intra canal meds, temp and bleaching

Question 1

rubber dam needed?

Answer 1

always

Question 2

single vs multivisit RCTs

Answer 2

Many studies show no statistical difference in
outcomes between RCT completed in a single
visit vs. RCT completed in multiple visits.

Question 3

is single visit RCT acceptable?

Answer 3

Single visit RCT is acceptable as a
modern evidenced-based standard
in general ; most predictable with
vital teeth and no P/R pathoses.

Question 4

what prevents single visit RCTs in the clinic here?

Answer 4

time

Question 5

multi visit possible advantage

Answer 5

multi visit may be superior in reducing the microbio challenge

Question 6

AT UMKC-SoD, Teeth with Peri-Radicular Pathosis or
Necrotic Pulp will be treated at least how long with CaOH before obturation?

Answer 6

at least one week with intra-canal medication with
Ca(OH)2 before Obturation.
DST should heal.

Question 7

Between RCT visits or at any time the canal is not
protected by adequate rubber dam isolation, the
canal must be?

Answer 7

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

Question 8

Anytime obturation is not yet accomplished, this is an indication for:

Answer 8

Anytime obturation is
not yet accomplished,
this is an indication for
intra-canal medication.

Question 9

Any Time that a Temporary
Restoration is placed, it is a
good idea to:

Answer 9

Any Time that a Temporary Restoration is placed, it is a good idea to Medicate & Seal with Proper Interim Temporization

Question 10

Calcium Hydroxide

Answer 10

• CaOH is currently the singular most popular
  intra-canal medication to use for disinfection of
  canal between RCT visits

Question 11

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?

Answer 11

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

Question 12

Calcium Hydroxide: Interim Placement

Answer 12

• 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

Question 13

If you have a mandibular PM or Molar with
open apices, how should you proceed with CaOH

Answer 13

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.

Question 14

Temporization Between Visits

Answer 14

• Sterile cotton in chamber over CaOH
• Place Cavit, IRM, Amalgam or Composite over cotton:

Question 15

Cavit

Answer 15

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

Question 16

IRM

Answer 16

1-4 week duration of seal = stronger = use when 2
surfaces or more are missing

Question 17

Composite, Amalgam, Temporary Crown indicated when?

Answer 17

when considerable tooth structure is compromised or a greater delay to next treatment visit is anticipated

Question 18

Temporization following Obturation

Answer 18

• “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.

Question 19

temporization with post/core antcipated

Answer 19

• 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.

Question 20

temporization with crown anticipated

Answer 20

• 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

Question 21

Restoration of RCT Teeth: ASAP
* Anteriors:
– Minimal structural loss:
– Significant structural loss:
* Posteriors:
– Minimal structural loss:
– Significant structural loss:

Answer 21

• 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

Question 22

post purpose

Answer 22

POSTS do NOT strengthen tooth (they weaken it)
- POSTS provide ONLY RETENTION of coronal restoration

Question 23

Bleaching of non-vital Teeth

Answer 23

• Teeth which are discolored and esthetically
  unsatisfactory to patient (usually an
  individual tooth) either following
  RCT or previously treated RCT

Question 24

• Stains you can’t help:

Answer 24

– 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

Question 25

Which discolorations can be bleached?

Answer 25

* Cases involving: – Pulp necrosis that releases discoloring compounds * Bilirubin & Biliverdin – Intrapulpal hemorrhage * Hemosiderin – Extrinsic stains that have not become chronically established in dentinal tubules.

Question 26

discoloration tx options? | why would pts choose bleaching?

Answer 26

* Do Nothing * Internal Bleaching * Veneer * PJC or PFM Crown Patient will often choose internal bleaching due to the lower cost factor

Question 27

informed consent of internal bleaching

Answer 27

* 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.

Question 28

Non-Vital (Internal) Bleaching: * Do NOT promise? * Don’t guarantee? * Be sure patient expectations are?

Answer 28

* Do NOT promise anything you can’t deliver. * Don’t guarantee RESULTS. * Be sure patient expectations are REASONABLE regarding the proposed procedure.

Question 29

photos with int bleaching

Answer 29

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

Question 30

sharing previous results of bleach w pts

Answer 30

OK to share your previous successes * Tell the patient: similar results may be obtained (OR NOT)

Question 31

discoloration following bleaching

Answer 31

Discoloration likely to recur following successful bleaching

Question 32

pt desired results of bleaching may actually require: | how to approach this

Answer 32

Veneers or crowns – Agree to TRY bleaching first – Set your fee relevant to your Stopping point – Always agree to 2 or 3 visits ONLY

Question 33

Non-Vital (Internal) Bleaching: * Requirements (2)

Answer 33

– 1. Well done Conventional RCT * Asymptomatic * Proven successful outcome – 2. Additional Barrier over RCF ***

Question 34

failure of seal above GP with int bleaching

Answer 34

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***

Question 35

Percolation Results:

Answer 35

* Extreme PAIN * Irate Patient * Ruined RCT lawsuit

Question 36

prevention of percolation

Answer 36

* Don’t forget Barrier * Will save you – Time – Trouble – Money – Loss of patient – Loss of patient’s contacts

Question 37

Non-Vital Bleaching: THE RISKS

Answer 37

* 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

Question 38

UMKC non-vital bleaching technique

Answer 38

* 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.

Question 39

Before you start to Bleach * Make Sure: – All metallic materials? – All pulp horns? – All defective?

Answer 39

– 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.

Question 40

walking bleach technique

Answer 40

Question 41

The “Walking Bleach technique” * Mixing

Answer 41

* Mix FRESH Sodium Perborate USP with sterile water or anesthetic to a thick consistency

Question 42

Sodium Perborate placement

Answer 42

* Place into the chamber with an amalgam carrier. * Remove excess and clean axial walls of access.

Question 43

The “Walking Bleach technique” * Inter-appointment seal

Answer 43

– 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