Intra-Canal Medication, Temporization and Non-Vital Bleaching Flashcards
Many studies show no statistical difference in
outcomes between RCT completed in
a single
visit vs. RCT completed in multiple visits.
Single visit RCT is acceptable as a
modern evidenced-based standard
in general ; most predictable with
vital teeth and no P/R pathoses.
Other respected studies show that cases with primary apical
periodontitis completed in multiple visits with — as an
interim intra-canal medication improved the microbiological
status of the root canal system.
CaOH
One of the primary goals of RCT is to
reduce
the microbiological status of the root canal
system to the extent at which P/R healing can
occur.***
Therefore the — visit protocol RCT is acceptable and
may be superior (in terms of reduction of micro-organisms in
the canal system in teeth with P/R pathosis) as a modern
evidenced-based standard in general.
2 or even 3
AT UMKC-SoD, Teeth with
Peri-Radicular Pathosis or
Necrotic Pulp will be treated
at least
one week with intra-
canal medication with
Ca(OH)2 before Obturation.
DST should heal.
Between RCT visits or at any time the canal is not
protected by adequate rubber dam isolation, the
canal must be protected from
salivary contamination
(micro-organisms) by some type of temporary filling.
Anytime obturation is
not yet accomplished,
this is an indication for
intra-canal medication.
Any Time that a Temporary
Restoration is placed, it is a
good idea to
Medicate &
Seal with Proper Interim
Temporization
— is currently the singular most popular
intra-canal medication to use for disinfection of
canal between RCT visits*
CaOH
Calcium Hydroxide
– Far less — than previous intra-canal medications
– — environment for most micro-organisms (pH –)
– — encouraged in a basic vs. acidic environment
– — activity extends over extended periods (up to 3 mos.)
– Helps to — a “weepy” canal
– Safe & easily removed by — at subsequent appointment
– DO NOT CONFUSE WITH —
toxic
Unfavorable, 12.4
Bone healing
Antimicrobial
dry
irrigation
BC SEALER
– (You will never get set BC SEALER OUT of the canal(s)
CaOH tip is placed about — short of WL (do NOT allow to BIND)
and the CaOH is expressed as the syringe is retracted from the canal.
Objective: fill the canal in its entirety to
2mm
Cervical Line
USE CARE! If you have a
mandibular PM or Molar with
open apices, it is possible to
force CaOH out the apex & into
the Mandibular Canal possibly
causing Paresthesia
and Severe and lasting Pain to
the jaw and Face.
Clear excess CaOH from –
chamber
Place sterile cotton pellet in chamber to prevent clogging of the canal with
temporary filling material ***
Temporary filling is placed following the
cotton pellet
Temporization Between Visits
(2)
- Sterile cotton in chamber over CaOH
- Place Cavit, IRM, Amalgam or
Composite over cotton
skipped
Place Cavit, IRM, Amalgam or
Composite over cotton:
(3)
– Cavit:
– IRM:
– Composite, Amalgam, Temporary Crown:
– Cavit:
Comes from the tube or jar ready to place in the
tooth. No mixing. (1-2 week duration of seal – seals better
than IRM but deteriorates rapidly)
Best used only for 1 surface access
– IRM:
(1-4 week duration of seal = stronger = use when 2
surfaces or more are missing)
– Composite, Amalgam, Temporary Crown:
(when
considerable tooth structure is compromised or a greater
delay to next treatment visit is anticipated
Temporary Filling
Material:
3-4 mm
Temporization following Obturation
* “—” (resin modified glass ionomer) is
recommended to seal the obturated canal (G.P.)
against leakage following successful RCT completion
while awaiting permanent restoration
Vitrebond
If Saliva remains in contact with GP for — hrs.
Retreatment will be required
72
Follow “Vitrebond”
–
Composite, Amalgam, Temporary Crown, etc. As a
base for crown to follow or as directed by restorative
faculty.
* Proceed to Final Restoration as directed in
your Team
“But, my Tx. Plan calls for a Post”
(4)
“But, my Tx. Plan calls for a Crown”
(4)
- Place cotton over obturation
- No Vitrebond
- Place substantial IRM,Amalgam or
Composite or temp. crown over cotton –
X-Ray - Completed RCT film without
rubber dam. - Place RUBBER DAM, remove IRM,
Amalgam or Composite and Cotton and
proceed with post & planned
Restoration in your Team. - Do NOT place cotton over
obturation - Place Amalgam or Vitrebond &
Composite as Build-up – X-Ray – RCT
without Rubber Dam. - Proceed later with crown
preparation in your Team. - 3 weeks – turn in for Grading to 231.
- Restoration of RCT Teeth: ASAP
* Anteriors:
– Minimal structural loss:
– Significant structural loss:
Vitrebond & Composite
Crown or Post & Crown
- Restoration of RCT Teeth: ASAP
* Posteriors:
– Minimal structural loss:
– Significant structural loss:
Crown (ALL posteriors)
Post & Crown
REMEMBER:
- POSTS do NOT
- POSTS provide ONLY
strengthen tooth (they weaken it)
RETENTION of coronal restoration
- Bleaching of non-vital Teeth
- Teeth which are discolored and esthetically
unsatisfactory to patient (usually an
individual tooth) either following
RCT or previously treated RCT
Vital External Bleaching of Teeth
(2)
– Generalized Whitening (Not associated with RCT)
– Not the subject of this Lecture
Stains you can’t help:
(4)
– Dental Fluorosis
– Systemic drugs (tetracycline,
etc.)
– Metallic components in
sealers or fillings
– INTRINSIC stains
Here’s where you may offer ONLY
alternate treatment:
Opaque layer +
Veneer, PJC or PFM Crown
Non-vital Bleaching
Which discolorations can be bleached?
* Cases involving:
(3)
– Pulp necrosis that releases
discoloring compounds
* Bilirubin & Biliverdin
– Intrapulpal hemorrhage
* Hemosiderin
– Extrinsic stains that have not
become chronically established
in dentinal tubules
PRESENT TREATMENT OPTIONS:
(4)
- Do Nothing
- Internal Bleaching
- Veneer
- PJC or PFM Crown
Patient will often choose
internal bleaching due to
the lower — factor
cost
Non-Vital (Internal) Bleaching:
* All treatment should be preceded
by a thorough Risk vs. Benefit
“case presentation” to the patient
in order to obtain “—”.
* Patient must be aware so
— can be met*
* Before you undertake to perform
internal bleaching for any patient,
you must fully —
which will become evident to you
as this Lecture progresses.
Informed Consent
expectations
disclose all risks
Non-Vital (Internal) Bleaching:
* Do NOT promise anything
you can’t deliver.
* Don’t guarantee —.
* Be sure patient expectations
are — regarding
the proposed procedure.
RESULTS
REASONABLE
Non-Vital (Internal) Bleaching:
* Take a shade AND
photos at …
(3)
outset and
again at conclusion
for documentation
– Pt. will forget how bad it was
to start with.
– Result may not meet their
expectations.
– Patients often forget the
original agreement in the
heat of expected payment
OK to share your previous successes
* Tell the patient:
* — likely to recur following successful bleaching
similar results may be obtained (OR NOT)
Discoloration
Desired result may require veneers or crowns
(3)
– Agree to TRY bleaching first
– Set your fee relevant to your Stopping point
– Always agree to 2 or 3 visits ONLY
Non-Vital (Internal) Bleaching:
* OK you have:
– Educated the patient
– Discussed alternatives
– Answered all their questions
– Pointed out all risks
– Obtained informed consent
– Documented your shade guide & photos
– Agreed upon fees and a —
Stopping Point
Non-Vital (Internal) Bleaching:
* Requirements (2)
– 1. Well done Conventional RCT
* Asymptomatic
* Proven successful outcome
– 2. Additional Barrier over RCF **
Non-Vital (Internal) Bleaching:
* Requirements:
(3)
– Excellent conventional RCT
– Asymptomatic tooth w/o PAR
– Additional Seal over GP*
Failure to provide an additional seal
(barrier) over the gutta percha of the RCT
when attempting internal bleaching will
result in
percolation of nascent oxygen
(released by bleaching agents) through the
gutta percha thereby destroying the RCT
seal and allowing irritating and toxic
bleaching agents to contact the periapical
tissues. . . OUCH***
Percolation Results:
(3)
- Extreme PAIN
- Irate Patient
- Ruined RCT
PREVENTION: Should Come to Mind
* Don’t forget —
* Will save you
– Time
– Trouble
– Money
– Loss of patient
– Loss of patient’s contacts
Barrier
Non-Vital Bleaching: THE RISKS
* — is a
potential problem
Cervical Resorption
- — Technique has
been shown to be associated with
Cervical Resorption
Thermo-catalytic
Thermo-catalytic
- 30% Hydrogen Peroxide catalyzed by
HEAT with or without Sodium Perborate =
NO
UMKC-SOD uses the “Walking Bleach”
(2)
- Sodium Perborate
- is a far safer chemical to
use and it can yield
reasonably comparable
results when sealed in the
tooth over a period of 2-3
visits.
Before you start to Bleach
* Make Sure:
(4)
– All metallic materials are out of
pulpal space
– All pulp horns are adequately
cleaned out
– All defective fillings are cleaned &
temporized
– This alone with a light shade of
composite may help clear up a lot
of the discoloration.
Think — when you are
accessing and finishing your RCT
…
Prevention
Clean pulp horns**
“Walking Bleach”
(9)
Perfect access
Remove caries
Remove pulp
horns
Brush dentin to
remove filling
remnants
Reduce GP at
least 2mm
apical
Make sure RCT
is well done
Isolate the
tooth in
question
Finish with CP
and Cavit
Final
restoration,
composite
The “Walking Bleach technique”
* Mix FRESH —- to a
thick consistency.
* Place into the chamber
with an amalgam carrier.
* Remove excess and clean
axial walls of access.
Sodium
Perborate USP with sterile
water or anesthetic
The “Walking Bleach technique”
* Inter-appointment seal
– Cover Na Perborate with a thin
layer of —
– Place IRM or composite temp.
filling that is well adapted to the
cleaned dentin walls at —
surface
cotton pellets
caval
Bleach lighter than desired – there will be some rebound – Finish w/ — composite
lightest
Sometimes, the — Crown may be found to be unsatisfactory as well
PFM
