Endodontic Sequence

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Re: Endodontic Sequence

Postby BarryMusikant on Wed Jan 15, 2014 8:57 am

bfinch383 wrote:Barry,
I don't see how you can shape a canal in 3 minutes. I generally start with a 10 and have to start all over when I get to 25 because the reamer won't shape to the constriction.  In the process I change out safesiders, thinking the particular one I'm using is dull.  Is it taking me 20 minutes per canal because my reamers are not sharp? I really get jealous when I hear about these systems that only require three files to shape.  The only reason I don't switch to the newer files is because I broke so many ntis' as an early adopter that I am gun shy.

Bernard


Bernard,

There are times you are absolutely right. There are cases where the pulps are highly receded making it a challenge just to find the orifices. It at times has taken me one visit just to find the canals and create patency to the apex with an 06 tipped reamer. HIghly curved canals will also meet with more resistance and slow us down. On the other hand, most canals are not highly curved and are not highly calcified, thank goodness. In these situations I have very little resistance in the entire shaping procedure. From what I am gathering from your description, what you are not doing is going 0.5 mm beyond the constriction thru a 25. If this is the case, and you are only shaping to the constriction, it is highly likely that you will impact some debris at this bottleneck giving you the problems you are describing.

If you take all the instruments from the beginning thru a 25 0.5 mm beyond the constriction, I don't think you will lose length certainly not at 25 and when the instruments 30 and 35 are pulled back 0.5 mm to the constriction you will not lose patency nor block the canals at that point. So, I don't think it is about dullness. It is more about technique.

Regarding rotary NiTi systems with fewer instruments: The are preparing the canal a good deal less than is recommended in the literature for effective irrigation and cleansing of the canals in the wider diameters of oval canals. A typical preparation for rotary NiTi is a 25/06 or 25/04 preparation. That is not much more apically than the 20 preparation that is recommended for the creation of an effective glide path.

Now interestingly, if fewer instruments are of interest to you, we have clearly shown and in fact I taught the following technique last night as one of the options one can use with the relieved reamers. After preparing the canal to a 20 0.5 mm beyond the constriction, you can then take the 25/06 3-4 mm short of the apex and then use the 30/02 relieved reamer to the apex. No use of the peeso. Just two extra instruments after the 20. You now have a preparation to the apex of 30 with a 25/06 over laid taper allowing the fit of an fine medium point (approximately an 04 taper).

This often takes less than 3 minutes and you are preparing the canal to dimensions that are still wider apically while minimizing the amount of dentin removed coronally.

Please let me hear your thoughts on my suggestions.

Regards, Barry

PS. Not breaking instruments will be appreciated even more if my suggestions help you speed up the shaping process.
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Re: Endodontic Sequence

Postby BarryMusikant on Wed Jan 15, 2014 9:06 am

klpete5560 wrote:Hello Barry-

I've been using SafeSiders for years and it's raised my endodontic confidence enormously. I follow the regimen you posted above with the addition of irrigating with Lidocaine and then Chlorhexidine at the very end before filling. I fill with MF GP and the EDS sealer.

Every so often, more often than I'd like of course, the patient reports moderate to severe post op pain lasting 2-3 days after which it calms down and all is fine. What are the most common mistakes that lead to post op pain like this?

Thanks in advance,

Kirk


Austin,

I'm sorry. I just realized I never answered the question you posed. I only realized it when I answered Bernard's post.

What leads to post op pain? In my experience, over instrumentation  can lead to post op pain. Instrumenting into the ligament is justifiably called a mistake. Leaving the bite high is another obvious cause of post-op pain. Excess cement into a vital pdl is another cause. From my experience, excess cement into a periapical area rarely results in post-op pain. In fact, excess cement into a vital pdl goes hand in hand with over instrumentation. So the two are closely related. Then there are flareups where nothing was done wrong. Non-vital teeth may unpredictably flare up because of the mechanics of instrumentation. What was a chronic infection can turn acute simply because the balance that previously existed with the body's defenses has been upset. Perhaps, prophylactic antibiotics would help reduce these incidences. Frankly, I don't like to give antibiotics routinely unless the medical history dictates it. But, with 20:20 hindsight there are times that I wish I had.

That is what comes to mind right now.

Sorry I am so late in my response.

Regards, Barry
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Re: Endodontic Sequence

Postby bfinch383 on Wed Jan 22, 2014 5:54 pm

Barry,
Why do you teach a technique of final instrument 30/02 when your instrumentation protocol is 40/02 to the constriction?  If that technique is effective for proper irrigation, then I would gladly use it to shorten my cleansing and shaping steps.

Thanks,
Bernard
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Re: Endodontic Sequence

Postby BarryMusikant on Wed Jan 22, 2014 6:42 pm

bfinch383 wrote:Barry,
Why do you teach a technique of final instrument 30/02 when your instrumentation protocol is 40/02 to the constriction?  If that technique is effective for proper irrigation, then I would gladly use it to shorten my cleansing and shaping steps.

Thanks,
Bernard


Bernard,

I don't teach this technique as the primary way to shape canals. However, with the advent of new rotating NiTi systems using fewer instruments and preparing the canals to a 25/06, I simply tried different combinations of our already existing system and found that an easy option to use would be the 25/06 within 3-4 mm of the apex followed by the 30/02 stainless steel relieved reamer used either manually or in the reciprocating handpiecce.

You are in effect shaping the canal to a wider apical diameter than the 25 prepared with wave one and reciproc, creating less of a taper than their 08 preparation coronally, using instruments multiple times that you know are not going to break and working oval canals laterally much more vigorously than anyone would attempt with rotating NiTi.. I really have only slowly been introducing this option. I must admit it seems to be popular among those i am teaching.

For the most part I am still using the original technique in my own practice, but i will tell you that it is working with great predictability on all the extracted teeth I have tried it on.

Try it and let me know what you think. Just make sure you use the 25/06 in the reciprocating handpiece, not manually.

Regards, Barry
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Re: Endodontic Sequence

Postby DentLee on Tue Feb 25, 2014 11:49 pm

Barry, you have discussed using this new shorter sequence of files with regards to more highly curved or narrow canals, but do you have any major reservations about using this shorter sequence routinely in all canals, and if so, why?
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Re: Endodontic Sequence

Postby BarryMusikant on Wed Feb 26, 2014 10:11 am

DentLee wrote:Barry, you have discussed using this new shorter sequence of files with regards to more highly curved or narrow canals, but do you have any major reservations about using this shorter sequence routinely in all canals, and if so, why?


Warner,

You ask a very good question. The motivation for the shorter sequence was the introduction of such systems as Wave One and Reciproc and now some other systems that use a fewer number of instruments. They pretty much produce an apical preparation of 25 with an overlaid 25/08 taper. The literature consistently says that the minimum apical preparation necessary for effective irrigation is a 30. Furthermore, we are learning that the greater the taper of the coronal portion of the preparation the more likely we are to remove excess tooth structure in this area particularly in the mesio-distal plane of molars where concavities often exist on the furcal side of roots.

So when I started experimenting with the sequences of instruments within our own system, I found that I could predictably use this shortened sequence improving on the apical preparation to a 30 rather than a 25 and removing less coronal dentin in the mesio-distal plane because the taper of the instrument is an 06 and is used 3-4 mm short of the apex. One major advantage of this approach is that it is done with 30º reciprocation rather than rotation virtually eliminating any concern for instrument separation. The confidence of knowing the instruments will remain intact, allows the dentist to apply pressure against all the walls of the canal, but particularly those constituting the wider extensions of oval canals and sheaths of tissue. Since we can use our thinnest instruments in this manner we have a much better chance of removing the tissue that is ensconced in thin isthmuses that greater tapered instruments would not be able to contact.

I know you didn't ask for the above explanation, but I felt compelled to expand on my thinking of the overall approach. As long as I am using this shorter sequence in canals that are thinner than the instruments used, at least in the bucco-lingual plane I have no problem with the shorter sequence. Naturally , if the canals are larger and the instruments meet much less resistance on the way to the apex, I am more inclined to shape up to a minimum of 35 and taking the 25/06 to the apex. In like manner, there are some teeth where apical resistance is not encountered until opening a canal to a70 or 80. In these cases we need 02 tapered stainless steel reamers sized from 45 up to 140.

So the short answer is that I think you can use this sequence in many situations, but you want to be aware when canal anatomy is wider and would benefit from apical instrumentation to a greater dimensions.

Regards, Barry
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Re: Endodontic Sequence

Postby scotty on Thu Feb 27, 2014 12:51 am

Barry
I like the shortened sequence you have been discussing.
You take the SafeSiders up to the yellow 20, 0.5 mm beyond the constriction. Do you mean the apex?
There was a great Swiss dentist who talked about the "apical sanctuary" and it concerns me to go beyond the apex, especially in a vital tooth.
Okay, once you have gone up to the size 20, you then take the 25/.06 NiTi 3-4mm short of the apex. (Good, I often had trouble getting that one to the apex anyway, and was more concerned with separation with it even though I was still using it in a reciprocating action.)
Next you use the 30/.02.(You leave out the 25?) That's the blue SafeSider in the sequence, right? This one goes to the apex.
At this point in the shortened sequence you are ready to fill the canal?
You now flood the canal with the sealer. I have used a 30 spiral filler with a stopper to the apex, since the times I have used the EDS spiral filler with the reverse threads, I have broken it. But if I were to use the EDS spiral filler you go to within 3-4mm of the apex? If you have a necrotic tooth with a pretty good radiolucency at the apex, even using the EDS spiral filler, don't you have a good chance of getting an overfill?
Alright once you have flooded the canal with sealer do you measure the medium GP point to get it to the apical area or just push it into the canal?
One last thing, and I should know this, but remind me again what the numbers mean e.g 30/.02
Does the memory go with age?

I'm going to Uganda in March with a team doing work in some areas.

Best wishes as always

Scotty.
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Re: Endodontic Sequence

Postby BarryMusikant on Sun Mar 02, 2014 12:41 pm

scotty wrote:Barry
I like the shortened sequence you have been discussing.
You take the SafeSiders up to the yellow 20, 0.5 mm beyond the constriction. Do you mean the apex?
There was a great Swiss dentist who talked about the "apical sanctuary" and it concerns me to go beyond the apex, especially in a vital tooth.
Okay, once you have gone up to the size 20, you then take the 25/.06 NiTi 3-4mm short of the apex. (Good, I often had trouble getting that one to the apex anyway, and was more concerned with separation with it even though I was still using it in a reciprocating action.)
Next you use the 30/.02.(You leave out the 25?) That's the blue SafeSider in the sequence, right? This one goes to the apex.
At this point in the shortened sequence you are ready to fill the canal?
You now flood the canal with the sealer. I have used a 30 spiral filler with a stopper to the apex, since the times I have used the EDS spiral filler with the reverse threads, I have broken it. But if I were to use the EDS spiral filler you go to within 3-4mm of the apex? If you have a necrotic tooth with a pretty good radiolucency at the apex, even using the EDS spiral filler, don't you have a good chance of getting an overfill?
Alright once you have flooded the canal with sealer do you measure the medium GP point to get it to the apical area or just push it into the canal?
One last thing, and I should know this, but remind me again what the numbers mean e.g 30/.02
Does the memory go with age?

I'm going to Uganda in March with a team doing work in some areas.

Best wishes as always

Scotty.


Scotty,

Sorry I am a little late in responding to your questions. We gave a two day course this past Friday and Saturday and they are pretty exhausting,. Still I wanted to give you complete answers and I needed a bit of time to give detailed responses.

When I say the constriction I am really thinking of it as the apex, the reading I get on my apex locator when it is working well. From that reference point I add 0.5 mm which takes me into the apical foramen, but short of the pdl. I have not found in either vital or non-vital cases that going at worst 0.5 mm beyond the constriction thru at most a 25 causes any noticeable problems in the final outcome. On the contrary, what I want to avoid is the loss of length that can result from impacting debris apically. If my endpoint is the constriction I increase the chances of impacting debris apically, something that is far less likely to happen using relieved vertically fluted instruments rather than K-files, but can still occur. With blockage comes loss of length and with loss of length comes the effort to regain that length that in turn increases our chances of creating apical distortions as the impacted debris tends to deviate the tip of the instrument to the outer wall. So I think it worthwhile to maintain the patency thru a 25 or in the case of the short sequence thru a 20.

Regarding the use of the 25/06 having trouble in the past getting it to length, that is usually a result of using the tapered peeso very conservatively. More conservative use of the tapered peeso (Pleezer) obviously removes less tooth structure coronally causing the 25/06 to encounter greater resistance as it negotiates to length, hence the trouble in getting it to length at times. With the short sequence, knowing you are not attempting to take the 25/06 to length precludes the need for the tapered peeso. To date and it has been years, I have not separated a 25/06 when used in the reciprocating handpiece and indeed they should only be used in the reciprocating handpiece, not manually.

Yes, the interesting observation was that creating the greater tapered space with the 25/06 within 3-4 mm of the apex allows me to routinely skip the 25 and go directly to the 30/02 stainless steel relieved vertically fluted reamer (SafeSider) to the apex. I am now ready to obturate. If you use the bidirectional spiral within 3-4 mm of the apex you should have no binding and minimal rotation around a curve leaving the applicator intact without any breakage at the tip. If an area exists meaning no pdl barrier there is an increased chance of pushing some cement beyond the apex, but this should not be a excessive amount given the fact that when a prefitted tapered point is placed into the canal the vast majority of the cement is first displaced laterally and then escapes coronally. Some cement will extrude apically, but if you use the original powder and gell epoxy resin (similar to AH-26) that excess is digested by the macrophage which are in abundance in apical areas. Within 3-6 months more often than not, any such extruded cement is pretty much gone.

Regarding the placement of the point. When I do the full sequence of instrumentation I prepare the canal to receive a medium point which would have been prefitted prior to the placement of the point. However, here we are creating a significantly narrow space at least in the mesio-distal plane. So I don't fit a medium point with a taper between 05 and 06. Rather I fit a fine-medium point from Maillefer Dentsply that has a taper between 04 and 05. Once fitted and the canals flooded with cement I then liberally coat the fine-medium point and place it to length within the canal. I should have tugback and see the extrusion of excess cement coronally as the point enters the canal to length.

Anytime you see something like a 30/02 the 30 or whatever that number is will be referring to the tip size. The second number which could be 02. 04 or higher refers to the taper of the instrument. The higher the number the greater the taper of the instrument. Being stainless steel, the taper never exceeds 02 or it would become too stiff. However, the 02 taper combined with a relieved vertically fluted design makes this instrument far more flexible than its K-file counterpart while preserving enough body to work the lateral walls aggressively in shaping oval or sheath-like anatomy.

Scotty, you amaze me with your adventurous exploits and your desire to help others. It's been a privilege to know you all these years and as usual you and your wife have a standing invitation to visit Bruni and me any time you want to come to the much more mundane environment of Manhattan.

Hopefully, I answered your questions satisfactorily. If not let me know and I'll try harder.

Warm regards to you and your wife and have a wonderful time in Uganda. I know its not Disneyland and perhaps that's why it should be a wonderful experience.

Barry
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Re: Endodontic Sequence

Postby scotty on Mon Mar 03, 2014 11:42 pm

Thank You Barry for your very informative and nice reply.
Just a clarification on fitting the GP point, once you have prepared the canal, do you measure the GP point and mark on it the length of the canal and then try it in the canal to make sure it goes to the apex? Is it important to get tugback? Once you have flooded the canals with sealer, you then place the GP point into the canal making sure it goes all the way to your mark on it, indicating it has gone all the way to the apex?
What sealer are you using and does it have far reaching biological activity?

I am looking forward to seeing you in Chicago in October!

Best wishes.

Scotty.
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Re: Endodontic Sequence

Postby BarryMusikant on Tue Mar 04, 2014 10:34 am

scotty wrote:Thank You Barry for your very informative and nice reply.
Just a clarification on fitting the GP point, once you have prepared the canal, do you measure the GP point and mark on it the length of the canal and then try it in the canal to make sure it goes to the apex? Is it important to get tugback? Once you have flooded the canals with sealer, you then place the GP point into the canal making sure it goes all the way to your mark on it, indicating it has gone all the way to the apex?
What sealer are you using and does it have far reaching biological activity?

I am looking forward to seeing you in Chicago in October!

Best wishes.

Scotty.


Scotty,

Pretty much whenever I am fitting a point I want tugback and then I will confirm proper length with a check x-ray. I then simply crimp the gutta percha with the college pliers at the correct length and set them aside as I flood the canals with cement. Before placing the gutta percha into the flooded canal, I also coat the point liberally with cement.

The cement I have been using for as long as I remember is an epoxy resin similar to AH-26. I like this cement because any excess over the apex will be digested by the macrophage. That is not the case for all epoxies, typically the one that goes under the name AH Plus. In terms of biologic activity it is not bone inductive, but it has been proven to have excellent sealing properties and does not attack the dentin in anyway. In contrast, some of the so called biologic cements (bioceramic sealer) have beern shown to produce more leakage than conventional cements. So while it may actually be bone inductive, the most important property of a cement is creating a good seal. The epoxy resin cements have been shown to bond to both gutta percha and dentin with good penetrating abiities. Being a polymer, the cement is also highly resistant to hydrolytic degradation. Perhaps most important, it has been in use for over 70 years as a highly successful sealer. It releases a small amount of formaldehyde as it sets and I consider that a good thing.

Again, always good to hear from you and wish you good tidings on your travels to Uganda.

Warm regards, Barry
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Re: Endodontic Sequence

Postby orcadent on Tue Mar 04, 2014 9:08 pm

I thought there are something to be verified in terminology and products.

In terms of biologic activity it is not bone inductive,
(Orca) In terms of biological activity, it means the formation of Hydroxyapatite (a kind of bone Calcium Phosphate) to increase the bone bioinductivity. Basic Bioactive materials are Calcium Phosphates or Hydroxyapatite (bone grafting cement) and bioglass, etc. Calcium Silicates like MTA are not bioactive material, but it is to form the hydroxyapatite layer with phosphate ions in the root and canal. So CSM is more important to be mixed with water, which is hydrated - Calcium Silicate Hydrate. But without any phosphate ingredient in vitro, there is no or less biological actitivity with distilled water. So in vitro test, they are used with PBS, or HBSS of phosphate ions' ingredient. Ordinary Portland Cement shows higher bioactivity than White Portland Cement because WPC is artifically made from Calcium Carbonate silica compouning like Limestone Silica Cement.

but it has been proven to have excellent sealing properties and does not attack the dentin in anyway.
(Orca) Every biological acive material has not been proven to have excellent sealing properties. Higher bioactive material like bioglass or Calcium Phsopahte will be bio-degraded in root and bone, which is called as bone-grafting material. But Calcium Silicate Based Selaer has higher compressive strength, but not an excellent sealing properties, but its sealing ability is higher than old root-end filling material of Amalgam, IRM, etc. Its dentinal sealing is not good as we expected. So its particle sizes are less than 5 micron meter as dentinal average porous. Nano-particulated CSM or cements are increasing the sealing ability. Attacking of the dentin is not made by biological cement, but by accelerator or liquid. As PAA (Polyacrylic acid) is setting MTA or CSM faster than 4-6 hours (setting within 15 minutes), this acidic solution attack the dentin. So it is trade-off in biological activites and setting time. Most like the slowly hydrated biocompatible process rather than faster setting by chemical accelerators like PAA, lithium silicate, over 70% high concentrated Calcium Chloride (CaCl2)..




In contrast, some of the so called biologic cements (bioceramic sealer) have beern shown to produce more leakage than conventional cements.
(Orca) In term of bioceramic sealer, it can be called as biological cement. Basically every dental products should be made by bioMaterials. As it is a bioceramic, it means that the product is not used by mineral (ceramic in nature) like portland cement, limestone cement, alumina cement of natural construction cement. Instead, the artificial chemical bonded ceramic materials are available in bioceramic or bioMaterial science. So when cement is made by bioMaterial, it can be classified as bioceramic sealer. MTA is a mineral of natural ceramic cement, pure medical graded Calcium Silicate is a bioceramic sealer. It's not a co-relation of leakage. GIC is also a bioceramic sealer because GIC is mainly made by bioceramic alumino-silicate cement. Even if bioceramic sealer is called, it doesn't have higher sealing ability than conventional cements. Especially, GIC hydrated silicate cement is too slow in setting and it's to produce more leakage. So higher strength bonding cement like MTA has been used in root canal sealer and root repair material.




So while it may actually be bone inductive, the most important property of a cement is creating a good seal.
(Orca) in good sealing ability, MTA has been used as root repair material and root canal sealing material. Bioceramic Aggregate (Calcium silicates with Tantalum Pentoxide Cement) shows higher sealing ability than MTA.
For reference,  
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3410335/


The epoxy resin cements have been shown to bond to both gutta percha and dentin with good penetrating abiities.
(Orca) in bonding to gutta percha, Epoxy resin is also used with resin coated gutta percha point like EDS Deluxe Gutta Percha Point in order to increase the bonding ability. Calcium Silicate is hydrated by water, hydraulic cement. Its particle size is below 2 micron meters, so it penetrates to the surface of gutta percha physically and set chemically and also its flowability is more than resin or similar to resin based sealer. The overcome of MTA sealer was made by nano-technology (nano-particulation) and flowability and hydration setting of silicate (non-resorbable calcium silicate like MTA.) Also when bioceramic coated or GI Coated Gutta Percha is reactivated by bioceramic sealer's water absorption and set chemically firm-ative reaction.


Dentin moisture conditions affect the adhesion of root canal sealers.

Being a polymer, the cement is also highly resistant to hydrolytic degradation.
(Orca) Even if resin is a polymer, it cannot be resistant to hydrolytic degradation permanently. Hydraulic cement is a hydrophillic water-sorption material. It has been used as filler with gutta percha as crosslinked material because MTA is expanded by hydration of water-sorption. So crosslinked gutta percha is introduced as the name of Gutta Core.
Even if the name of product is a bioceramic sealer, the properties of phsyiochemical and biological behaviors are different from the material and products.

MTA mixed with Epoxy resin is called as ER MTA.
MTA mixed with Salicylate Resin is classified as SR Resin Based Sealer with MTA like MTA Fillapex.
TheraCal LC is MTA Sealer with HEMA-Free methacrylate resin. It's main application is pulp-capping and liner. So it cannot be used as root canal sealer even if it is Resin Modified MTA Sealer. But it can be used as root canal sealer, its setting time is 6-12 hours slower than LC. In root canal sealer, Light curable resin is not necessary. So without LC META-Resin, TheraCal SC (Self Cured) will be a CSM based Sealer with normal hydrated setting time of 4-6 hours.

EZ-Fill is mixed with MTA, which is MTA Epoxy Resin Sealer. The concept is easy in mixing of MTA or CSM or any filler for specific purpose.

Thanks,

- Orca
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Re: Endodontic Sequence

Postby BarryMusikant on Tue Mar 04, 2014 9:11 pm

Alvin,

As usual, it is always nice having you there to bring another level of understanding to questions being asked. Thank you for your participation.

Warm regards, Barry
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Re: Endodontic Sequence

Postby scotty on Wed Mar 05, 2014 2:52 pm

Barry
Would you recommend the Auto EZ fill over the powder/liquid EZ fill?
I have been thinking about using my current sealer with 1% Hydrocortisone ointment on the reamers as I clean and shape the canal with also some CHX in the necrotic teeth. and then using the EZ fill for my final fill with a GP point.
Seems to me the Auto EZ fill takes some of the guess work out of getting the right consistency and also you don't have to warm the spatula.
I like the fact that there is a small amount of formaldehyde released.
I remember the days when I used the ThermaFill system.  I used lots of hypochlorite and still got failures.
In my own case my two max laterals had both have been endodontically treated by an endodontist. I now have an implant replacing one and a bridge replacing the other.
It is important that the sealer has some biological activity and is not just passively filling the canal.
Do you use full strength Hypo or half strength in the canals.

Thanks as always for all your great help.

Scotty.
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Re: Endodontic Sequence

Postby BarryMusikant on Thu Mar 06, 2014 4:43 pm

scotty wrote:Barry
Would you recommend the Auto EZ fill over the powder/liquid EZ fill?
I have been thinking about using my current sealer with 1% Hydrocortisone ointment on the reamers as I clean and shape the canal with also some CHX in the necrotic teeth. and then using the EZ fill for my final fill with a GP point.
Seems to me the Auto EZ fill takes some of the guess work out of getting the right consistency and also you don't have to warm the spatula.
I like the fact that there is a small amount of formaldehyde released.
I remember the days when I used the ThermaFill system.  I used lots of hypochlorite and still got failures.
In my own case my two max laterals had both have been endodontically treated by an endodontist. I now have an implant replacing one and a bridge replacing the other.
It is important that the sealer has some biological activity and is not just passively filling the canal.
Do you use full strength Hypo or half strength in the canals.

Thanks as always for all your great help.

Scotty.


Scotty,

I don't recommend the Auto EZ fill. That cement is the equivalent of AH Plus which is not digestible by the macrophage if it gets over the apex.
In addition, it is more viscous than the powder gel. For those two reasons I use the powder gel that I am very comfortable with. It works great with the bidirectional spiral. Your idea of using the 1% hydrocortizone ointment may be a good idea. God knows we've put everything else in the canals over the years and a reduction in inflammation sounds like it could be a good thing if it goes along with other antibacterial elements and the routine cleansing and shaping that we do. If you are going to use the cement on the point I think it is also a good idea to coat the canals with the cement. If may already be doing that and I think that adds to an effective seal.

Powder and gel are easy to mix with a wide margin of effectiveness. It will flow better and the amount of heat added is easily done in a few seconds if it is even necessary. By the way more formaldehyde is released from the powder/gel than the dual syringe pastes. I use NaOCl full strength right out of the Clorox container. Regarding your missing laterals, that is not an upbeat story.

The antibacterial properties are a plus, but most important is a continuous interface that has the best sealing properties. In that regard, the fact that the epoxy resins don't shrink and bond to everything imaginable is a plus.

Scotty, always a pleasure to converse with you. Stay well and prosper. I think I got that from StarTrek.

Warm regards, Barry
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Re: Endodontic Sequence

Postby scotty on Fri Mar 07, 2014 12:20 am

Thanks Barry, I usually get "beam me up, Scotty."
When you use the full strength Chlorox, do you leave it in the canals for any length of time?
Do you ever put the Chlorox in the canal and place a SafeSider reamer down the canal too, and just oscillate the hypochlorite. I have done that when irrigating with CHX.
Do you alternate between Hypo and CHX or use Hypo at the start and finish with CHX?
The great Swiss endodontist used to talk about leaving vital pulp tissue in the canals. He felt this was the best sealer of all and he showed cases in his book when he'd filled the canal to the curvature and the case was doing well many years later.
When I am dealing with a vital tooth, a classic case would be a vital pulp exposure, I really don't want to use Chlorx in that case. I am not dealing with an infected pulp , really just an inflamed pulp. I would rather extirpate the pulp into the apical third, fill and seal the canal quickly, using no CHX or hypo. What thinkest thou?
You have probably discussed all these issues elsewhere on this forum. I hope you don't get tired of answering the same questions over and over again.

Margaret and I are heading off to Taos, New Mexico, for a Scottish Country Dance workshop this weekend.

Thanks again Barry for all your patient instruction and kindness.

Best

Scotty.
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Re: Endodontic Sequence

Postby orcadent on Fri Mar 07, 2014 12:51 am

scotty wrote:Thanks Barry, I usually get "beam me up, Scotty."
When you use the full strength Chlorox, do you leave it in the canals for any length of time?
Do you ever put the Chlorox in the canal and place a SafeSider reamer down the canal too, and just oscillate the hypochlorite. I have done that when irrigating with CHX.
Do you alternate between Hypo and CHX or use Hypo at the start and finish with CHX?
The great Swiss endodontist used to talk about leaving vital pulp tissue in the canals. He felt this was the best sealer of all and he showed cases in his book when he'd filled the canal to the curvature and the case was doing well many years later.
When I am dealing with a vital tooth, a classic case would be a vital pulp exposure, I really don't want to use Chlorx in that case. I am not dealing with an infected pulp , really just an inflamed pulp. I would rather extirpate the pulp into the apical third, fill and seal the canal quickly, using no CHX or hypo. What thinkest thou?
You have probably discussed all these issues elsewhere on this forum. I hope you don't get tired of answering the same questions over and over again.

Margaret and I are heading off to Taos, New Mexico, for a Scottish Country Dance workshop this weekend.

Thanks again Barry for all your patient instruction and kindness.

Best

Scotty.


Hi Scotty,

Barry is very tired...

Irrigation is to remove the debris and necrotic tissue and pulp from the canal. NaOCl or CHX is a devitalized irrigation solution - NaOCl is an oxidized irrigation and CHX is an chlorination irrigation chemicals. But these chemicals are also harmful toxic with too much. For example, NaOCl's recommendation concentration is between 0.5% and 5.25% (generally 6% in market).

In necrotic canal, it needs devitalized irrigant, which is stronger. CHX 2% or higher concentrated. Instead, CHX 2% gel with Calcium Hydroxide has been used for necrotic canal (devitalization and easily coming out from the canal.)

As you mentioned about great Swiss endodontist, it should be about Vital Pulp Therapy, Regenrative Endodontic Procedures (REP). In REP, regeneration of pulp doesn't need root canal therapy. So exposed pulp capping or pulputomy (partial pulptomy) doesn't need strong irrigation solution because living pulp tissue can be grow(regenerated) by the natural body process.

In REP, it is the next level endodontics with biological active material as pulp capping or pulp-regenerative material without strong devitalized solution.

This is not special for specific area, but general for regeneration of pulp and apex.

Thanks,

- Orca
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Re: Endodontic Sequence

Postby BarryMusikant on Sat Mar 08, 2014 1:17 pm

scotty wrote:Thanks Barry, I usually get "beam me up, Scotty."
When you use the full strength Chlorox, do you leave it in the canals for any length of time?
Do you ever put the Chlorox in the canal and place a SafeSider reamer down the canal too, and just oscillate the hypochlorite. I have done that when irrigating with CHX.
Do you alternate between Hypo and CHX or use Hypo at the start and finish with CHX?
The great Swiss endodontist used to talk about leaving vital pulp tissue in the canals. He felt this was the best sealer of all and he showed cases in his book when he'd filled the canal to the curvature and the case was doing well many years later.
When I am dealing with a vital tooth, a classic case would be a vital pulp exposure, I really don't want to use Chlorx in that case. I am not dealing with an infected pulp , really just an inflamed pulp. I would rather extirpate the pulp into the apical third, fill and seal the canal quickly, using no CHX or hypo. What thinkest thou?
You have probably discussed all these issues elsewhere on this forum. I hope you don't get tired of answering the same questions over and over again.

Margaret and I are heading off to Taos, New Mexico, for a Scottish Country Dance workshop this weekend.

Thanks again Barry for all your patient instruction and kindness.

Best

Scotty.


Scotty,

I always like to hear from Alvin (Orca). He is a great contributor. I appreciate him very much.

I work with the Clorox only as long as it takes me to shape the canals. That can vary with the difficulty of the canal, but it is rarely less than 10 minutes, longer if you consider its use in teeth with multiple canals. I activate the Clorox with the 30/04 relieved reamer oscillating 3000-4000 times per minute after I am done shaping the canal. I also do this with the 17% EDTA and in non-vital teeth with the 2% CHX.

In vital cases I don't use CHX. I limit the irrigants to NaOCl and aqueous EDTA. When the tissue is vital my first irrigant is  17% EDTA because exposing vital pulp tissue to NaOCl tends to make it more fibrous before dissolution, something akin to boiling an egg and having the albumin go from gelatinous to solid. So in vital teeth I won't use the NaOCl until most of the tissue is removed, generally to a minimum of a 20.

Quite simply I think Dr. Sargenti knew exactly what he was talking about when he maintained vital tissue wherever he could. Sometimes hard to make that judgement, but when the conditions are good, particularly with the biocompatable materials we have available to day, I think it is a good idea.

My wife goes to Santa Fe once a year. There is a group that fosters understanding between Palestinian and Israeli girls from about the age of 15 to 18 by getting them together for some period of time, hoping the gap in understanding can be lessened. It is truly a drop in the ocean, but its goals are admirable in my opinion and am proud that she takes part.

Have a wonderful time in Taos and enjoy the dancing. I'd know I would make a major transformation in my life, if I attempted to try that.

Warm regards, Barry
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Re: Endodontic Sequence

Postby scotty on Sun Mar 09, 2014 4:39 pm

Barry
Your final fill is the EZ fill self mix, correct?  Can we order that from Schein?
You mix this material as demonstrated on the EDS site?
This material also releases formaldehyde for a short while?

Dr. Sargenti did not advocate any irrigants to flush out the canals. It the canal was gangrenous as he called it, placing a warm cotton pellet with NaOCl in the pulp chamber would deodorize it.
If keeping some vital pulp tissue is a good thing, why would you use any caustic irrigants at all?
Wouldn't it be better to extirpate the pulp down to the apical third or as far down as you are reasonably able to do, and then obturate?

Best wishes

Scotty.
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Re: Endodontic Sequence

Postby BarryMusikant on Mon Mar 10, 2014 7:06 am

scotty wrote:Barry
Your final fill is the EZ fill self mix, correct?  Can we order that from Schein?
You mix this material as demonstrated on the EDS site?
This material also releases formaldehyde for a short while?

Dr. Sargenti did not advocate any irrigants to flush out the canals. It the canal was gangrenous as he called it, placing a warm cotton pellet with NaOCl in the pulp chamber would deodorize it.
If keeping some vital pulp tissue is a good thing, why would you use any caustic irrigants at all?
Wouldn't it be better to extirpate the pulp down to the apical third or as far down as you are reasonably able to do, and then obturate?

Best wishes

Scotty.


Scotty,

Yes, Schein carries that product. Make sure it is the original powder and gel. Simply place enough powder on a glass slab and then add enough gel to create a sour cream like mix without any granularity seen on the surface. You don't have to use drops and scoops, something I find more confusing despite its presentation in the mixing instructions. It does release formaldehyde for a short while and like you I consider this a good thing.

The main advantage of NaOCl is its ability to digest organic tissue and kill a range of bacteria. I don't want to flush more for mechanical reasons. I float irrigant into the canal using perhaps 4-5 drops per second from the syringe. I then activate the irrigant(s) using the reciprocating handpiece oscillating at 3000-4000 cycles per minute. You can see the foaming action when such oscillations are applied to theNaOCl in the canal.

I think we go for complete pulp extirpation even in vital cases because of its predictability. It would be great if we knew beforehand which cases have enough healthy pulp tissue to survive if and when we irrigate and fill short with say an MTA dressing. Taking out the entire pulp to the constriction gives us a routine standard which appears to give us a pretty good success rate. If the root is fully formed, nothing is lost in the process. It is when we want further root development that the issue of keeping any remnants of vital pulp apically takes on importance and here I would agree with you.

Warm regards, Barry
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Re: Endodontic Sequence

Postby bfinch383 on Sat Mar 22, 2014 7:28 pm

Barry,
Despite following your instructions on the shortened sequence, I am having no luck in fitting a Dentsply fine-medium point to the constriction. Have you tried using this method on any of your cases? It is very frustrating because I really don't like using the  Pleezer in tight mesial canals and this new sequence was what I was hoping for.

By the way, a colleague of mine had a relatively young associate use the "Wave One" system and broke files in two consecutive molars.  I considered switching to that system to shorten the time used to file to 40, but know I am not so sure.

Best wishes,
Bernard

I am looking forward to seeing you in Chicago in October!

Best wishes.

Scotty.[/quote]

Scotty,

Pretty much whenever I am fitting a point I want tugback and then I will confirm proper length with a check x-ray. I then simply crimp the gutta percha with the college pliers at the correct length and set them aside as I flood the canals with cement. Before placing the gutta percha into the flooded canal, I also coat the point liberally with cement.

The cement I have been using for as long as I remember is an epoxy resin similar to AH-26. I like this cement because any excess over the apex will be digested by the macrophage. That is not the case for all epoxies, typically the one that goes under the name AH Plus. In terms of biologic activity it is not bone inductive, but it has been proven to have excellent sealing properties and does not attack the dentin in anyway. In contrast, some of the so called biologic cements (bioceramic sealer) have beern shown to produce more leakage than conventional cements. So while it may actually be bone inductive, the most important property of a cement is creating a good seal. The epoxy resin cements have been shown to bond to both gutta percha and dentin with good penetrating abiities. Being a polymer, the cement is also highly resistant to hydrolytic degradation. Perhaps most important, it has been in use for over 70 years as a highly successful sealer. It releases a small amount of formaldehyde as it sets and I consider that a good thing.

Again, always good to hear from you and wish you good tidings on your travels to Uganda.

Warm regards, Barry[/quote]
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