Advice Needed for Success Endo Tx Tooth 7, 8, 9 & 10

Transcription

1 Advice Needed for Success Endo Tx Tooth 7, 8, 9 & 10 vasquezdds Post: 1 of 68 Patient came in with pain and pressure on teeth 7, 8, 9 and 10. X-rays shows large radiolucency on apical area involving all four front teeth. Patient reports large fillings, and had trauma about two years ago. My question is what will be the best protocol for a successful RCT [root canal treatment]? Fig. 1 Fig. 2 Fig. 3 Fig. 4 Fig. 5a Fig. 5b Figure 1: Pulp test result non-vital. Figure 2-4: After access, tooth numbers 8 and 9 had lots of exudation (pus) draining out, clean canals. Figure 5a & 5b: Final RCT. gnovotny Post: 2 of 68 Multi-step the root canals with Ca(OH) 2 [calcium hydroxide] as an interim dressing. Wait to see healing before gutta percha obturation if you want to be perfectly ideal. Post: 3 of 68 Clean, shape, get it dry, then obturate. You cannot eliminate all the risk by waiting for a sunny day. There will always be a risk for apical surgery in these kinds of cases. sunbusrtlespaul Post: 4 of 68 I agree with Greg. To be ideal change Ca(OH) 2 dressings over time until you see healing. That s pretty ideal and probably after one to two applications and asymptomatic you can t argue against obturating if everything is dry. Warn the patient that continued on page 22 20

2 continued from page 20 they might need surgery when the lesions are this big! Also try re-orienting your access more incisally and avoid taking away as much tooth from the cingulum... particularly in the laterals. Let us know how things progress! Post: 5 of 68 I ve seen many cases where Ca(OH) 2 dressings were done, and the apical pathology (bone loss) got worse over the next month. The most ideal condition in this case is obturated canals and restoration for apical healing. Now, if these were open apices, I would agree with Ca(OH) 2 attempt at first. Just stating my experiences, not wanting to start a debate here, both approaches are acceptable. aston Post: 6 of 68 If the patient is in pain I would also use an anti-inflammatory paste, like Odontopaste, in addition to your Ca(OH) 2. Not Ledermix, as it will stain and in an anterior tooth you want to minimize that as much as you can. vasquezdds Post: 7 of 68 I open and drain, tooth #8 left it open for drainage, patient has an appointment tomorrow to close #8, Ca(OH) 2 will be used. For one month, I have fully develop roots on all four incisors I will be able to get a good seal. I ll keep posting X-rays for updates. continued on page 24 FREE FACTS, circle 31 on card 22

3 continued from page 22 nxb8373 Post: 8 of 68 First of all do not leave teeth open to drain. What is the main reason for doing root canals? Bacterial contamination of the pulp. The oral cavity is full of bacteria. Place calcium hydroxide and temporize the teeth with something that seals the access cavity. Calcium hydroxide is 100 percent indicated in this case. Any long standing lesion especially with purulence needs intracanal medicaments. I definitely agree with changing out the calcium hydroxide once or twice to see if you start to get healing. Give the patient the heads up they might need surgery later if the lesions don t heal. Nate Post: 9 of 68 Guys, I think you are making this much more complicated than what it is. On a theoretical note, can someone review the benefits of Ca(OH) 2 in this case? I am aware it is bacterialcidal (antibacterial?) as Ca(OH) 2 dissolves into Hydroxyl ions and Ca [calcium] mineral, but if one did obturate, is not the primary source of the infection eliminated? Is that not the first priority? Is there something about Ca in the bony defect that helps to accentuate reparative osseous tissue or does the Ca just make the PA look nice and white? Does the body not have its own supply of Ca in the blood stream that should be sufficient for mineralization of the reparative bony matrix? The apical surgery, if needed should be easy in this case, mostly just curettage and bit of smoothening of bone. sunbusrtlespaul Post: 10 of 68 Dimitrios, I think the Ca(OH) 2 dressings will kill more bacteria than if not used. Sure with no drainage one can obturate and have the canal well sealed but have left a ton of bacteria behind. Especially with lesions this big the Ca(OH) 2 might help kill a lot more than if just one-stepped. Of course one-stepping works and a lot of people do it. I guess with a lesion this big and two-stepping you are just tipping the scale in your favor and maybe also helping avoid a post-op flare up! Post: 11 of 68 Here s a one shot endo. The young patient had been to previous dentist with large cellulitis. Had pulpectomy done two to three weeks prior, still had swelling and now bone loss when I saw the patient. Had pus which drained through an opening I made on the buccal furcation area. Extra oral swelling still present, though not as acute as was described initially. M2-3 mobility. Went ahead and obturated same appointment. Patient was fine a few weeks later, the mobility had returned to normal. This is the day of the obturation. A lot of pus everywhere. Sherwin Cheng, DDS skchengsmithsonjr Post: 12 of 68 Dimtrios, I disagree. What is the ph of Ca(OH) 2? The use of Ca(OH) 2 has nothing to do with making the PA look nice and white. I used to one-step everything years ago. More and more I two-step my cases. I would miss a lot of anatomy if I insisted on one-stepping, and I wouldn t allow for adequate debridement and irrigation/soak on these nasty necrotic cases that are teaming with bacteria. With the scope, you can truly see just how dirty the canals are. And you can see the seepage and muck that we re trying to seal by obturating these wet and purulent cases. continued on page 26 24

4 continued from page 24 Once again, I don t agree that apical surgery would be easy here. Question? If you do apico surgery on these teeth, where would you lop off the roots? Or would you? sherwin vasquezdds Post: 13 of 68 I do understand infection and bacteria, I left tooth #8 open for drainage (pus), to help and minimize pressure and pain. We called patient today and he was doing fine. Pain was gone. He has an appointment tomorrow for cleaning canal and application of Ca(OH) 2 like teeth #7, 9 and 10. I will keep you posted. Post: 14 of 68 Sherwin, ph is basic for Ca(OH) 2 Ca plus Hydroxyl ions (basic/high ph). I did explain the basic ph was antibacterial... I was being somewhat sarcastic about the radiopacity of the Ca minerals. The reason why your one-step failed was you did not clean the canals enough. I feel when I one-step, which I do about 50 percent of the times, I clean out the canals just as much as the two-steps.the days before the rotaries I never onestepped, but with the rotaries there is less chance of pushing garbage out the apex. The point about apico in this particular case is for debridement of granulation and necrotic/cystic periapical pathology and not so much about the root tips. That is assuming the endos fail. Young Padawan Posts: 15 & 17 of 68 If you want to minimize pressure let it bleed as long as it wants and then close the access. I&D if you want, but don t leave the access open. [] The primary benefit of Ca(OH) 2 is ph, not calcium release. However, the literature on the effectiveness of Ca(OH) 2 is decidedly equivocal. Sunburst, let me ask you, if you instrument/irrigate a canal then place Ca(OH) 2 for a week/month is the tooth sterile? Most of the literature says no. Dig deep enough into dentin and you ll find bacteria hidden in dentinal tubules. Sherwin, most endodontic offices complete the majority of treatments in one visit and their treatment times are under one hour. How does that fit in with the rest of what we know? nicetooth Posts: 25 & 29 of 68 It can get a lot worse fellas. continued on page 28 26

5 continued from page 26 It looks like your osteomyelitis is taking on a life of its own. Schedule with OS [oral surgeon] the same day as your obturation. Go long and get the patient to OS for enucleation, graft, GTR [guided tissue regeneration], retrograde, whatever. Knock out this infection for this young patient, rapidly! [] What? You Sherwin? We re going for the save on this one! You of all people should appreciate that. The bx [biopsy] report came back radicular cyst and the CT showed its extent to the cranial base. The patient underwent enucleation and graft last week and we ll follow up CT in three months. I ll be posting it. vasquezdds That was the main reason I posted this case, to avoid the advance of Post: 30 of 68 periapical lesion like this one. Thank you for posting the X- rays. It will be good to establish a good protocol for treatment. Yes, I left the tooth open for drainage for a day. Patient doing well. Antibiotics (Z-pak) and Motrin 800 given to patient. Ca(OH) 2 will be used and close tooth. My plan is to bring in patient in two weeks, evaluate teeth, and see if there s any need to do more cleaning. Finish RCT in one month. Evaluate with X-rays every three to six months and see if there is a need of apicoectomys. I been reading this thread and it is great. I m putting my plan together. Any other suggestions please post! Thank you. Daniel doctored Another vote for two or more stepping. Post: 38 of 68 I also leave weeping canals open to drain for a day or two before re-cleansing and applying Ca(OH) 2. Ed aston What is Buchanan s rationale Posted: 10/14/2009 behind leaving the tooth open? I Post: 39 of 68 don t know what his thinking is, but if you know that the RC system already has a lot of bacteria and pus in it and you know that no amount of endo will remove all the bacteria. Then why keep the tooth open continued on page FREE FACTS, circle 11 on card

6 continued from page 28 and risk putting more in? More is just going to make things worse. The NaOCl [Sodium hypochlorite] irrigants and intracanal medicaments are what will help. I don t think a saliva irrigant filled with bugs will. Sherwin Cheng, DDS skchengsmithsonjr Posted: 10/14/2009 Post: 40 of 68 The rationale is fairly simple. Sometimes you don t want to bottle up that shaken soda can. Another instance where I ll leave the tooth open is that root canal where you started the case and the cotton/cavit fell out two years ago. Now the patient is swollen and the tooth is draining like a jelly donut oozing blood and guts all over the place. I ll also leave that one open for a day. Do you think leaving that one open is also harmful? Tell me how effective NaOCL is when the tooth is spewing crap back at you? Do you think that saliva will make things worse? Did you finish that upper first molar? sherwin nicetooth Posted: 10/14/2009 Post: 42 of 68 Daniel, I would strongly consider getting an oral surgeon on your team right now and discuss the option of finishing the RCTs and enucleating the cysts, end-treat, and graft all on the same day. aston Posted: 10/15/2009 Post: 47 of 68 So is he saying that if the bleeding and pus discharge cannot be controlled, then leave it open? If it s spewing out then that is an even greater indication to keep on irrigating and draining to get to a point where it is controlled. It will stop eventually. Never let the sun set on pus. As for the RCT started two years ago, the answer to that is not to let it happen in the first place. Don t use the cotton to seal access cavities, cavit and a top layer of a stronger GIC [glass ionomer cement], unbonded composite (as some guys here do) or even IRM will be fine. Certainly better than cotton. I guess that s an extreme example. But if that happened I would still close it up. NaOCl is antibacterial, it will certainly help. As for how effective it s hard to say, but every clinical situation will be different. Saliva will make things worse by introducing more bacteria. As for the significance, too many factors are involved. If minimizing or eliminating saliva entry does not make things better, it certainly will not make it worse. Nope haven t finished the upper six, she was booked in to come in last week for the finish but she rescheduled for next month. A 40-year-old mother of three young kids and full-time student with upcoming exams living in a low to medium SES [socioeconomic status] area - maybe she has more important things on her mind. I ll post it when I ve finished it. Find it online at Advice Needed 30