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Innovations in endodontic retreatment - Part I
Dolobid has the same properties as aspirin but it has a greater duration of action. For management of pain 1000 mg stat and 500 mg every 8-12 hours of Dolobid is very effective. For the pregnant patient the safest drug is acetaminophen with codeine. Most dental drugs are categoryA, BorC for pregnancy. Category Bshows noevidence of birth defects in the fetus but there is no evidence in humans yet. The pregnant patient in pain should be treated; the fetus will suffer more if treatment is not provided. Acetaminophen is a contraindication for the patient taking AZT. It may induce bone marrow suppression if used for more than 10 days. The prostaglandin synthesis inhibitors (NSAI) are very appropriate in dentistry due to their anti-inflammatory properties. Three are approved by the FDA for control of post-op dental pain: Ibuprophen, Naproxen and Naproxen sodium (Anaprox). Naproxen sodium has the most efficient absorption rate and it has the longest duration of action. These are contraindicated in patients with a history of bleeding ulcers or chronic gastritis. Toradol injectable is very effective for post-operative pain but it shouldn't be used for more than five days as renal toxicity can occur. Narcotic analgesics have many side effects--mostly nausea and vomiting. The culprit is codeine; Hydrocodone causes less nausea and vomiting and it has more efficacy than codeine. Hydrocodone is present in Lortab, Lorcet, Vicodin and Vicodin ES. They are safe for the pregnant patient. Oxycodone also causes less nausea and vomiting, but it is more addictive. Local anesthetics category B (lidocaine and prilocaine) are the safest to use on the pregnant patient. Mepivicaine and bupivicaine are category C. Marcaine provides a long period of analgesia after its soft tissue anesthetic effects are over. If the patient is premedicated with an anti-inflammatory analgesic one day prior to surgery and marcaine is used, pain control is usually achieved. Amides are very safe local anesthetics because they have low antigenicity and no cross allergenicity. In patients taking tricyclic antidepressants or nonselective B-blockers, the amount of vasoconstrictor should be reduced. The management of orofacial infections requires the clinician to identify the microorganism, determine antibiotic sensitivity and choose an antibiotic with low host toxicity, low resistance potential and bactericidal properties. Penicillin has these characteristics. The standard of care today is 1000 mg stat 500 q6h for a minimum of 7-10 days. Amoxacillin is the first drug of choice for SBE prophylaxis (3 mg 1 hour before procedure and 1.5 mg 6 hours later), Erythromycin is the second drug of choice and Clindamycin is the third drug of choice (300 mg one hour before procedure 150 mg 6 hours later). Patients with prosthetic joints do not need to be premedicated, but a consultation with the doctor is recommended. Patients taking tetracycline are a contraindication for penicillin, therefore erythromycin is the drug of choice for SBE prophylaxis. Abstracted by Evelyn Abreu, DDS, Tufts University School of Dental Medicine, Boston, MA. Scientific Session X Innovations in Endodontic Retreatment- Part I Clifford J. Ruddle, DDS (Santa Barbara, CA) This was an enlightening presentation that primarily focused on the techniques of endodontic retreatment using the microscope. The presentation also touched upon the fundamentals of cleaning and shaping the root canal system. Dr. Ruddle noted that there are strong winds of change in endodontic therapy. Looking back atthe breakthroughs, in 1960, Schilder emphasized canal packing. In the 1970s, shaping the canal was keyto getting the proper pack. The 1980s brought us new instrument designs. In the 1990s, Gary Carr brought us ultrasonic root-end management; a simple, yet powerful breakthrough using the microscope. The microscope will change everything and will verify everything we always knew but we only had in our minds conceptually. It may be more appropriate to use the term "operating microscope" instead of "surgical microscope" because it can be used every day not only for surgical procedures but for diagnosis, treatment and retreatment procedures as well.
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Dr. Ruddle stressed the importance of cleaning and shaping. Sodium hypochloride warmed to approximately 98 ° creates more reactivity to help digest the tissue and clean the canal, including lateral canals. Do the apical preparation last. Open up the coronal two-thirds to allow irrigant to flow vertically and laterally. Eliminate restrictive dentin to allow precurved files to be directed into pathways of curvature. Forthe apical preparation, use increasingly larger files being held back progressively furtherfromthecanalterminus. Recapitulate! Sometimestobeone mm short is to miss three, four or even five mm of root canal system. It is important to have a concept of what you are trying to accomplish, getting the shape and getting the fill. Are you still missing the curvature? Divide the tooth into thirds. Most teeth are 19 to 25 mm. Eliminate 10 mm of clinical crown, these are three, four and five mm events. Break the big problem down into component problems, solve each component problem and you will solve the case. Dr. Ruddle then discussed the retreatment of: 1 ) missed systems, 2) broken instruments and 3) perforations. He showed numerous cases with important highlights. Progressively remove gutta percha and use copious irrigation. Although silver points can be removed by a variety of techniques, Dr. Ruddle suggests working laterally with smaller files. An example of a missed system might be a failing root canal because of a missed canal. Always look for extra canals and treat them. The microscope is extremely helpful for this. The microscope can also help you find bifurcations deep in the canal. To remove a separated instrument with the microscope, first open up with Gates Gliddens to obtain straight line access. Trephinate around the file and then use the Cancellierinstrument. Usefailuresasstepping stonestosuccess. The Gonan Post Puller is a wonderful instrument to help disassemble in a retreatment case. Recently, the microscope has been used nonsurgically to repair perforations internally. Use of smaller surgical instruments dramatically expands our endodontic treatment possibilities and predictabilities in non surgical and surgical procedures. The new generation of apex Iocators, such as the Root ZX and Endex, are also very useful as they can work in fluid filled canals. The microscope can allow us to improve our surgical procedures significantly. In microsurgery, the higher magnification allows us to better evaluate our apical preparations and provides the ability to find isthmuses, extra foramina and fractures. Dr. Ruddle stated that he typically works at 8 - 12x magnification. Soft tissue management can also be improved with microsurgical tools, such as smaller blades and elevators. Dr. Ruddle recommends using a 45 ° directed handpiece and Lindemen bur for apical surgical preparation. To control hemorrhage, use only a drop of astringent and burnish into the nuisance bleeder. However, local anesthetic is still the first line of control. In summary, Dr. Ruddle discussed numerous cases in which the featu res of the operating microscope were used to manage a wide range of frequently encountered clinical obstacles successfully. He also briefly reviewed the root canal system anatomy and its role in endodontic prognosis, and Dr. Ruddle mentioned that we must become expert disassemblers and that the microscope provides an enormous edge. Abstracted by Michael D. Carter, DMD, Graduate Endodontics, Tufts University School of Dental Medicine, Boston, MA.
Scientific Session XI Innovations in Endodontic Retreatment- Part II Gary B. Carr, DDS (San Diego) The clinician is challenged daily by such obstacles as having to deal with separated instruments, coronally obstructed canals, resorption defects, anatomic variations and other situations that requi re sophisticated skills and techniques. The purpose of this session was to provide the clinician with recent advances in endodontics, specifically in terms of instruments and in particular regarding the use of the microscope in such a manner as to minimize or even exclude the guess work.
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Dr. Ruddle stressed the importance of cleaning and shaping. Sodium hypochloride warmed to approximately 98 ° creates more reactivity to help digest the tissue and clean the canal, including lateral canals. Do the apical preparation last. Open up the coronal two-thirds to allow irrigant to flow vertically and laterally. Eliminate restrictive dentin to allow precurved files to be directed into pathways of curvature. Forthe apical preparation, use increasingly larger files being held back progressively furtherfromthecanalterminus. Recapitulate! Sometimestobeone mm short is to miss three, four or even five mm of root canal system. It is important to have a concept of what you are trying to accomplish, getting the shape and getting the fill. Are you still missing the curvature? Divide the tooth into thirds. Most teeth are 19 to 25 mm. Eliminate 10 mm of clinical crown, these are three, four and five mm events. Break the big problem down into component problems, solve each component problem and you will solve the case. Dr. Ruddle then discussed the retreatment of: 1 ) missed systems, 2) broken instruments and 3) perforations. He showed numerous cases with important highlights. Progressively remove gutta percha and use copious irrigation. Although silver points can be removed by a variety of techniques, Dr. Ruddle suggests working laterally with smaller files. An example of a missed system might be a failing root canal because of a missed canal. Always look for extra canals and treat them. The microscope is extremely helpful for this. The microscope can also help you find bifurcations deep in the canal. To remove a separated instrument with the microscope, first open up with Gates Gliddens to obtain straight line access. Trephinate around the file and then use the Cancellierinstrument. Usefailuresasstepping stonestosuccess. The Gonan Post Puller is a wonderful instrument to help disassemble in a retreatment case. Recently, the microscope has been used nonsurgically to repair perforations internally. Use of smaller surgical instruments dramatically expands our endodontic treatment possibilities and predictabilities in non surgical and surgical procedures. The new generation of apex Iocators, such as the Root ZX and Endex, are also very useful as they can work in fluid filled canals. The microscope can allow us to improve our surgical procedures significantly. In microsurgery, the higher magnification allows us to better evaluate our apical preparations and provides the ability to find isthmuses, extra foramina and fractures. Dr. Ruddle stated that he typically works at 8 - 12x magnification. Soft tissue management can also be improved with microsurgical tools, such as smaller blades and elevators. Dr. Ruddle recommends using a 45 ° directed handpiece and Lindemen bur for apical surgical preparation. To control hemorrhage, use only a drop of astringent and burnish into the nuisance bleeder. However, local anesthetic is still the first line of control. In summary, Dr. Ruddle discussed numerous cases in which the featu res of the operating microscope were used to manage a wide range of frequently encountered clinical obstacles successfully. He also briefly reviewed the root canal system anatomy and its role in endodontic prognosis, and Dr. Ruddle mentioned that we must become expert disassemblers and that the microscope provides an enormous edge. Abstracted by Michael D. Carter, DMD, Graduate Endodontics, Tufts University School of Dental Medicine, Boston, MA.
Scientific Session XI Innovations in Endodontic Retreatment- Part II Gary B. Carr, DDS (San Diego) The clinician is challenged daily by such obstacles as having to deal with separated instruments, coronally obstructed canals, resorption defects, anatomic variations and other situations that requi re sophisticated skills and techniques. The purpose of this session was to provide the clinician with recent advances in endodontics, specifically in terms of instruments and in particular regarding the use of the microscope in such a manner as to minimize or even exclude the guess work.