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Ultra conservative access - Courtesy ROOTS

From: John A Khademi, DDS MS
Sent: Wednesday, November 16, 2005 7:53 PM
Subject: [roots] Ultra conservative access

I'm all for preservation of tooth structure. But you gotta find the canals. This ridiculous pee-hole access (pic1) by the
previous endodontist (yes you read right) precluded him fron finding a big-as-a-house (BAH) MB2. After d-gooking the
chamber floor, we stuck a file in the BAH MB2 and witness the egress of the black gook of death (Pic5). This fuse root
tooth ended up having an isthmus from the MB all the way to the palatal, but I was only able to get down in three places
(Pic7 page2). Final and porcelain repair follow. The last two pics are the other tooth he treated. At least he is
consistent, which is also symptomatic. (Sorry for the sarcasm, but this is supposed to be a specialist. And YES, the molar
was all banged up inside too.) - John A Khademi

Nice case, nice sarcasm - Terry Nice case.....how are you getting the floor so clean , only bleach, heated up ?? I use EtOH and H3PO4 at the same time on a microbrush and scrub - John Nice case on the first one. System B with Obtura backfill and did y ou troughthe isthmus on the MB to the palatal to get the ribbon fill that we see on the last obturation photo - Glenn After the "prep" shot (Pic6 visit one) I had him back and dried the chamber out and looked around again. I could see a fin connecting from the MB to the MB2 to the palatal. I troughed and poke and prodded, but no joy. Fit four cones, systemB, obtura. BTW, the second case is not mine...it belongs to the same pee-hole endodontist who first treated the molar - John John , I too would always love to preserve the tooth structure but eversince being on Roots the desire to find the extra canals and to get a straight line access I often sacrifice good tooth structure and on the other had I find people performing Endo thru a round bur hole ( a bit enlarged ) ..............doing all the 3 canals ( upper moalrs) no Mb2s and leaving a lot pulp tissue in the pulp chamber itself. You are absolutely right when you say that the primary objective is to do a good Endo...............afterall what good is a good restoration if the Endo is not up to the mark - Sachin Sachin, Thank you. The access does NOT need to be big, just appropriate for the given clinical situation. This access was inappropriate in size, shape and location. Basically, nothing was right about it. Couple this with the lack of illumination and magnification, this is what most endodontic cases look like inside. Terry and I spend a considerable amount of time on the endodontic access, as it sets the foundation for the case. It is not uncommon for me to spend 20-30 minutes on access (which includes the coronal portion of the canal) before ever placing a file in the canal. Any retreatment based endodontist will tell you that improper access is present in almost all of the failing cases that present . Keep up the good work - John A Khademy Cliff ruddle spoke at the ada meeting a few weeks ago, he stated he almost always enlarges the access presented to him on retreats - Gary I would not say that I "enlarge" the access preseted to me on retreatments. I just extend it in the proper areas. Usually, the previous access is centered over the tooth i.e. it is too far distal. And usually not far enough buccal - John How could he miss the Mb2 when he could see all the other canals. the Mb2 was in the centre...?? :) very conservative access. But poor quality for a specialist...Nice work John! i like your cleaning up very much - Vipin Vipin, Thank you. How can anyone miss all the anatomy that is routinely presented here on rxRoots that you almost never see on DT? How can some endodontists practice for over 30 years and have never seen this stuff? In my eyes, in increasing order of importance: 1) Lack of vision 2) Lack of time/patience/determination/effort/care/all the qualitative stuff that comes from inside you 3) Lack of belief If you do not believe that this stuff is there...and there routinely...no amount of #2 will lead to predictable discovery. If you do not have #2 in ample supply, your microscope (#1) will become a very expensive coat-rack. The definition of conservative access depends upon which side of the chair you are on. It certainly wasn't conservative on my patient's wallet, who had to pay twice - John Dear John, I am also amazed at the cleanliness of the pulpar floor. What is the Etoh % and do you use just etching ? Many times I get spots and stuff I can't get rid of even if I scrub the floor. Maybe this is the solution ? Wonderful - Thomas Thanks Thomas, It is the EtOH and the H3PO4 in there TOGETHER that makes the difference. Just plain jane Albertsons Brand 70% rubbing (which is actualy not EtOH, it is isopropyl.) - John