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The braiding technique can be used to remove large single GP cones and is helpful for removing carriers. So both!
The largest file goes to the apex and the second file goes as far as possible, if possible to the apex
Separation is always a risk with any procedure involving files but it’s never happened to me using the braiding technique, use new files and you should be fine.
Use the largest file which will reach the apex and the second file should be as wide as possible to engage the obstruction, aim to get the second file at least halfway down the canal.
The debris created during instrumentation can block the canal
I assume this would be from an inflamed pulp rather than a perforation. If the pulp is so inflamed it keeps bleeding you can use adrenaline containing anaesthetic to stop the bleeding, or if you are confident you are at the correct working length and inside the canal just keep preparing the canal to remove the tissue.
There are a variety of ways to remove a crown- cutting the crown off is one way or using a crown remover, of which there are many. The WAM key is the one I have been using the longest and I find this extremely helpful for reusing the crown as a temporary crown between visits.
In these cases where the canal is narrow but the apex is wide (like a bottle), you need to adequately taper the preparation to deliver the irrigants and after cleaning and shaping MTA is usually the best material, to close the apex.
Yes, the pulp chamber is filled with hypochlorite during establishment of the glide path
The size of the preparation is determined by the existing anatomy and the pulp status. If the root is narrow then you cannot taper the prep much, but maybe if there is an inflamed pulp and no apical disease you do not need to prepare the canal much apically either, because the pulp apically is probably healthy. If you the apical 5mm of the file on the last pass are filled with debris, in my opinion the canal has been debrided.
There are many good apex locators. Propex pixi is a good one I have used. The Morita Root ZX is also a great tool.
Yes this is a reliable apex locator, there are many good ones which I have used during my specialist training and at public hospitals I have worked in.
When you get good at using an apex locator then the radiographs just back up your apex locator readings. In the right hands the apex locator is much more superior to visual inspection of radiographs. But remember if someone is to assess your treatment the radiographs will stand up against the notes, so having good radiographs is extremely important.
Wave one gold is a reciprocating file and has a patented movement angle and rpm and torque settings. These can be found on the motor.
As long as this is easily passed through the apex this technique is recommended. The idea is for the file to pass passively through the apex.
If the passing of the file through the apex is passive then it should not cause a flare up.
This is safe and often in wide canals we don’t need to use rotary files because the canal has a natural wide taper already.
I assume you mean canals with immature apices. In these cases often we rely on activation of irrigants to clean the canal because the taper of the canal is wider than the rotary files
Every case I take the working length as soon as the smallest k file looks like it is near the apex. So at the beginning of each case.
It is important to be able to negotiate the coronal curvature and then just take the 10 K file to length, use an apex locator and then I find ProGlider good to use if it is particularly curved.
There are new cones that fit the preparations better.The other possibility is that you need to brush a little more to make space for the GP cone.
3 sizes up from the first file that binds was popular when we had narrow tapered preps due to hand filing, now that we have taper we just need to create an apical stop rather than some theoretical size.
Start X2 doesn’t require water because you can’t see when water is being used. The power at which it is used should therefore used at low power in short bursts to locate the canal. The Start X4 tip for removing posts creates a lot of heat and is used at high power and therefore requires water.
Yes you can get them for EMS scalers
Yes, it is recommended that these files are for single use only.
It is not essential to use GuttaCore with Protaper NEXT but it is a technique which can be used to quickly and adequately fill canals
GuttaCore is a carrier based obturating system and is useful in narrow long roots with moderate curvature. If you are able to master the technique it is an quick and efficient way to fill canals
ProTaper next is my go to system and most cases I treat with this system. If the case is more simple I use Wave One GOLD, because it significantly reduces preparation time for me.
There are so many differences between these rotary files. Protaper NEXT files have shape memory and cut efficiently. I have not used Hyflex files. The best thing to do is to try the files and see which one you prefer. Your local rep should be able to provide you with a sample.
Size 10 K is my recapitulating file
The smallest file which is easy to see radiographically size 15 for this reason I find ProGlider helpful to quickly get to length after the size 10 K file, so then you can take a radiograph using a 15 K
ProTaper next is my system I use most, but in simple untreated cases I use Wave One GOLD. I prefer to use Wave one gold when the curvature is not severe.
This is not recommended because if you make an error then it can be catastrophic!
In wide canals, I almost never use these files as X3 has sufficient taper for a 30 gauge irrigation needle to reach the apex.
Yes when you meet resistance you withdraw the file and keep it running and brush away from the furcation.
the same motion as a probe
a watch winding motion also called the balanced force technique.
C+ files are good for starting preparation of calcified canals. C pilot files are for use after this.
Once the file has progressed 2-3mm I would try again to use K files
C+ files are stainless steel and not diamond coated.
This moves the prepared canal away from the furcation. We don’t want to strip the furcation when preparing the canal.
The brushing action used with Protaper next is a brush away from the curvature on the retrieval stroke, as opposed to a gliding action used with Proglider, to learn about this you really need to attend a hands on course.
I prefer the use of slow speed round burs such as the LN bur.
LN Bur and Micro Opener 10/06
It isn’t mandatory but it helps create a tapered glide path and eliminates the big jump in file size from 10 k to 15k (50% bigger)
Yes you definitely need to obturate at some point! There are new variable tapered cones available that appear to be easier to use than the previous ones.
Use whatever root filling technique that works for you, but if you can get experienced using warm vertical condensation with the custom GP cones it will save you time.
You can use a single cone obturation technique but I don’t use this technique
I don’t routinely use carrier based obturation systems. If you like Thermafil you should try Gutta Core as it has a gutta percha carrier.
There are so many ways to remove GP, you can use small sized 2 Gates Glidden drills and also there are retreatment files available D1-D3
I try and restore all the cases I treat and have been doing so for 4 years now. My favoured base over the GP is SDR (smart dentine replacement).
I use EDTA as a rinse after my last file and then sodium hypochlorite after this.
In theory if the treatment has been done to a high standard there is no need to delay it.
This is another option rather than ProGlider, but ProGlider will be able to fit in smaller glide paths as it has smaller taper at the tip.
No, if the tip binds in the canal edta will not prevent this. Creation of a glide path does reduce torsional force on the next file and this is why creation of a glide path is so important to what we do.
I use sodium hypochlorite and EDTA as my stock irrigants
This is a difficult thing to prove. We have a high success rate without activation of irrigants and so its difficult to show it makes a difference but, in theory it helps remove bacteria and circulate irrigants into lateral canals
I use 30 guage irrigation needles and also the TruNatomy plastic irrigation needle. I also use the EndoActivator and the Eddy they are useful for moving the irrigant solutions into lateral canals
Sealer extrusion per se is unlikely to reduce success but many sealers are cytotoxic and if they are extruded this can delay healing. It is thought that overpreparation often results in overfilling. These may go hand in hand and maybe the reduction in the ability to create a good apical seal is part of the reason for delayed healing with extruded treatments. In general, its better to aim to finish your root canal preparation 0.5mm-1.5mm short of the radiographic apex. This has been shown in many studies.
Sealer extrusion per se is unlikely to reduce success but many sealers are cytotoxic and if they are extruded this can delay healing. It is thought that overpreparation often results in overfilling. These may go hand in hand and maybe the reduction in the ability to create a good apical seal is part of the reason for delayed healing with extruded treatments. In general, its better to aim to finish your root canal preparation 0.5mm-1.5mm short of the radiographic apex. This has been shown in many studies.
There is no significant differences with regard to success of cases based on sealer.
I have used bioceramic AH+ sealers. My go to sealer is AH+ and I would consider bioceramic sealers only if there was a resorptive defect.
I commonly use fibre posts to restore teeth, either if the referrer has requested this or I feel it would benefit the clinical situation.
Yes this is their purpose
EndoActivator is simple to use and useful as an agitator of irrigants. I also use the Eddy, which is higher in frequency.
If you want to use loupes just for endo then I would recommend at least 4X magnification.
There is no advantage in heating hypochlorite when using the bubble technique, as the oxygen release is similar
Sodium hypochlorite releases oxygen as it dissolves organic tissue and this creates bubbles. So it can be used to locate canals
I don’t routinely use lentulo spiral fillers, I prefer to inject calcium hydroxide using Navi tips or place it using EndoActivator
The width of the preparation depends on many things but if you can reach a size 30 then in theory a 30 gauge irrigation needle can easily reach 1mm short of the apex and fully irrigate the canal
There are many ways to do this and probably it would be difficult to describe this without being at a hands on course
To prevent forming them create a glide path with hand files and use small rotary files like X1 and ProGlider. Ledging usually occurs as a result of incorrect angle of insertion and use of files which are wide and rigid. It is less of a problem for rotary instrumentation, due to the emphasis on gradual increase in preparation size and tactile sensitivity.
I recommend dressing the canal long enough to resolve their symptoms or sinus tract and occasionally I do this over 3 visits. But if you can prepare the canals and then remove symptoms after 1 dressing then that is often enough.
Older patients often have calcified canals and in cases of long standing apical periodontitis I would recommend dressing the canals for many weeks and then making sure symptoms are gone before filling the canals.
The Radix Paramolaris case which is a lower molar with 2 separate mesial roots was the rarest case I’ve treated. I have also treated dens invaginatus cases where the canals are in completely random formation. These are fun!
Brushing with the X2 file or using one of the new variable tapered GP cones would overcome this.
Calcium hydroxide can block the canals, you should use the X1 file to remove it, this will correct this problem
This is just narrowing of the canals and this is when your balanced force hand filing technique needs to be good to overcome this
In theory yes, but because of the reduction in resistance to cyclic fatigue I do not recommend this. What I do is try to prepare all the canals to the same size and if I want to do more at the next appointment, then use the next file in the sequence which is new from the sterilised pack.
The law and your code of conduct require an informed consent. This includes a financial informed consent. There should be a warning about any “material risks” – A significant potential for harm that a reasonable person would want to consider when deciding about undergoing a medical or surgical treatment.
This is a controversial subject, and they may have some use if infected debris is extruded during treatment. In general, I do not recommend antibiotics in hypochlorite accident cases. But it is a clinical case dependent decision.
There is usually very little change in colour of the gingival tissues, the inflammation is usually deeper, the patient usually reports a burning sensation during irrigation and there is commonly bleeding from the root canal.
Ng et al 2011
Short root fillings in primary root treatments 74.3% success. Rerct cases 64.8% success
Long root fillings in primary treatments 67.1% success. Rerct cases 61.5% success
Flush root fillings in primary treatments 85.8% success. Rerct cases 84.6% success
Assuming the perforation is small enough to repair I recommend repairing these immediately using an MTA or Bioceramic product. That way you can assess the set of the material at the next visit.
Any obturation technique has a learning curve and due to carrier based obturation being a very quick and efficient way to fill a canal, it does have it challenges. I have used carriers to fill canal before, but due to the diverse cases I treat do not use this technique routinely. If you get good results using carrier based obturation, then keep doing what works for you.
Trichloroacetic acid is used to remove resorbing tissue present in external cervical resorption cases. It removes tissue and coagulates it to prevent haemorrhage.
Sodium hypochlorite is antibacterial due to its high Ph and production of chloramines. It also produces hypochlorous acid and this dissolves tissue which is food for bacteria. So, it is the only irrigant that accomplishes both aims. Removal of bacteria and removal of tissue. EDTA supplements sodium hypochlorite by removing the inorganic smear layer (which sodium hypochlorite does not do).
Other irrigants like chlorhexidine and hydrogen peroxide have no tissue dissolving property and therefore do not dissolve the bacterial biofilms present on the wall of root canals. Therefore, they need to be supplemented with sodium hypochlorite.
Chlorhexidine can be used after sodium hypochlorite, and the canal is flushed prior to its use. Mixing the two irrigants creates a brown precipitate which is difficult to remove.
Diagnosing irreversible pulpal disease is a clinical decision based on many factors, a radiograph is just one of them. The presence of a radiolucency is often a sign of pulpal disease, but there are more tests required to diagnose pulpal disease. Vitality testing, patient history and percussion, palpation tests are important. Many of the symptomatic irreversible pulpitis cases have no signs of apical disease clinically or radiographically and then the use of temperature sensitivity plays a big role in diagnosis. If in doubt get the patient back another day and reassess when the pain changes.
The diagnoses are both pulpal and periapical. Both diagnoses relate to the tooth and are merely a reflection of your interpretation of generally what is going on inside the pulp and outside in the apical tissues, based on imaging and clinical tests.
The use of ‘chronic’ in apical diagnosis was removed some time ago. There is debate whether it should come back into use. So If I interpret this question to be- Can a symptomatic irreversible pulpitis also have symptomatic apical periodontitis. The answer is yes of course!
If the pulp is inflamed due to microorganisms their toxins can still leave via the apical foramina and cause inflammation, that would create a symptomatic apical periodontitis. Usually in these cases a lesion is difficult to see radiographically or very small. But of course anything is possible.
The term phoenix abscess is merely a name for an acute exacerbation of what was a chronic or low-grade periapical inflammation. In other words, the asymptomatic periapical inflammation (visible before treatment radiographically) has now become acute, and an abscess has formed. This causes pain and swelling, as well as pus creation (because without pus it’s not an abscess) and the usual signs of abscess.
Measure the working length correctly using an apex locator and back this up with a periapical radiograph, measure the syringe to 2mm short of the working length and irrigate the canals with sodium hypochlorite carefully. You should also use an activator to bring the irrigants apically. Bear in mid teeth with open apices usually have healthy stem cells that close the apex after removal of infection so you often do not need to go over the top with irrigating the apical part of the root canal in these open apex cases. Remove the infection in the canal and close their path of entry and the body will heal nicely.
Great question! From my ortho knowledge we first should establish whether the 3rd molars will be present. Then if they are extraction of the first molar should occur when the bifurcation of the second molar forms and then the second molar generally erupts into the space left by the first molar!
The use of non steroidal anti-inflammatory medications reduce the prostaglandins that are responsible for creating hypersensitivity in the pulp. This is how they improve success of inferior alveolar nerve blocks.
The patient will always tell you that they have severe temperature sensitivity and that they have changed their daily routine to deal with this sensitivity. Drinking iced water, warming tap water to brush teeth, pain when breathing cold morning air etc. Then you can be reasonably sure the pulp is inflamed. As always you need to do your tests to confirm an endodontic cause of this.
These are usually easier. Preoperative ibuprofen, buccal and then palatal infiltration, intraligamentary anaesthetic and if needed inhalation sedation is always helpful.
Yes, but it has to offer an advantage over full root canal treatment. The healing potential of a root with a closed apex is not as good as one with an open apex. The success of root canal treatment to the apex is very high. I have used it in patients who are difficult to treat in the chair and only for teeth not requiring a crown after treatment.
Sodium hypochlorite creates oxygen when it interacts with pulp tissue, and this can be seen as bubbles. These should guide you to the canal or at least reveal that it is present. To use this technique, you require good magnification and a light. Most likely an operating microscope.
Use of local anaesthetic with high adrenaline and just start preparing the canals! If you remove the tissue the bleeding will stop.
The Start X2 tip is a good one for ultrasonic location of MB2 the disadvantage I find with ultrasonics is they scratch the pulpal floor, making the floor anatomy trickier to read, but they provide less damage and more visual access of calcified canals, so I do use these when the going gets tough!
I like using C pilot and the C+ files for these.
The best burs I’ve found for location of MB2 are the Endo Tracer burs and the LN bur which is a short goose neck 0.5 mm round bur
I will withdraw the irrigant with a syringe and then place the calcium hydroxide. I don’t dry the canals prior to placement of the medicament. Just remove the irrigant by pulling back on the syringe.
I place one cone in the MB1 and then another in the MB2. Before filling you should establish whether these canals join. Using the GP point and file technique. Then you know whether the cone in the MB2 needs to go to the reference point or it will hit the MB1 cone. Fill Mb1 and 2 both at the same time.
Inject the calcium hydroxide using Navi tips and then activate it using the Endoactivator or Eddy sonic activation unit, to move the medicament apically.
Calcium hydroxide needs significant time to dissociate into ions and exert the effects of its high PH. This makes it ideal for endo because if a small amount us pushed inadvertently outside the canal, then the body removes it before its able to exert a significant effect. However, inside the canal it can stay in place and exert its effect. The time it takes to have a significant effect is approximately 1 week. So, it takes a few days of it being in contact with cells to do this.
Thanks for your kind comment, but you are the real star for giving up your time to watch and learn for the betterment of your knowledge and for your patients! Teachers can only show their students the door, but the student opens it.
The sequence for wave one gold would be glide path preparation till size 10 K file and then either the Wave one gold glider or a size 15K depending on difficulty. Then use of the primary 25 07 file. If the first 0-5mm of the blades are filled with dentine on the last pass of the file, then no further work is required. However small is available for cases where primary does go to the apex and medium and large sizes for wide canals where the primary doesn’t debride the canal apically.
Good question. Our diagnoses are just snap shots of what we find clinically. Often the pulp is a mix of necrotic inflamed and even sometimes abscessed areas and we have multirooted teeth. So yes a pulp can have areas of necrosis and inflamed areas or canals which will make it sensitive to hot. Almost anything is possible when we are treating the human body!
Another good question! There is no answer to this though. Some patients have pulpitis for many months and others just a few days before necrosis. It probably has something to do with a number of factors such as viability and age of the pulp (immature pulps survive better), size of the defect the bacteria are gaining access through and the type of bacteria involved.
The term symptomatic means the patient has symptoms of the disorder. Symptomatic apical periodontitis means the patient feels discomfort related to apical periodontitis. So this is generally tenderness when touching the sulcus or percussing the tooth. A painless tooth with a necrotic pulp – which has a radiographically visible radiolucency would be described as- Asymptomatic apical periodontitis associated with a necrotic pulp.
Removal of the bacteria and their food/energy source (pulp tissue), then closing this ‘clean’ environment are the most important steps. Filling of the canals is a way to show the length of preparation and create a rudimentary apical and coronal seal, but removal of bacteria (and the pulp tissue) is what heals apical periodontitis.
I place the stopper 1-2mm short of the apex and don’t let the tip bind. Extrusion of calcium hydroxide has not been an issue using this technique.
As I mentioned sodium hypochlorite interacts with everything because the chlorine ion is in a positive state and its stable state is Cl-. So yes if you add anything to sodium hypochlorite it dissociates and the chlorine is used up interacting with what was added to it. What this means is that you should not mix sodium hypochlorite with any other irrigants when you want it to work on biofilms and pulp tissue. Because you just reduce the available chlorine and therefore its effectiveness by doing so.
Currently I’m using 4% sodium hypochlorite and Chlorcid surf 3% when I treat cases in a single visit.
I use files and irrigants to do this, the citric acid 20% is recommended for removing Ultracal.
It’s the sodium hypochlorite which interacts with everything and that includes EDTA. So EDTA is unaffected by sodium hypochlorite and still functions well. BUT the available chlorine is degraded when anything is added to sodium hypochlorite. Therefore, if the sodium hypochlorite is interacting with the pulp tissue and bacterial biofilm then this is what we want. But we don’t want anything in the canal that wil take away from thus interaction. So, I use sodium hypo the entire time and just at the end after all preparation use EDTA to remove the inorganic smear layer. Then sodium hypochlorite again just before finishing. Because we want to get sodium hypochlorite into areas covered by the inorganic smear layer once it is removed. The smear layer plugs lateral canals and covers microbes on the canal wall and offers them further protection. SO, after EDTA it is advisable to use sodium hypochlorite. After that you could go back with EDTA to finish off if you wish that would help remove sodium hypochlorite and open the tubules prior to filling the canal and restoring the access.
I have used bioceramic sealers, mainly in situations where there is a long canal and a blunderbuss (cola bottle shaped) apex. So in situations where the canal is narrow and long but the apex is very wide from resorption. I wouldn’t recommend them routinely we have epoxy resin sealers which I use routinely. But in theory bioceramics should be good for resorption cases. The jury is still out on their effectiveness and there needs to be some moisture BUT not too much fro them to actually set. This is a major problem. How can we judge moisture? They wash out a lot before setting. As you mentioned there may be difficulties with post placement, but you would need to use a lot of sealer for this to occur. I don’t recommend using large amounts of bioceramic sealer and a single cone. Use enough to fill the defect you need to fill and use GP and the rest.
Increasing the percentage of sodium hypochlorite will improve tissue dissolving speed and biofilm dissolving speed. If you treat patients in multiple visits I see no advantage in increasing your percentage of sodium hypochlorite , unless you treat single visit cases or lots of retreatment cases with established biofilms. These are the kind of cases I treat every day and that’s why I use higher strength sodium hypochlorite. The same principles apply irrigate safely and if you are concerned about perforations don’t irrigate using sodium hypochlorite until you are sure that you are inside the canals.
You should use sodium hypochlorite. This dissolves flushes the canal, removes pus, biofilms and tissue and kills bacteria. Saline only flushes the debris out.
If you cant isolate the tooth you will need to have the orthodontic arch wire removed.
This improves tissue dissolving capacity, but mist be down inside the pulp chamber. Heating outside the mouth wont retain the temperature after the small volume enters the chamber.
Really a microscope changes your life and quality of treatment you can provide. It’s a bit like upgrading your car. At the start it takes a little while to get used to but once you get used to it, the reduction of eye strain, neck strain, back strain and STRESS is amazing. A good scope makes endo fun and fascinating. It is almost impossible to deliver good quality endodontics for teeth with those ‘extra’ canals. The second mesio-buccal canal in upper molars, the lingual canal in lower incisors, the second distal in lower molar teeth and those premolars with 3 canals, just to name a few, without a scope!
If you don’t have a scope, then be prepared to refer these cases. If you love endo, you should get a scope and there is huge variation in quality amongst these as well! If you are happy to refer these tricky cases, then loupes will be fine.
There are so many possibilities here- was the diagnosis correct? Is the tooth cracked into the periodontal tissues, is the restoration high, is there food impaction……the list of possibilities is immense. If you get a case where you think you’ve done well and there are still problems this means you should refer the patient for assessment to a colleague who can assist.
There are many reasons why I would treat a patient in a single visit. Generally speaking, if I can do the treatment in a time that allows enough time for preparation and copious irrigation and there are little to symptoms, I will try and complete all the treatment the in one very long session. To do this you need the right tooth in the right patient. Not one or the other but both !
This is called a hypochlorite accident and is a serious side effect of root canal treatment. It would commonly occur after a perforation rather than overzealous irrigation. Most dentists are cautious whilst irrigating. But if there is a perforation and they are unaware this can be a problem.
I am currently using the Eddy sonic activator or the EndoActivator. Both utilise polymer tips and they cannot damage the canal wall. They are very safe to use on patients and I’ve never had any complications using either of these. The EndoActivator is also very transportable as it runs off batteries that cant be bought in most stores. Its handy for my general anaesthetic surgery cases, due to its transportability. The Eddy is a higher frequency version and requires a separate air scaler, but I love it for those wide canals, where the file doesn’t touch the walls very much.
Yes, I recommend activation of sodium hypochlorite, it creates microstreaming and this aids in tissue and bacterial removal. I activate at least 1minute per canal.
Activation of EDTA has not been shown to be required but it cant hurt to try and get it into latreral canals and isthmuses.
The general rule is a burst of less than 3 seconds using these units is ok. If the setting is 200 degrees this is ok for a short burst, in the same way that its ok when you use it to fill a canal.
Just short bursts of heat with the tip less than 3 seconds at a time. I generally just do 1 second bursts to warm it.
There is good evidence for use of ibuprofen 600mg and 500mg paracetamol taken together for a few days (less than 5 days). If pain goes longer than 5 days, patients need to know they can call you. Remember patients who have long standing pain following root treatment (longer than 5 days) often (assuming the diagnosis is correct) have either an acute exacerbation (phoenix abscess) or the restoration is high thus reducing the speed of post operative healing. Reducing the bite helps these patients heal faster.
This is what I recommend, because it has good evidence for its use.
The more rigid files are better for opening calcified canals. The 19mm long XA orifice opener is a favourite of mine.
Sodium hypochlorite is always the first irrigant I use.
With a case like this if you can use the buccal cavity to access the canals this would be my preferred method. If not you should restore the buccal cavity and then access occlusally.
These are tricky cases! Preoperative non-steroidal anti-inflammatories may help. You need to anaesthetise as much as possible before starting treatment. Use of a tungsten carbide bur also creates less vibration than a diamond bur and this may help get into the canals. Intrapulpal is another option once you reach the chamber.
There are several techniques, my favoured one is to use a stainless-steel bur like the LN bur and create debris to show the orifice and then open using an orifice opening file.
I prefer to treat vital inflamed /elective cases in a single visit, but this depends on the complexity and patient being treated.
Preoperative non steroidal anti-inflammatories then good anaesthesia and if needed intrapulpal injection and then if needed inhalation sedation. Prepare the apex well and make sure that pulp tissue is removed
I do this procedure in the same way whether there is a sinus tract. I just prefer to see this sinus tract before I complete the root treatment, at the next visit.
I have not used a steroid/antibiotic paste in many years.
The recommended time between visits for root canal treatment with calcium hydroxide is between 1 to 3 weeks. Riccucci et al 2011 showed best success less than 3weesks. But remember the seal of the temporary restoration is everything. If you can seal the access, you can leave it a long time if you need to. If its tricky to obtain this seal temporarily I suggest 1 week which is the shortest time.
For patients who require antibiotic cover. The regulations are different in every country.
If the tooth has a crack onto the pulpal floor or the crack involves the periodontal tissues then I usually recommend extraction.
Patients can take paracetamol if they cant take ibuprofen.
I dress the canals with calcium hydroxide in these cases and monitor.
Citric acid is used to replace EDTA. It removes the smear layer and cleans the access cavity due to its acidity.
Use new files for patients, learn to use the preparation system by attending hands on courses and practicing using it on extracted teeth. Always prepare a good reproducible glide path to reduce cyclic and torsional forces on the files.
The maximum dose of ibuprofen is 2400mg in 24 hours. So, if you do the maths, that is 600mg a maximum of 4 times in 24 hours, If you are giving 800mg that can only be taken 3 times in 24 hours.
Sealer is cytotoxic therefore we hope not to extrude this. It has the potential to damage cells, and this is most important around nerves, such as the inferior dental nerve and the mental nerves. If we extrude a small amount it rarely causes problems but it can be catastrophic in the wrong situation. We should always aim to use enough sealer to coat the walls and avoid extruding too much.
I only consider antibiotyic prescription if the patient has systemic signs of infection OR if they are immunocompromised (diabetic etc). Local disease around the tooth should be treated locally- with incison drainage and opening of the canals. Systemic disease should be treated BOTH locally and systemically.
Not if you can establish drainage successfully. There is generally no reason to prescribe systemic antibiotics unless the patient is immunocompromised or shows systemic signs of infection.
Citric acid can be used as an alternative to EDTA
This has been shown to be a helpful adjunct in studies!
The irrigant is helpful but I don’t use viscous chelation gels at all.
‘Acute’ and ‘chronic’ were removed from the diagnostic terminology some time ago. So these two terms mean essentially mean similar things. Acute apical periodontitis formerly meant swelling, redness, and pain – essentially acute signs. The only small difference is that an abscess must contain pus. Because without pus it can’t be an ‘abscess’.
The same as with an acute abscess. Drainage via the canal and or incision. Reduction of occlusion. No antibiotics are required unless the patient is immunocompromised or exhibits signs of systemic infection- such as fever, malaise, lymphadenopathy.
Citric acid can be used as a replacement for EDTA and to clean the pulp chamber after.
An electric pulp tester has been shown to be a useful test for use along with cold testing. It is more open to false positives because the electrical signals can stimulate other teeth and the periodontal ligament.
The most accurate way to assess vitality or presence of a blood supply, is laser doppler flowmetry, because it assesses movement of red blood cells. This machine is not readily available so, all routinely used tests are aimed at stimulating A delta fibres in the pulp and then assuming this means vitality (or blood supply) is present. Testing with cold is the most reliable test but the test must be done with very cold CO2 snow or Endofrost. The cold draws the dentinal tubule fluid outwards, and this causes firing of the A delta fibres, felt by the patient as a sharp pain. The electric pulp tester is helpful also, as it stimulates the A delta fibres by electrical signal. The major flaw of the electric pulp tester is that false positives are relatively common.
Don’t forget radiographs and CBCT also are helpful tools for assessing vitality. If we can see root closure or development in teeth with immature apices, this indicates vitality!
I have not prescribed this medication before.
I don’t use this because I prefer use of irrigants which do not attract debris to the blades of the file.
I don’t see any harm in doing this
If I place a temporary restoration the base is either IRM for its strength and antimicrobial properties or grey Cavit which is easily removed. Usually, I place a glass ionomer over these bases.
IRM is easier to remove from the pulpal floor, rather than GIC and easier to visualise also. You can use ethanol on the pulpal floor to remove the eugenol after filling the canals. This is not a problem, if you do this.
If the infection in the canals has been treated there is no reason to prescribe antibiotics systemically. This is a clinical decision though dependent on the patient.
Sealer puffs should not be something we try to create, so are an undesirable side effect of treatment. Most of the time they are of little consequence, but they can injure nerves if they are close to the apex.
Anti-inflammatories are important and reduction of the occlusion.
Treat the source of the infection such as the tooth and review. Often the dental treatment will help resolve this and then a plastic surgeon can be required to improve the aesthetics.
I dont recommend leaving the tooth open to drain.
Work out the apical size of the root before filling, you can do this by using hadn files pressed down the canal or paper points to check for bleeding on the tip. Good radiographs and an apex locator also help.
Saline isn’t antimicrobial or a tissue solvent so it neither dissolves bacterial biofilms nor their energy source (pulp tissue). Sodium hypochlorite accomplishes both of these important features.
Passing a small file such as a size 10 k file through the apex by 0.5mm is unlikely to damage the apical tissues.
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