intra canal meds, temp and bleaching Flashcards
rubber dam needed?
always
single vs multivisit RCTs
Many studies show no statistical difference in
outcomes between RCT completed in a single
visit vs. RCT completed in multiple visits.
is single visit RCT acceptable?
Single visit RCT is acceptable as a
modern evidenced-based standard
in general ; most predictable with
vital teeth and no P/R pathoses.
what prevents single visit RCTs in the clinic here?
time
multi visit possible advantage
multi visit may be superior in reducing the microbio challenge
AT UMKC-SoD, Teeth with Peri-Radicular Pathosis or
Necrotic Pulp will be treated at least how long with CaOH before obturation?
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?
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:
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:
Any Time that a Temporary Restoration is placed, it is a good idea to Medicate & Seal with Proper Interim Temporization
Calcium Hydroxide
- CaOH is currently the singular most popular
intra-canal medication to use for disinfection of
canal between RCT visits
CaOH
– Far less toxic than?
– environment for most micro-organisms?
– Bone healing encouraged?
– Antimicrobial activity time frame?
– Helps to dry?
– Safety and removal?
– DO NOT CONFUSE WITH? why?
Calcium Hydroxide
– Far less toxic than previous intra-canal medications
– Unfavorable environment for most micro-organisms (pH 12.4)
– Bone healing encouraged in a basic vs. acidic environment
– Antimicrobial activity extends over extended periods (up to 3 mos.)
– Helps to dry a “weepy” canal
– Safe & easily removed by irrigation at subsequent appointment
– DO NOT CONFUSE WITH BC SEALER
– (You will never get set BC SEALER OUT of the canal(s
Calcium Hydroxide: Interim Placement
- CaOH tip is placed about 2mm 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 Cervical Line - 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
If you have a mandibular PM or Molar with
open apices, how should you proceed with CaOH
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.
Temporization Between Visits
- Sterile cotton in chamber over CaOH
- Place Cavit, IRM, Amalgam or Composite over cotton:
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 acces
IRM
1-4 week duration of seal = stronger = use when 2
surfaces or more are missing
Composite, Amalgam, Temporary Crown indicated when?
when considerable tooth structure is compromised or a greater delay to next treatment visit is anticipated
Temporization following Obturation
- “Vitrebond” (resin modified glass ionomer) is
recommended to seal the obturated canal (G.P.)
against leakage following successful RCT completion
while awaiting permanent restoration. WHY?
If Saliva remains in contact with GP for 72 hrs.
Retreatment will be required. - 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.
temporization with post/core antcipated
- 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.
temporization with crown anticipated
- 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
Restoration of RCT Teeth: ASAP
* Anteriors:
– Minimal structural loss:
– Significant structural loss:
* Posteriors:
– Minimal structural loss:
– Significant structural loss:
- Anteriors:
– Minimal structural loss: Vitrebond & Composite
– Significant structural loss: Crown or Post & Crown - Posteriors:
– Minimal structural loss: Crown (ALL posteriors)
– Significant structural loss: Post & Crown
post purpose
POSTS do NOT strengthen tooth (they weaken it)
- POSTS provide ONLY 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
- Stains you can’t help:
– 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
Which discolorations can be bleached?
- Cases involving:
– Pulp necrosis that releases discoloring compounds - Bilirubin & Biliverdin
– Intrapulpal hemorrhage - Hemosiderin
– Extrinsic stains that have not become chronically established in dentinal tubules.
discoloration tx options?
why would pts choose bleaching?
- Do Nothing
- Internal Bleaching
- Veneer
- PJC or PFM Crown Patient will often choose internal bleaching due to the lower cost factor
informed consent of internal bleaching
- All treatment should be preceded by a thorough Risk vs. Benefit “case presentation” to the patient
in order to obtain “Informed Consent”. - Patient must be aware so expectations can be met*
- Before you undertake to perform internal bleaching for any patient, you must fully disclose all risks which will become evident to you as this Lecture progresses.
Non-Vital (Internal) Bleaching:
* Do NOT promise?
* Don’t guarantee?
* Be sure patient expectations are?
- Do NOT promise anything
you can’t deliver. - Don’t guarantee
RESULTS. - Be sure patient expectations
are REASONABLE regarding
the proposed procedure.
photos with int bleaching
Take a shade AND photos at 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
sharing previous results of bleach w pts
OK to share your previous successes
* Tell the patient: similar results may be obtained (OR NOT)
discoloration following bleaching
Discoloration likely to recur following successful bleaching
pt desired results of bleaching may actually require:
how to approach this
Veneers or crowns
– 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:
* Requirements (2)
– 1. Well done Conventional RCT
* Asymptomatic
* Proven successful outcome
– 2. Additional Barrier over RCF ***
failure of seal above GP with int 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:
- Extreme PAIN
- Irate Patient
- Ruined RCT
lawsuit
prevention of percolation
- Don’t forget Barrier
- Will save you
– Time
– Trouble
– Money
– Loss of patient
– Loss of patient’s contacts
Non-Vital Bleaching: THE RISKS
- Cervical Resorption is a potential problem
- Thermo-catalytic Technique has been shown to be associated with Cervical Resorption
- 30% Hydrogen Peroxide catalyzed by HEAT with or without Sodium Perborate = NO
UMKC non-vital bleaching technique
- 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:
– All metallic materials?
– All pulp horns?
– All defective?
– 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.
walking bleach technique
The “Walking Bleach technique”
* Mixing
- Mix FRESH Sodium Perborate USP with sterile
water or anesthetic to a thick consistency
Sodium Perborate placement
- Place into the chamber with an amalgam carrier.
- Remove excess and clean axial walls of access.
The “Walking Bleach technique”
* Inter-appointment seal
– Cover Na Perborate with a thin layer of cotton pellets
– Place IRM or composite temp. filling that is well adapted to the cleaned dentin walls at caval surface.
The idea is that Bleaching will occur as the patient walks around between visits
