Endodontic Sequence

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Endodontic Sequence

Postby BarryMusikant on Wed Jan 04, 2012 11:47 am

BarrySir, a request from me. It would be nice if you can write up a threadabout the latest in the sequence of intrumentation followed by you& pin it to the top of the message boards. Then make changes to itas & when you modify it. I realize that we have to improviseaccording to the specific case requirements but what I (& may be afew others) are looking for is the sequence by & large you wouldadvocate.(or may be there is a thread that's already been written but Iam too lethargic to search for it ).
Thank You.
Amar.


Amar,

Below is the sequence that I typically use to shape canals.

The most challenging part of the sequence is to negotiate tightcurved canals. I test for patency in these situations with 06 stainlesssteel reamers. At times the 06 is so thin that it bends too easily. Inthese cases, I will cut a mm or 2 off the apical end of the 06 reamerand place it into the reciprocating handpiece. It this reamer makeseven a mm or 2 worth of progress, I will then switch to an uncut 06reamer and attempt manually to negotiate to the apex. Always usereamers because they engage far less along the length of the canal andtheir vertically oriented blades shave dentin away far moreeffectively.

So the first step is to manually negotiate the  06 reamer to the apex.Of course if the canals are wider and straighter, you can your initialinstrument can be an 08, 10 or higher.

Assuming the 06 reamer was your first instrument, after manuallynegotiating to the constriction (referred to as the apex with the apexlocator), place the next instrument, the 08 reamer, in thereciprocating handpiece and negotiate to a distance 0.5mm beyond theconstriction with the canal irrigated with either 17% EDTA  (in vitalcases) or 6% NaOCl (in non-vital cases). We are assuming in these casesthat you are not encountering an abrupt curve that would result in thetip of the instrument hitting a wall and necessitating bending at thetip and the manual manipulation around the impediment beforereattaching to the reciprocating handpiece. This assumption isgenerally the one you will encounter.

Next, negotiate the 10 reamer in the reciprocating handpiece 0.5 mm beyond the constriction.

Next, negotiate the 15 relieved reamer in the reciprocating handpiece 0.5 mm beyond the constriction.

Next, negotiate the 20 relieved reamer in the reciprocating handpiece 0.5 mm beyond the constrction.

Now take the tapered peeso generally to within 6 mm of the preparedcanals leaning to the outside wall on the upstroke. The purpose is toprimarily straighten the canal to the outer wall and secondarily imparta taper to the coronal and middle portion of the canal. If youencounter resistance on the way to getting within 6 mm of the apex,don’t attempt to gain this full length. You can always go back forfurther length extension after the canals have been widened furtherwith the relieved reamers.

Check for patency with the 20 relieved reamer

Next, take the 25 relieved reamer in the reciprocating handpiece 0.5mm beyond the constriction.

Next, take the 30 relieved reamer in the reciprocating handpiece to the constriction.

Next, take the 35 relieved reamer in the reciprocating handpiece to the constriction.

Next, take the 40 relieved reamer 1 mm short of the constriction

Next take the 25/06 relieved reamer in the reciprocating handpiece 0.5 mm beyond the constriction.

Finally use the 30/04 as an irrigant activator to the apex with both NaOCl and EDTA for 30 seconds each.

Above is the standard instrumentation technique. If canals are larger,I also will use regular reamers from 45-140 in a stepback fashiondepending upon the individual situation.

I should add that the uniqueness of the relieved reamer design allowsthese instruments in most situations to reach the apex with just a fewstrokes at most. I would estimate the time necessary to shape a routinecanal to a 40 as no more than 2-3 minutes in most cases from the momentthe apex is reached and confirmed with the apex locator.

If variations to this technique occur over time I will post them. Feelfree to ask any questions that come to mind regarding this technique.

Regards, Barry  
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Re: Endodontic Sequence

Postby tba on Wed Jan 04, 2012 10:36 pm

Thanks for the information Barry.  Will you also comment on how you decide to finish a devital case with bone loss at apex in one appointment.  I will sometimes after cleaning and file fill with calcium hydroxide and wait for signs of healing; then complete
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Re: Endodontic Sequence

Postby BarryMusikant on Thu Jan 05, 2012 8:38 am

tba wrote:Thanks for the information Barry.  Will you also comment on how you decide to finish a devital case with bone loss at apex in one appointment.  I will sometimes after cleaning and file fill with calcium hydroxide and wait for signs of healing; then complete


Theodore,

Please give me until tomorrow to answer this question. I'm not crazy about calcium hydroxide among other things and I want to give you as complete an answer as I can.

Regards, Barry
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Re: Endodontic Sequence

Postby BarryMusikant on Thu Jan 12, 2012 8:52 am

BarryMusikant wrote:
tba wrote:Thanks for the information Barry.  Will you also comment on how you decide to finish a devital case with bone loss at apex in one appointment.  I will sometimes after cleaning and file fill with calcium hydroxide and wait for signs of healing; then complete


Theodore,

Please give me until tomorrow to answer this question. I'm not crazy about calcium hydroxide among other things and I want to give you as complete an answer as I can.

Regards, Barry


Theodore,

Sorry I overlooked answering this question. Thanks for remindiing me. The good news abougt calcium hydroxide is that it will kill bacteria. However, it needs direct contact which means you have to make sure quite a bit is placed into the canals. The bad news is that there is a lot of research out there that shows probably because of the need for direct contact that on second visits the bacterial count has actually increased. Secondly, it impairs the seal when obturation follows unless it is completely removed, something that is not easy to accomplish. Third, I have had in the past significant patient discomfort when it is extruded over the apex most likely due to its high pH.

For these reasons I still use formocresol that may make me antideluvian (before the flood), but it has worked well for me for over 40 years. Of course the other problem is that long exposure of dentin to calcium hydroxide (over 5 weeks) has been shown to significantly reduce its strength again attributed to the high pH.

Perhaps, Alvin will add his thoughts.

Regards, Barry
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Re: Endodontic Sequence

Postby orcadent on Thu Jan 12, 2012 1:04 pm

tba wrote:Thanks for the information Barry.  Will you also comment on how you decide to finish a devital case with bone loss at apex in one appointment.  I will sometimes after cleaning and file fill with calcium hydroxide and wait for signs of healing; then complete

Dear Theodore,

Regarding devital case with bone loss at apex,
as you mentioned Calcium Hydroxide dressing (temporary filling) several times (means waiting and confirmation of signs of healing) for 2-4 weeks.

1. Formocresol
Formocresol has been used for over 60 years in dentistry and esp. in pediatric dentistry.
Calcium Hydroxide is everyday intrim medication for dentistry, esp. endodontic temporary filling because it's resorbed to the denin, root. Instead, it has been used as dentin bridge formation  like Cvek Techniuqe or apexification (making of apex, Calcium ions attachment to the apex), apexogensis (generation or promotion of growth of apex in immature tooth), etc.

Calcium Hydroxide is a daily medication in everywhere if it is USP, not mixed with any antiseptics or unknown medication (antibiotics).

Unfortunately, Formocresol was banned in Canada because Formaldehyde direct ingredient's product cannot be pemitted by Canada Health. This is Canadian regulation. Formaldehyde is registered as toxic substance like BP-A (Bispenol-A). Indirect generation of Formaldehyde is not regulated, but direct ingredient like Formocresol (16-17% Formaldehyde) is prohibitted by the law. So we cannot buy and use Formocresol at hospital. Sargenti paste was containing 6-7% Formaldehyde. Still it cannot be permitted by the Canada Health.

In the USA, I don't know about Formocresol regulation. So some articles in pediatric dentistry was published about Alternatives to Formocresol.. like this.

http://www.tenndental.org/docs/ce/Exam%2014%20-%20Are%20You%20Still%20Using%20Formocresol.pdf

2. Calcium Hydroxide dressing
Calcium Hydroxide paste (Calcium Hydroxide USP powder with water mixing) has been used for over 100 years like Gutta Percha and Formocresol. CaOH is daily intrim medication. But it's resorbed to bone and calcium stucture like root. It's non-setting (resorbable) material. Ca(OH)2 with H2O is Ca++ and H2O (hydrogel process). During hydration, the calcium ions' release is Alkaline environment (high pH), which is a cause of antibacterial effect. This high alkanity process is not antiseptic or pharmacological effect like formaldehyde and Iodoform.

Well-known Bacteria like acidic environment, so we drink alkaline water (pH 8-10) for health. The concept is same as Calcium Hydroxide effect. So we recommend to use USP (US Parmaceutics) pure Calcium Hydroxide powder with distilled water for canal. Some newly developed Calcium Hydroxide pastes (water-base) are no problem (just premixed Ca(OH)2 water base) to be used in dressing, which is easier delivery concept.
But polysiloxane oil or polymer based Calcium Hydroxide is to review the literatures. Because it does not set by silicone oil and these are containing the pharmacological agents of iodoform. This silcone based Caclium Hydroxide is not classified as caclium hydroxide paste, but as Iodoform Paste. In case, Calcium Hydroxide is a filler, not main medication material.

Pure Calcium Hydroxide paste placement:
Caclium Hydroxide is purer one but due to high pH, it is also cytotoxic, but less cytotoxic than any pharmacological agent. Calcium ions are main composition of hard tissue in the body. So with antibacterial effect, Calcium ions make a dentin bridge with phosphate or biological ceramics in the body. So these dentin bridge formation in the pulp or apex has been reported and Calcium Hydroxide has been used as daily dressing in Endodontics.
For temporary filling for healing of lesion or reinforcement of bone loss at the apex, Calcium Hydroxide has been used for over 100 years. So place it in the canal for 2-4 weeks and replace it again till the sign of healing. - this process can be taken for 1 year or 18 months. Multivisit RCT with Calcium Hydroxide Placement

Some indicated Calcium Hydroxide is to weaken the dentine. It is probable matter because Calcium Hydroxide is resorbed and this means that Calcium Hydroxide is changed to Calcium ions, non-setting material and then resorbed to the bone or root. In case, calcium ions can be reacted with some substances in the body. If phosphate, it can be a reinforcement of bone/root, but just calcium ions cannot make bone, Calcium ions make touching area alkaline and then can be weakening the calcium or hard tissue structure by high alkaline reaction.

But normally pure Calcium Hydroxide paste has been used with Pack & Wack method in the presence of PA lesion in USA. Mostly it cannot be recomendable due to overextrusion of Calcium Hydroxide.

Anyway Calcium Hydroxide has been used for temporary filling material in your case. But it's multi-visit RCT. For 2-4 weeks, and then replace it and replace it till sign of healing.
Main effect of Calcium Hydroxide is well-known. So there are many Calcium Hydroxide Sealers (Sealing means setting in the canal, permanent sealing is required in RC sealer) and studied.

http://www.tenndental.org/docs/ce/Exam%2014%20-%20Are%20You%20Still%20Using%20Formocresol.pdf

3. one visit RCT
As you understand the property of Calcium Hydroxide, it cannot be permanent filling in the canal.

In bone loss, if you want to graft lost bone or defective root, there is Calcium Phosphate Paste instead of Calcium Hydroxide paste. CPC or HAP (Hydroxyapatite) has been used as dental grafting or bone grafting material in Implantology and as root-end filling material. So if you want to reinforce the lost bone or regeneration of bone, CPC or CP paste first is obturated to the apex and then fill the normal RCT in the canal. As CPC is extremely biocompatible and medical field, we can trust the effectivenss of CPC (proved product is required as bone grafting, not MTA made from Egg Shell or fish bone, etc..). But CPC is also biodegradable. So it will be resorbed to the bone but it's not weakening effect, but inforcement of bone - different process of Calcium ions. So if you use CPC as apex plug, it can be used only as plug or extrusion and then fill the canal with normal permanent filling material..

Another approach is the Calcium setting material as you can see in the article. What is Calcium setting (aggregation)? That is Calcium Silicate Cement. Calcium Silicate is compound of Calcium and Silicon (Ca/Si). So Calcium Oxide and Silica mixing is not a Calcium Silicate. Silicate is aggregation of Calcium. (Calcium Rock after set). These silicate compounds with Calcium has same effect as Calcium Hydroxide during hydration - one month till complete setting-no Calcium ions' release and movement -, and then Calcium silicate ions are activated with phosphate ion in the body. After 8 weeks, the hydroxyl apatite layers are shown. this biological apatite is biological substance to promote the regeneraton of defective tissues or lost bone. (Bioactivity/Biomineralization)

So if you use Calcium Silicate sealer at one visit, you can get the both effects of Calcium Hydroxide for one month and then bioactivity like MTA - set sealing material. So recently bioceramic Endodontists used Calcium Silicate Sealer at one visit. The reason is the above.
But multi-visit of Calcium Hydroxide is no problem at all. After Calcium Hydroxide placements, the normal RCT with Calcium Silicate is the more predicable treatment.

In one-visit RCT, Calcium Hydroxide is not proper due to resorbable temporary dressing, instead, Calcium Silicate paste or cement is proper for one time obturation..

Always there is no perfect material for all cases. So if you learn the material and the apply for the cases and make it your protocol.

I hope it is helpful to your question.

- Orca
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Re: Endodontic Sequence

Postby tba on Thu Jan 12, 2012 8:30 pm

Thanks Barry and Orca  The information is very helpful  A university endodontist stated that on some occasions rather than complete a case he will put a calcium hydroxide fill in hopes for better success.  He did site some studies for support.   However my concern was also what criterior does one use in non vital cases to finish in one appointment.  One dentist said his criterior would depend on where he would be the next day (smile)
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Re: Endodontic Sequence

Postby orcadent on Thu Jan 12, 2012 11:32 pm

tba wrote:Thanks Barry and Orca  The information is very helpful  A university endodontist stated that on some occasions rather than complete a case he will put a calcium hydroxide fill in hopes for better success.  He did site some studies for support.   However my concern was also what criterior does one use in non vital cases to finish in one appointment.  One dentist said his criterior would depend on where he would be the next day (smile)


Dear Tba,

This is one appointment endodontics.
One appointment treatment vs Multi-visit....

What is the criteria on one appointment endodontics?

One appointment endodontics, Yes or No?
http://www.endoexperience.com/filecabinet/Clinical%20Endodontics/Single%20Appointment%20Treatment/Single%20Appointment%20Endodontics%20%20Yes%20or%20No.pdf

By researches, the outcome is similar or cannot tell which is better..
http://www.endoexperience.com/documents/1vs2visitnfectedteeth.pdf

As I explained, one appointment endodontists are using Calcum Based Sealer, which has the same effect as Calcium Hydroxide dressing during the curing..

Some bioinductive sealers' guys treat the endo at one appointment by biological healing effect.
For example, European dentists used Ceramic-based sealer at one-appointment endodontics. (ex. "Endodontic Grafting Technique")
http://www.endoexperience.com/userfiles/file/Ceramic_based_sealers.PDF

This one appointment endodontics still is on question, yes or no?

- Orca
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Re: Endodontic Sequence

Postby daatoon on Mon Jan 16, 2012 6:25 am

Hello Barry Sir,
                     How do you use formocresol in between endo visits? I take a small quantity of formocresol on a cotton pellet, blot the excess on a tissue paper or cotton, place the pellet in the pulp chamber & then seal of the tooth. Previously I would do the same using paper points, which I would then place in the canals (making sure that they are short of WL by about 5mm by bending the PP).

Thank You.
Amar.
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Re: Endodontic Sequence

Postby BarryMusikant on Mon Jan 16, 2012 9:31 am

daatoon wrote:Hello Barry Sir,
                     How do you use formocresol in between endo visits? I take a small quantity of formocresol on a cotton pellet, blot the excess on a tissue paper or cotton, place the pellet in the pulp chamber & then seal of the tooth. Previously I would do the same using paper points, which I would then place in the canals (making sure that they are short of WL by about 5mm by bending the PP).

Thank You.
Amar.


Amar,

I pretty much use formocresol they way you use it today. By the way, I make sure that the temporary seal is always glass ionomer. For many years I used pink cavit and found that even when I had circumferential walls for support the cavit would at times wear out and the patients would complain about the taste of the formocresol. Obviously, there was some leakage. With the glass ionomer, I have a much stronger cement that does not wear out even when fewer walls are available for support. I also get far fewer instances that the patient complains about the taste of the formocresol that is placed between visists.

The old way of placing formocresol on a paper point even when 5 mm short of the apex places a lot more f-c into the chamber and canals. From my readings this is not necessary since the small amount placed into the chamber from a blotted cotton pellet evidently evaporates touching all the walls of the canal throughout its length. I like its antibacterial effect. I have never had a negative reaction to its placement for the past 43 years, something that I cannot say about calcium hydroxide which in addition also needs direct contact with the bacteria to kill them.

Regards, Barry
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Re: Endodontic Sequence

Postby tba on Mon Jan 16, 2012 10:49 pm

Barry, I like the way you simplyfy most situation as it is much easier to use the formo.  So how do you decide when to finish in one visit.  Also what brand of glass ionomer do you use. the automix is slightly  expensive.
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Re: Endodontic Sequence

Postby tba on Mon Jan 16, 2012 10:50 pm

Barry, I like the way you simplyfy most situation as it is much easier to use the formo.  So how do you decide when to finish in one visit.  Also what brand of glass ionomer do you use. the automix is slightly  expensive.
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Re: Endodontic Sequence

Postby BarryMusikant on Tue Jan 17, 2012 8:48 am

tba wrote:Barry, I like the way you simplyfy most situation as it is much easier to use the formo.  So how do you decide when to finish in one visit.  Also what brand of glass ionomer do you use. the automix is slightly  expensive.


Theodore,

I like to simplify as much as possible while recognizing that there are situations where simplifying leads to simplistic adaptations that may not enhance our success rate. I am thinking of the preparation of canals to a 25/06 which in light of the canal anatomy that has been made so abundantly clear to us does not reflect that degree or orienation of cleansing that these instruments produce.

Generally, it is an issue of time. If the canals don't present complexities beyond the alloted time I will finish in one visit. There are exceptions to that rule. If a patient is in extreme discomfort because of an active infection, I will not complete in one visit. Obviously, if I cannot get the canals dry, I will not finish that visit. I must say this doesn't happen very often. There are times the patients themselves will request a second visit, for it not to be done in one visit and I always honor their request for no other reason than they asked for it. In fact, I will not complete in one visit if I think there is the possibility of a blowup. For that reason, the presence of a fistula encourages me to finish in one visit although I always bring these patients back for 5 minutes to make sure the fistula has disappeared.

As for the glass ionomer I use, I've used just about any brand available in powder and gel. My assistant mixes it and then places it in a Centrix syringe and I place it into the tooth. I've used Fuji and several other brands that I can't remember at the moment and they are all about the same.

Regards, Barry
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Re: Endodontic Sequence

Postby ASHOK on Wed Jan 18, 2012 5:22 am

Hi Dr.Barry !!!!!!!, great discussion is going on and i learnt so much from this thread, thanks to you and Orca for explaining and other members for their doubts.

I really appreciate your patience for explaining the same answers for somany times!!!! kudos!!!. Hope everything is fine with you, regards, Ashok.
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Re: Endodontic Sequence

Postby BarryMusikant on Wed Jan 18, 2012 1:50 pm

ASHOK wrote:Hi Dr.Barry !!!!!!!, great discussion is going on and i learnt so much from this thread, thanks to you and Orca for explaining and other members for their doubts.

I really appreciate your patience for explaining the same answers for somany times!!!! kudos!!!. Hope everything is fine with you, regards, Ashok.


Ashok,

Always good to hear from you. Yes I agree, Alvin has a fine mind and the patience to explain things in detail. I never mind answering same questions because I find over time there is often a subtle change in emphasis with some points being more developed or recently discovered.

Hope you are well and one day look forward to seeing you again.

Warm regards, Barry
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Re: Endodontic Sequence

Postby ASHOK on Fri Jan 20, 2012 1:30 am

Thanks Dr.Barry, its my pleasure to meet you once again and discuss and learn more from you, you just let me know when--iam there!!! (but it should happen before you stop teaching!!!), warm regards, Ashok.
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Re: Endodontic Sequence

Postby BarryMusikant on Fri Jan 20, 2012 9:01 am

ASHOK wrote:Thanks Dr.Barry, its my pleasure to meet you once again and discuss and learn more from you, you just let me know when--iam there!!! (but it should happen before you stop teaching!!!), warm regards, Ashok.


Ashok,

We have a bit of a distance between us, but I am now making at least two trips to China this coming year and it appears that the company representing us in China is quite enthusiastic about our approach. In fact, the head of their educational division took our two day course along with the head of marketing and they appeared to like it very much. He is the person who does all the translating for me when I lecture in China. I tell you this because we are actively looking for an effective marketing company in India. I would love the same arrangement in India that we have in China. What I like about them so much is that they have a large domestic sales force allowing them to place orders which then justifies my traveling to China. If this ever comes to pass, I could go to India on a regular basis and have a practical way of meeting you.

I have no plans to stop teaching and, in all honesty, with Alvin's participation on the message board, I am learning so much that I feel I gain more than I contributre. He has expertize in areas that I don't and I find the situation very complimentary and good for all our members. That's the weird thing. Next month I am going to be 68 and yet I feel like a kid who recognizes there are a lot of smart people out there and I don't want to fall behind.

Warm regards, Barry
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Re: Endodontic Sequence

Postby ASHOK on Sat Jan 21, 2012 4:34 pm

Hi Dr.Barry, i wish, you get a good response in India, so that i get one more chance to meet you (the one who taught me the simplest way of doing root canal treatment). Warm regards, Ashok.
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Re: Endodontic Sequence

Postby sald112 on Sun Jan 29, 2012 9:03 pm

Hi Barry,
            I currently use the Hero system to do retreatments but I want to move that aspect over to the safesided system as i have had good success withthe safesided files thus far.Is there a sequence or system you have in place for retreatments. Also to cut the gutta Percha off at the end of obturation,do you use a specific instrument or just a flame with a wax instrument.
Best Regards,
Austin
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Re: Endodontic Sequence

Postby BarryMusikant on Mon Jan 30, 2012 10:24 am

sald112 wrote:Hi Barry,
            I currently use the Hero system to do retreatments but I want to move that aspect over to the safesided system as i have had good success withthe safesided files thus far.Is there a sequence or system you have in place for retreatments. Also to cut the gutta Percha off at the end of obturation,do you use a specific instrument or just a flame with a wax instrument.
Best Regards,
Austin


Austin,

When I have to retreat a case, the first thing I look at is the x-ray. If there was a thin wispy fill then I am going to be more cautious in how aggressively I will retreat. I may just remove a bit of coronal gutta percha and then place chloroform as gutta percha solvent. I will then in these cases take an 08 or 10 reamer in the reciprocating handpiece and using a pecking motion attempt to advance thru the dissolving gutta percha. This generally works quite well. In those cases where I feel like I am hitting a wall, I will the same procedure manually and place a bend on the instrument if I still feel I am hitting a wall and continue in this manner until I hit the constriction as noted by the apex locator.

If the previous fill is much thicker, I will perhaps ream out  several mm of gutta percha as a well for the chloroform and proceed to the constriction using a 15 relieved reamer in the reciprocating handpiece. When I do retreatments, I am always aware that removing the gutta percha may not be the biggest challenge. I am on the lookout for any canals that may have been missed in the first go around and secondarily looking at any extensions of tissue that may have not been included in the original shaping and cleansing procedure. This is most often evident in tissue extensions that may exist in the mesial root of lower molars or the mb root of maxillary molars, but they are often present in missed second canals of lower bicuspids and lower anteriors.

And then if you find that there were no extra canals and the original treatment did not look that bad, we still have to consider the possibilities of root fracture as the underlying cause, something we won't be correcting no matter how diligent we are.

I use a flame applied to just about any old plugger I have to sear off the gutta percha at the orifices. Sometimes I bend the plugger at the angle I want to get the best access to the orifice of a particular canal, most often the mb of a maxillary molar.

Regards, Barry
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Re: Endodontic Sequence

Postby sald112 on Mon Jan 30, 2012 7:39 pm

Thank You for your response.I will most likely refer out most the retreatments as I can use my time more efficiently and with more predictable results doing other dental procedures.
Austin
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