as a
so-called perfect apical prep. Well if you look at the Hess apices, rarely do
the root ends have a Tulsa Shape and there is no technique of cleaning and shaping
that would make them look like the end of an Autofit gutta percha cone taken
straight out of the box unless it was actually radiographic representation of cone
placed into the canal without deformation, straight out of the box.
Below is the telling forensic section I looked at a few weeks ago.
So, Terry, at level 6-7 on the T&H, what is the temperature at the tip of the
smallest heat carrier available? If it is not the desired temperature (330 deg),
what should be the setting then? -Vince
Vince, I can’t tell you because I don’t know the consistency of manufacturing and
the variability from one specific unit to the next, cut judging from the one unit
I tested today I’d crank it up to the max as the best guess.
Until we have some quality assurance from the manufacturers, I’d buy your own
tester and make sure. I’ve always suspected that the System B was one of the
worst products and I’ve routinely had inconsistent heating experiences with it in
my practice. - Terry
No thanks after you found that out. Have you had an opportunity to test the
elements unit from sybron I’m currently using? How about parkell’s unit. I’d
love to know how accurate they are - gary
Btw, if you are referring to my statements on obturation, my point was not that
it is unimportant. But if I’m going to screw something up, I’m not going to screw
up disinfection and shaping. I have zero chance then. My point was good people
are getting good results with both gp and with the nasty stuff from the dark side
of Connecticut - Gary
Gary,Well, I’m not going to buy them to find out.
It’s pretty cheap to buy the temp calibrator/tester. It was about $80 online for
the unit and $20 for the two K-type thermocouples. I’d do it yourself. It’s well
worth it. I’m heading off to hardware store to buy some very fine copper wire so
I can wrap the tip to the thermocouple and get the most accurate reading.
I’m certain that the readings I got today are in the ballpark,
but I want them exact. -Terry
Yep, I was thinking of them. The problem is the perceptual and human motivational
aspect of thinking that obturation is not important. It fails to instill a
motivation to achieve the highest level of success. I want to scream every time
I hear someone rationalizing their mucked up endo case with the excuses offered by
the literature, that obturation doesn’t matter anyway. For one thing these same
people that fill short, fail to coronally flare, fail to extend accesses, and fail
to trough grooves; are the same people whose cases I constantly retreat that .
In a theoretically controlled environment a librarian that only reads literature
and doesn’t treat endo will think that obturation is unimportant because the
statistics and studies tell them so, they take pride in knowing the literature and
take no pride in completely finishing an endo case.
Debridement is accomplished through shaping and flushing irrigants and obturation
cannot be accomplished properly without the cleaning and shaping. It’s all related
and to comment that one is less important than the other is not productive, doesn’t
instill clinical excellence and serves to motivate one to perform inferior treatment.
In the lab obturation is not important in practice it is.- Terry
We are in total agreement my friend. We simply choose to use different media to
achieve the same goal. Where do I get ahold of a thermalcouple? - Gary
I’m at home now, but I think the company name that I googled was Technika and the
model number of the K-type thermocouple accessory was 800060.- Terry
There are some issues. Terry and I talked and he's solving them.
In a nutshell, I expect the SystemB to be accurate in the range it is "designed"
to be used in, namely 200 or so to about 250.
Above that, or with larger tips, it does not have enough grunt to get to and hold
the higher temps.It's kinda like the speedometer in your Toyota. It goes to 140mph,
but will the car really go that fast? - John A Khademy>
John & Terry, I have literally spent years looking at this problem...without using
a thermocouple in the tip and calabrating it....the temperatures seen on the unit
will never be reflective of what's dialed in. - Joey D
Terry, I agree on long term follow ups, however, you keep saying about 2 years
success being unimportant, do you have any reference or anything to back up
statements like that or could you explain how healing of the periradicular tissues
could take place and then suddenly bacteria could regain nutrients to cause the
disease again?. What is the exact time frame in which we could really say you have
success and according to What?. Kuttler followed many of his cases for more than
20 years, some up to more than 30, he would call it a failure when he found a
LEO after that long of a time. Disinfection is the key to get healing my friend,
show me a study that shows an hermetic seal anywhere no mater what the technique
used to fill.- Jorge
For years, I’ve retreated cases, pulp chambers corroded with silver points in a
slurry of a pus filled soup, single uncondensed gutta percha cones sticking half
way down canals with neighboring untreated MB2’s, and every other type of septic
stew that obviously was brewing in a root canal system for decades while only
eliciting a mild periapical reaction, usually with an inflammatory effect like
resorption on the root apex.
Some people don’t mind sleeping an unmade hotel bed where the previous guest
crapped in it, but some people do. The literature calls these successes, I don’t
and it depends on your tolerance for filth. - Terry
Terry,Here are two papers ( I know you don't love too much that kind of
research ;-) ) that show also the difference between what SysB displays and the
real temperature. I attach the full text papers but for those of you who are busy
and don't have time to read all I just cut the interesting parts. On the second
image you can read that actually SysB is estimated to have an accuracy of
+/- 10 degrees, but they found differences of about 50 degrees (which is still
optimistic regarding the results of the first study, which shows differences of
more than 100-150 degrees)
Hmmm...I hope we won't get anyone too mad on us with what
we are showing here .- Roberto
System B temperature Paper 1
System B temperature Paper 2
Great read - Terry
I find these numbers worse than shocking. That kind of quality control is like
having no control at all. +/_ 10 % is 20 degrees at 200, not 50 or 100.
I’m going to beat up on some of my local engineers, get a hold of a thermalcouple
and test all 4 of my units. - Gary
Terry, The testers are relatively inexpensive (the one in your picture goes for
US$88) and worth having for checking System B and Touch and Heat units on a
regular basis ... akin to having a curing light testing unit, only much cheaper.
Would it be possible to expand on the testing protocol? eg, how do you rig the
tester's probe to the heating tip? Perhaps a photo would explain everything
nicely. - Michael Moran
PS: For those wanting a Technika link, go to
http://www.technika.com/Sper/s800010.htm
I’m definitely going to look into this more and recommend others
do the same.- Terry
I have tried the sys b with narrow posterior heat carrier and temp setting 600.
It was cherry red . I think that this is not only 200 at the tip.... Camil
The System B is calibrated for centigrade,
so the tip was a lot hotter than 200. DougR
.and there seems to be an initial spike in temp then it cools down. I find the
temp readings all over the map with the System B. I’ll do some more tests once
I wrap it with copper wire, but I’m convinced the System B is not as consistent
as other units and the temp gauge is
way off - Terry
Terry, Do you think the initial spike could be to do with the " Separation burst"
that is promoted for the continuous wave technique?
I presume you will be repeating the test with the TNH and letting us know
what sort of settings that gives us?
What heat source did Goodman use in his Thesis?
Was touch n heat out in 1973? - Bill
Goodman used Bunsen burner which heated the heat carrier cherry red but as
it was transferred to the canal and plunged into the gp pad would dissipate heat.
Stephens wrote a very detailed thesis that correlated the Touch n Heat setting of
a specific model available in 1984 to the research done by Goodman with the
Bunsen burner.
You shouldn’t think that the 330C is the exact temp that it has
to be because there is a buffer range that is acceptable and will
not overheat the gp apically. One thing is very clear: IF YOU
DON’T GET THE HEAT TO AT LEAST 330C THERE WILL BE NO APICAL
DEFORMATION AND YOU ARE JUST PLACING AND SINGLE UNMOLDED CONE
INTO THE APEX.
I want to laugh every time I hear people brag about their nice tiny smooth
apical preps. They don’t understand Schilder’s concepts at all. Small as practical
is not Small as possible and if you don’t have a properly shaped root canal system
you won’t be able to achieve the objectives of obturation; it will not be
3-dimensionally molded and the nice tiny smooth tapering shape these people are
bragging about are nothing better than a silver point floating in a pool of sealer.
It’s about time some dispels the myths propagated by the Schilder Imitators.
A VW is not a Porsche. Quick and dirty, all-rotary endodontics does not clean out
a root canal system or adequately explore lateral anatomy. The concept of a
continuous wave does not create the thermal profile required to deform apical gp
because the temp is too low and the compaction is not created in the sequential
waves of heating-cooling cycles that elevates the apical gp temp to the thermal
plateau of 43.5 C required to deform the gutta percha and create appropriate
apical obturation. If you don’t get the temp up to at least 330C you have a
problem, if it’s a little higher it probably isn’t a problem and still creates the
same thermal profile: - Terry
P.S. The big problem is that the Schilder Imitators promote junk science and the
product industry follows suit and creates junk products. If I get a reading of
330C I expect it to be 330C, not 220C. At least the Touch n Heat gives you no
information rather than false information. I’ll take the Touch n Heat any day.
I hate being lied to.
In my opinion, this is part of the problem with the classic Schilder technique.
It is very technique sensitive, too sensitive for the wide range of operator
variability to be reliable and predictable. It does work for some operators but
the classic technique is too complicated. According to the graph there are 5-8
heat applications necessary for each canal and there is no way of knowing just
what temperature was achieved in the GP at the apex. It's guesswork. The apical
GP temperature should also be affected by the diameter of the root, the diameter
of the apical preparation, the length of the root, the temperature of the
condenser, the speed with which the condenser was advanced apically, the diameter
or volume of the GP in the coronal 1/3, the diameter or volume of the GP in the
middle 1/3 . Too many variables to get consistent results for most operators.
IMO there are better and easier ways to accomplish a consistently high quality
obturation than the classic Schilder technique. To those who can do it
consistently congratulations. - Randy Hedrick
Thanks. That’s the one I ordered they had a little better meter available for
146 that has a software interface, that will let me record in real time the
entire heating and dropoff event. For instance, Sybron claims the elements unit
will cook for 4 seconds then auto shut down. I’m going to check to see how
accurate the display is, but also evaluate the timing of max
temp and minimum temp. I’ll try to do this on 4 units: Sybron elements,
touch and heat, system b, and parkell’s thermique. I’ll post the data when
I get it. Should have it on Tuesday
This could be interesting. - Gary
There should be an initial spike to around 300 for about a second or so, then
the temp should settle in at the dialed in temperature subject to some of the
constraints we discussed.
You may not see the initial spike to 300 due to heat capacity, conduction and
latency in the system.- John A Khademy
Bill: Supposed the dial temp is above 300, does the spike still stop
at 300 or does it go up to the dialled temp? As Terry's described technique
only applies the heat for a couple of seconds, it's pretty important.
I suppose you could activate without touching the gp, and after a couple of
seconds apply to the gp to get round the spike.
Terry: You need the tip to be heated to at least 330C apply it for
3 seconds and remove it. If the damn instrument is spiking up and down from
330C to 220C it ain’t happening. The System BS is useless for the Schilder
technique.
Philippe: Sorry to jump in,,we have been teaching the Schilder
technique for over 10 years at the University as THE obturation technique for
undergraduate students, it is a sensitive techinque true, bit with proper
initiation they were able to handle it beatifuly.
Terry I know that you are a warm gutta percha Fan, try the RCPSL ( root
canal plugger sleiman) from Hu_friedy and give me your opinion.
Thanks Philippe, I will try it and let you know. - Terry
In my opinion, this is part of the problem with the classic Schilder
technique. It is very technique sensitive, too sensitive for the wide range
of operator variability to be reliable and predictable. It does work for some
operators but the classic technique is too complicated. According to the graph
there are 5-8 heat applications necessary for each canal and there is no way of
knowing just what temperature was achieved in the GP at the apex.It's guesswork.
The apical GP temperature should also be affected by the diameter of the root,
the diameter of the apical preparation, the length of the root, the temperature
of the condenser, the speed with which the condenser was advanced apically,
the diameter or volume of the GP in the coronal 1/3, the diameter or volume of
the GP in the middle 1/3 . Too many variables to get consistent results for
most operators. IMO there are better and easier ways to accomplish a
consistently high quality obturation than the classic Schilder technique.
To those who can do it consistently congratulations. - Randy Hedrick
Wrong, it’s simple and the temp buffers out at 43.5C - Terry
If System B units are having problems with indicated and true temperature
discrepancies, how do Obtura II units perform in this respect? Wouldn't
temperature accuracy be critical for the Squirt Technique? - Michael Moran
Allow me to chime in for a moment:The Obtura temperature is calibrated by
the internal temperature of the heater chamber, at a specific location
along its length. The temperature of the GP as it's extruded will be as
much as 100 C lower and that depends on the rate it is extruded and the
size needle as well. The GP carries most the heat to the end of the
needle If you want more data, let me know & I'll see what
I can come up with. - Steve Conger
Steve, My testing with thermocouples showed it was within 10% and typically
within 1-3% of the set temp - Joey D,
"This was measured at the nut....not the tip of the needle"
Was not bad at all - I just wanted to clarify where we take our measurement
from so the comparisons are valid. The other problem is when measuring
external surfaces you need to turn your year round air conditioning off or
at least make sure you're not setup under a vent! ;-) - Steve Conger
Thanks for your input - You need to measure it inside the chamber to
replicate what we do here. We set it at the hottest point of the heater
chamber and claim we heat the GP up to 200 C, not that it exits the
needle at that temperature. We do have a tolerance of + - 5 deg C but
set it on the mark, or on the high side rather than the low. We recognize
that a lower temperature may cause some issues with handling. Some of
the older units vary a little more but we recalibrate those of course when
in for any repairs and they've shown to stay within specs for a remarkable
number of years.- Steve Conger
That seems more reasonable in the sense that chamber temp what you expect
to be measured and it’s known that gp is a very poor conductor of heat
and that it would cool off rapidly. It’s a little different than a metal
tip that is supposed to be a certain generated temp. No temp display is
better than a wrong temp display. If I am told something, I expect it to
be correct or I’m going to scream if it’s bogus. - Terry
As I understand it, the T & H and B tips heat from the point back, so the
measurements would need to be taken from there. The further away from
the end you place your thermocouple the cooler it will be. - Steve Conger
Steve:Can you find what temperature in the chamber and then the projected
temps at the tip, and how much the rate of extrusion and needle size effect
it. I’d like to know the numbers for resilon as well. - Gary
I'll look in to it - this won't be real easy or accurate since the tip &
GP will begin to immediately cool after you stop extruding it. There is
a delay (I'm not sure how long) between the temp and the reading on the
digital thermometer that it gets from the probe.
What I'm saying is, I'm not sure we have the equipment to give you those
kinds of accurate results. They way the units are tested now is by
placing the probe in the heating chamber for 10 minutes in order to verify
the temperature stability. If it's off, the units are adjusted and it's
given another 10 minutes to stabilize. That doesn't mean you need to
leave the unit on for 10 minutes prior to use, it's just the timeframe
we've identified over the years. They take longer at times to cool down
than they do to heat up.
I'll toss this at engineering as see what they say. - Steve
Dr. Henkel, Out of curiosity, what temperature do you use Resilon at with
what gauge needle? This seems to vary widely by user from 120 C up to
200 C. Thanks for your time, - Steve
In looking through the literature on the temperature concept I found
this related article.
Related literature
Terry, you have mentioned needing to get to 331 c several times in this
thread. On what is that based. I’ve looked at several studies, this is
the first of 4 where they took the temp up to 300, most
being at 200-250. - Gary
330C based on Jim Stephens thesis. 200-250C is based on junk science and
has nothing to do with the true thermal profiles that occur. - Terry
>
Another footnote regarding the Sweatman study is the probable difference
between in vitro and in vivo study models. Like the Goodman and Stephens
work you’re looking at a lab set up that doesn’t necessarily account for
the heat dissipation that occurs in an actual clinical case. The
surrounding PDL and bone draws heat away from the tooth surface unlike
the lab apparatus that won’t as efficiently conduct the heat away.Multiple
interrupted waves are safer in that they allow the temp to peak and drop
in multiple applications allowing a steady plateau of peaks leveling off
at the 43.5C level apically and dissipation of thermal energy laterally.
Basically it is hard to overheat and easy to underheat leading to
incomplete apical deformation. The likely error is underheat the apical
gutta percha by failing to deliver an adequate number of cycles at an
inappropriately low temp.
There’s nothing technique sensitive about this but you have to know the
rheology and understand the appropriate temp settings and delivery
sequence. I’m pretty PO’d that I’ve had units with bogus temp gauges.
I’ve always felt a need to hold the compaction pressure longer than
required and now that I know it wasn’t the right temp,
I understand why. - Terry
OK folks. There is some HARD evidence from Terry . Not just opinion.
Thanks Terry. The facts are that the displays (either on EPTs, EFLs or
Systems B heating units) are simply WRONG and INNACURATE.Total Bullshit.
But they look nice.
I've been using my Touch N' Heat (M2005) units for 20 years and I'm always
tweaking them for proper heat? Why? Cuz the tips wear out,lose conductivity
with time, some tips heat more easily than others etc. For proper classic
warm vertical technique you must constantly be watching how the material
reacts to your heat. Too much heat and the material "melts"- becomes soupy
and is actually more difficult to pack properly. That's not "the technique".
Not enough heat and you don't get adequate plugger compression into the
material - hence proper deformation is impossible. (That's also why you
need properly sized preps so the heat can be transferred to the mass o gutta
percha.) You can usually tell you have the right amount of heat when
the heat carrier is placed into the GP AND IT REMOVES THE RIGHT AMOUNT of
GP UPON WITHDRAWL. Too much heat and you get nothing removed cuz its soup.
Too little heat and you get minimal amount cuz its too cold. The right
amount?...Walls are clean upon removal, you can clearly easily see the
remaining GP and its EASY to pack. You can see the GP as it is deformed
with the piston-like compressions of the plugger especially if you use a
scope. That's one of my favorite reasons for using a scope now- packing
cases with a scope is SO COOL!! Sometimes you have to vary the temp
( depending on whether you use "thick" anterior or posterior tips).
The point is that you need to know how the material handles - in order to
get a good result. That's one of things I've never liked about pure
System B. As my friend Donald Yu has been known to say , it's the
"Fake Orgasm" of Schilder Warm vertical endodontics.
The criticism that "The Schilder warm GP technqiue sensitive is too
technique sensitive" is so much BS. What is DOES require is attention to
prepping the canal. That's the hard part. That's why some of us hate
Thermafil so much. It the lazy persons filling technique - for people
who wouldn't know a well shaped canal
I've got nothing against Resilon but it simply doesn't heat like GP.
I have 25 years of experience knowing EXACTLY how much I can move a GP
cone. With a larger apex, I can (and often do) fit a cone shorter than
normal and then "Sit on it" with a plugger and get it to exactly the
location I want. My staff see me moving GP in this way every day
especially with necrotic cases that have resorbed apices. In other
cases with especially tough anatomy, I'll squirt. I'm simply not
ready to give up that kind of material control with a material that
has produced reliable results and has a proven track record. And as for
the coronal leakge issue - I suggest that Orifice Bonding offers a
reasonable alternative with materials that the average dentist ALREADY
HAS in his op. He's much more likely to do that rather than trying a
material and technqiue that he is totally unfamiliar with. - Rob
Have not posted much,,,but Rob gets my juices flowing ;-)
I love the literature and spent 40+ years reading it....
but nothing beats clinical experience.
I enclose my references
collection ( most with abstracts ) on the subject. But Rob's post
right here is more relevant. - Ben
Liviu, beautiful as usual. tell me, how did you control the soft tissues
when placing the composite? the fractures appear to go subgingivally to
quite a degree. Would an instrument such as a Zekrya margin protector
have helped, or did you pack cord? - Bill
Thanks Bill,I have indeed packed cord and used the
Zekrya margin protector. 0:))))) - Liviu
Hi Liviu, Beautiful recovery! Any rads? - Marga
Well done Liviu.....it is always wonderful to see your cases.What is the
likelihood of the pulp staying vital. Secondly, in a case like this when
do you offer more permanent restorations. Thanks - Glenn
Tahnk you Glenn!
(G) What is the likelihood of the pulp staying vital.
(L) Chances are far higher than 90%.
(G) Secondly, in a case like this when do you offer more permanent
restorations.
(L) At a later age as the young lady was just below 14 years. - Liviu
Liviu, the 90% pulpotomy success is trauma induced teeth with open apices or
closed? and how long are these recalls for? Cvek's studies are on immature
teeth, I believe..
i personally would have done endo on teeth with closed apices.. fantastic
restorative result....you are an artist.- Sashi Nallapati
Thank you Sashi for your words! I doubt if this was to be your daughter,
the root canal treatment would have been your treatment of choice? The only
addition you might have been done than would have been to apply Emdogain on
the pulps!Here is some literature to the topic. - Liviu
Effectiveness of 4 pulpotomy techniques--randomized controlled trial.
Huth KC, Paschos E, Hajek-Al-Khatar N, Hollweck R, Crispin A, Hickel R,
Folwaczny M. Department of Restorative Dentistry & Periodontology,
Dental School, Ludwig-Maximilians-University, Goethestrasse 70, 80336
Munich, Germany.
Pulpotomy is the accepted therapy for the management of cariously exposed
pulps in symptom-free primary molars; however, evidence is lacking about
the most appropriate technique. The aim of this study was to compare the
relative effectiveness of the Er:YAG laser, calcium hydroxide, and ferric
sulfate techniques with that of dilute formocresol in retaining such molars
symptom-free. Two hundred primary molars in 107 healthy children were
included and randomly allocated to one of the techniques. The treated teeth
were blindly re-evaluated after 6, 12, 18, and 24 months. Descriptive data
analysis and logistic regression analysis, accounting for each patient's
effect by a generalized estimating equation (GEE), were used. After 24
months, the following total and clinical success rates were determined (%):
formocresol 85 (96), laser 78 (93), calcium hydroxide 53 (87), and ferric
sulfate 86 (100). Only calcium hydroxide performed significantly worse than
formocresol (p = 0.001, odds ratio = 5.6, 95% confidence interval 2.0-15.5).
In conclusion, calcium hydroxide is less appropriate for pulpotomies than
is formocresol.
J Clin Pediatr Dent. 2005 Summer;29(4):307-11.
Success of mineral trioxide aggregate in pulpotomized primary molars.
Farsi N, Alamoudi N, Balto K , Mushayt A .
Pediatric Dentistry Division, Department of Preventive Dental Sciences,
Faculty of Dentistry King Abdulaziz University, Jeddah, Saudi Arabia.
N_Farsi@yahoo.com
The aim of the present study was to compare, clinically and radiographically,
the mineral trioxide aggregate (MTA) to formocresol (FC) when used as
medicaments in pulpotomized vital human primary molars. METHODS: The sample
consisted of 120 primary molars, all teeth were treated with the same
conventional pulpotomy technique. Sixty molars received FC and 60 received
MTA throughout a random selection technique. RESULTS: At the end of 24-month
evaluation period, 74 molars (36 FC, 38 MTA) were available for clinical and
radiographic evaluation. None of the MTA treated teeth showed any clinical
or radiographic pathology, while the FC group showed a success rate of 86.8%
radiographically and 98.6% clinically. The difference between the two groups
in the radiographic outcomes was statistically significant. It was concluded
that MTA treated molars demonstrated significantly greater success. MTA seems
to be a suitable replacement for formocresol in pulpotomized primary teeth.
Dent Traumatol. 2005 Aug;21(4):240-3. Related Articles, Links
Vital pulp therapy with mineral trioxide aggregate.
Karabucak B, Li D , Lim J, Iqbal M.
cSchool of Dental Medicine, University of Pennsylvania,
Philadelphia, PA 19104, USA. bekirk@mac.com>
The present case report describes the treatment of complicated crown fractures
using mineral trioxide aggregate (MTA). MTA was used as pulp-capping material
after partial pulpotomy to preserve the vitality of the pulpal tissues in two
cases. Follow-up examinations revealed that the treatment was successful in
preserving pulpal vitality and continued development of the tooth.
Dent Traumatol. 2003 Dec;19(6):314-20.
Comparison of bioactive glass, mineral trioxide aggregate, ferric sulfate,
and formocresol as pulpotomy agents in rat molar.
Salako N , Joseph B , Ritwik P , Salonen J, John P, Junaid TA.
Faculty of Dentistry, Kuwait University, Kuwait.
Bioactive glass (BAG) is often used as a filler material for repair of dental
bone defects. Although there is evidence of osteogenic potential of this material,
it is not clear yet whether the material exhibits potential for dentinogenesis.
Hence, the aim of the present study was to evaluate BAG as a pulpotomy agent and
to compare it with three commercially available pulpotomy agents such as
formocresol (FC), ferric sulfate (FS), and mineral trioxide aggregate (MTA).
Pulpotomies were performed in 80 maxillary first molars of Sprague Dawley rats,
and pulp stumps were covered with BAG, FC, FS, and MTA. Histologic analysis
was performed at 2 weeks and then at 4 weeks after treatment. Experimental
samples were compared with contra-lateral normal maxillary first molars. At
2 weeks, BAG showed inflammatory changes in the pulp. After 4 weeks, some samples
showed normal pulp histology, with evidence of vasodilation. At 2 weeks, MTA
samples showed some acute inflammatory cells around the material with evidence of
macrophages in the radicular pulp. Dentine bridge formation with normal pulp
histology was a consistent finding at 2 and 4 weeks with MTA. Ferric sulfate
showed moderate inflammation of pulp with widespread necrosis in coronal pulp
at 2 and 4 weeks. Formocresol showed zones of atrophy, inflammation, and fibrosis.
Fibrosis was more extensive at 4 weeks with evidence of calcification in certain
samples. Among the materials tested, MTA performed ideally as a pulpotomy agent
causing dentine bridge formation while simultaneously maintaining normal pulpal
histology. It appeared that BAG induced an inflammatory response at 2 weeks with
resolution of inflammation at 4 weeks.
Liviu, the first two studies you referenced are in primary molars
the third, is a case series of two cases in immature (open apices) teeth where
pulpotomy is the treatment of choice to facilitate apexogenesis.
the last study merely compared, if you decide to do a pulpotomy ,
what material is best...
Cvek's classic studies of pulpotomy were very successful in traumatised teeth
with open apices, which is a different ball game.
AAE guidelines for teeth with closed apices that undergo trauma with fractures
and pulpal involvement is pulp cap/pulpotomy OR RCT.
my opinion ( and strictly an opinion) is, pulpotomy in a vital tooth with closed
apices (trauma/caries) is ,at best, a temporary measure than a final, definitive
and predictable (over a long period of time .over 25+ years) treatment option.
for my daughter , i would do endodontics to maintain periapical health with out
any hesitation.- Sashi Nallapati
Sashi, thank you very much for your point.
I understand where you are coming from.
I understand that still my treatment plan was conform the AAE guidelines! :0))
Indeed as you remember from the words I addressed to Glenn, the treatment is
to be considered a temporary one. :0)))
But I do understand and appreciate your worries still I do not share your
treatment opinion. Time will show! The patient is now in recall, ....and yes
I am fully behind my treatment plan selection! - Liviu
Partial pulpotomy healing:
Cvek 1982: 178 cases--95% success
Fuks 1987: 63 cases--94% success - Fred
average recalls of what period ? was the Cvek study in 1982 done in humans?
can you give me a full reference? thanks... Sashi Nallapati
re: Emdogain is not better than Ca(OH)2 for pulp capping.
Int Endod J. 2005 Mar;38(3):186-94. Dental pulp capping: effect of Emdogain
Gel on experimentally exposed humanpulps.Olsson H, Davies JR, Holst KE,
Schroder U, Petersson K.Department of Endodontics, Faculty of Odontology,
Malmo University, Sweden.
helena.olsson@od.mah.seAIM: To investigate the effect of Emdogain Gel
(Biora AB, Malmo, Sweden),consisting of a enamel matrix derivative (EMD)
in a propylene glycol alginate
(PGA) vehicle, on experimentally exposed human pulps and to register
postoperative symptoms. METHODOLOGY: Nine pairs of contralateral premolars
scheduled for extraction on orthodontic indications were included. Following
a superficial pulp amputation performed with a small (016) diamond bur,
either EMDgel or a mix of calcium hydroxide and sterile saline was placed at
random incontact with the pulp wound. The subjects made records of symptoms
and were also
interviewed about pain/discomfort by a blinded examiner. After 12 weeks
the teeth were extracted, prepared and subjected to light microscopic
examination inwhich the inflammation and newly formed hard tissue in the
pulp were analysed.
Immunohistochemistry was performed using affinity-purified rabbit anti-EMD
polyclonal antibodies. RESULTS: Postoperative symptoms were less frequent
in theEMDgel-treated than in the calcium hydroxide-treated teeth, especially
during the first six weeks. In the EMDgel-treated teeth, new tissue partly
filled thespace initially occupied by the gel and hard tissue was formed
alongside theexposed dentine surfaces and in patches in the adjacent pulp
tissue. EMD was detected in the areas where new hard tissue had been formed.
The wound area ofthe EMDgel-treated teeth exhibited inflammation in the
majority of the teethwhereas less inflammation was seen in the calcium
hydroxide-treated teeth where the hard tissue was formed as a bridge.
CONCLUSIONS: In the EMDgel-treatedteeth, postoperative symptoms were less
frequent and the amount and pattern ofhard tissue formation were markedly
different than in the teeth treated with calcium hydroxide. However, the
operative procedure and the formulation with EMDin a PGA vehicle do not
seem to be effective for the formation of a hard tissuebarrier.- Fred
re: Emdogain is not better than Ca(OH)2 for pulp capping.
Fred,this is true. Emdogain is also in Perio not considered to be better
than classical techniques but it is liked as it enhances a nice
wound healing. - Liviu
Liviu, Amazing case! One doubt, Is it possible in these kind of cases
to use calcium hydroxide
Ca(OH)2 (Dycal) instead of MTA? Which is the different? I have read
that the only different is in the physics properties, Is this true?
- Marcela
Absolutely beautiful, Liviu. I hope the caps work. Guy
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