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Endo tips    Better Endo    Endo abstracts    Endo discussions

The opinions within this web page are not ours. Authors have been credited
for the individual posts where they are. - -X-Rays courtesy: Richard Schwartz, Gary, Mark Dreyer, Murat Aydin

From: "Richard  Schwartz"
Date: Fri, 27 Apr 2001 19:19:30 -0500

     Oh great endo minds from around the world, how should I proceed with
this patient?  She is a 36 year old office manager from a 3 dentist
practice who are fairly good referrals.  I saw her a couple months ago, initiated
endo on #19, found a vertical fracture and sent her to see an oral surgeon.
Last week she was back.  One of her employers had prepared #18 for an FPD
and it recently started to hurt.  It was tender to pressure and
hyper-responsive to cold with lingering pain.  I initiated endo, didn't see
any significant cracks, so proceeded with preparation of the canals.  The
canals were in a C-shaped configuration and bled a lot, but the preparation
was otherwise uneventful.  When it was time to obturate the mesial canals
dried nicely but I couldn't get the distal canal dry.  So I placed CaOH
(aren't you proud of me Fred?) and reappointed her.  I spoke to her that
night and she said the tooth was hurting and the numbness hadn't worn off.
I assured her the soreness in the tooth was not unusual and would subside
in a couple days, but the numbness concerned me.  I spoke to her 2 days later
and the tooth was still killing her and her chin was still numb.  At that
point I perscribed a 5 day course of steroids, which she told me today
didn't help her at all.  Today, a week later, I had her come in.  Her chin
is still numb and her tooth hurts to the point of taking Vicodin.  The
tooth is very tender to touch and woke her up at 2 am this morning.  I re-entered
the tooth to see if I might have missed something.  I transilluminated
under the microscope in a dark room.  I feel confident the tooth does not have a
vertical fracture.  I couldn't detect any additional canals.

     So the first question in my mind is:  Did I enter the mandibular canal
and damage the IA nerve during preparation?  My second question is:  Why is
the tooth still hurting?  Any suggestions on how proceed with this patient?

Rick Schwartz

From: "Yosi Nahmias" Sent: Saturday, April 28, 2001 1:49 AM Do you have a pa after CaOH placement??? From: Gary B. Carr Sent: Saturday, April 28, 2001 6:27 AM Rick, I think I know what happened. Not because I'm so smart though. But because it happened to me(or rather my patient a short time ago). The problem is with the CaOH! My patient is still numb--just like she had a block. It's been two months. I keep praying. I used Ultradent hypercal but no longer. What brand and [ ] of CaOH did you use? Gary
From: "Mark Dreyer, DMD, PA" Sent: Saturday, April 28, 2001 6:51 AM Rick, I think you somehow traumatized the IA nerve. I'm quite sure things will return to normal with time. This is a case which the same thing happened to me. The sensation returned fully in a couple weeks. I theorized that my sealer puff impinged on the IA nerve-if you look close on the film, you can see the canal in pretty close proximity to the apex of the tooth I treated. The sealer I used was AH-26. I guess that would have been a good time to be a pulp lover :-) Mark Dreyer, DMD, PA Von: Fred Barnett Gesendet: Samstag, 28. April 2001 13:41 Paul, While Ledermix may have its uses, please don' think that Ca(OH)2 is a dangerous substance. There have been more reports in the literature of paresthesia following sealer extrusion than anything else. As far as I am aware, paresthsia following Ca(OH)2 has not been reported(?) (HWH): Fred, CaOH2 IS dangerous if being extruded periapically into the canalis alveolaris inferior. Its neurotoxic. The high pH is responsible for the toxidity. In german literature I mentioned this case, published in 1997 (Endodontie 1997; 3: 207 - 215) R. Weiger, Carl P. Cornelius : "Inferior Alveolar Nerve Paresthesia Due to Extruded Calcium Hydroxide" Abstract: This clinical report describes the immedeate occurence of a mentale nerve paresthesia following accidental extrusion of calcium hydroxide. The intracanal dressing was placed in the prepared root canal of a pulpless second lower premolar associated with a symptomatic periapical lesion. The surgical therapy was initiated immediatly after radiographic diagnosis and included the removal of the extruded foreign material, the obturation of the root canal and the apicoectomy on tooth 35. The gradual sensory recovery of the paresthesia and the complete resolution of the periapical lesion are documented. I donīt think that especially the Ultradent CaOH2 is responsible for such a paresthesia. It could have happened with any other brand too. Best regards - Hans .W. Herrmann Fred Barnett wrote: Hi Dr. Hermann, You made Ben very happy. One case report out of millions of Ca(OH)2 treated cases. Of course, if you bathe the nerve with any caustic material, adverse reactions can occur. It is therefore important to look at the anatomy of the periapex and then decide if patency files, puffs, whatever, should be taken through the apical foramen. I'm sure you have seen cases where a patient has a transient paresthesia because of the swelling at the root apex that is in close proximity to the nerve. = Fred From: gary Sent: Saturday, April 28, 2001 7:20 PM Fred, I'm not sure you are seeing my point. There is no question in my case that it was the CaOH. The apical size was small. There was a deliberate effort made to minimize any extrusion because of the proximity of the nerve. . The purple tip end was never engaged with the canal wall. I barely touched the plungger and the response was immediate! She descibed it as an intense burning sensation through the whole side of her face. . It's not like I have never done this before. Remember, I do no one visit endo in my practice. Every tooth gets CaOH. I feel fairly skilled at the technique. She's still numb. I don't care if it happens once in ten million cases. I don't want it happening EVER in my office. The idea that it could have been the anesth. injection or the instrumentation COULD explain some nerve damages, but not this one. I don't know about you, but the fact that such an amount could flow where it did so quickly and with so little pressure gives me great concern about this particular product especially in second and third molar areas and lower bi's. . Gary From: "Uziel Blumenkranz" Sent: Saturday, April 28, 2001 6:42 PM Dear Friends: The message from Dr. Schwartz surely pinpoints to an extra sensistive area. I am very happy about this posting, not because the patient is experiencing a traumatic episode, not only physical but to a much higher degree a mental one. This case shows once again that all of us at any time of our procedures, wether delivering local anesthesia, cleaning and shaping or packing may run int a very dramatic episode. However once again it demonstrates that some of us are willing to stick their necks out trying to get an answer for a "non existing problem" or "it never happens to me". situation. From the responses it seems that more than one has experienced this situation. I will post a case I did yesterday of a lower bicuspid with necrotic pulp and internal resorption, calcified pulp chamber, where I almost perforated the side of the mesial wall looking for the canal. I am surely not happy about it, but it happens. Once again Rick congratulations on your case and your concern. I am also happy the same as the patient must be that it seems to be solving. Thanks Gary for your posting, I was not aware of the possible hazards when using Calcium hydroxide, so from now on you can be damned sure I will be EXTRA CAREFUL with it's use. (The citanest is already in the garbage can since some time ago when I learned, also in this forum about it's possible toxic. effects) - Uzi From: John Coetsee Sent: Tuesday, May 01, 2001 12:27 AM Dear Gary, Fred and all There is an abstract in In JOE vol. 27 No3 . Abstract of research to be presented at the AAE, 58th Session, March 29, New Orleans. Ti - Calcium Hydroxide as an intracanal medication: effect on post treatment pain {walton, holton, machaelich - U of Iowa} Here they reportedly observed 140 patients with vital or necrotic pulps - placed CaOH in some while others wre just given a cotton pellet. CONCLUSION - The use of Calcium hydroxide as an intracanal medicament was unrelated to incidence and or severity of post Rx pain. - John From: Jerry Avillion Sent: Tuesday, May 01, 2001 1:11 AM Interesting that CaOH doesn't cause more post op pain than a plain cotton pellet, but DOES cause more post op pain than 1 visit endo. (As per Trope) I wonder what the explanation is. - Jerry Avillion From: Murat AYDIN Sent: Thursday, May 03, 2001 12:12 PM Subject:CaOH I wonder Why this lesion (see pic) doesnt heal since ~2 months. How long time do you leave CaOH in the canal.? 1 or 2 months? more ? From: "Igri" Sent: Saturday, May 05, 2001 2:08 AM I would finish the RCT and wait half a year to see if it heals (make sure there is no second canal and the adjacent tooth is vital). Regards, - Igor From: "Branislav Andrijevic" Sent: Friday, May 04, 2001 2:42 AM Hello Murat, Hello All, Problem is a radiograph cannot specify the histological state of the periapical tissue I belive a radicular cyst has developed. The peripacal conective tissue has no chance to penetrate thrue the cystic epithelium.That is why You can't see a difference after 2 months, the radiolucency still exists. But that is not the ultimate proof, because a such a defect musn't heal osseus, it can heal fibrous. Allthought there is Ca(OH)2 placed in the canal, and probalby less of bacteria, there are enough disintegrated material in the cystic lumen that can be vasoactiv and keep the inflamation on a certain level. Help could be a combionation of steroid&antibiotic (Septomixine- Septodont, France) for a short period not more than 7 days (imunosupression), the symptoms (if some available) get soothe. But this doesn't solve the problem: the cystic epithelium. Neither does Ca(OH)2. Still this thing exists after even 2 months. I think apical surgery would do the job better. By the way I place Ca(OH)2 not less than 1 month, or even longer. After 14 days I allways refresh the filling. I have got the impression that after that time there is a lot of Ca(OH)2 lost because of dissolving in the tissue fluid. Regards.Sending to all the spirit of a beautiful spring day. Branislav Andrijevic From: "David H. Wilhite" Sent: Thursday, May 03, 2001 7:55 PM Could it be a cyst? - David Wilhite How can I distinguish? biopsy - Murat That's the only way that I know of. Give it another couple of months. - David From: "Pagani Mauro" Sent: Thursday, May 03, 2001 2:59 PM Maybe because the tooth which is the real cause of the lesion is not that one you've treated is but the right one in the radiograph (its apical portion seems involved by the endodontical lesion). Maybe in the root of the tooth you've treated there's a root canal you've not found or there's a root fracture which is impossible to see in that radiograph. Mauro Pagani From: "Joseph A. Belsito" Sent: Thursday, May 03, 2001 5:44 PM I leave CaOH in for 5-6 weeks and either -replace if no resolution of luscency (even the slightest) -finish if slightest resolution check the adjacent tooth for vitality Joseph A. Belsito From: "H. Anthony Chung" Sent: Friday, May 04, 2001 5:16 AM 1. what if there is no change in the lesion after a year, but the tooth is asymptomatic? Would you still not obturate? 2. Radiographic changes can be because of angulation differences. The "slightest" change in a radiographic lesion does not necessarily mean that healing has taken place. Just wondering... H. Anthony Chung From: "Branislav Andrijevic" Sent: Saturday, May 05, 2001 3:16 PM Good questions! Bone in the throat! Still I think something should be done. Waiting with 50-50 chances doesn't promise much. I don't like to be a observer; iniciative and solution of a problem is something I like more. By the way, Murat, a biopsy is allready apical surgery. IMHO... Regards. Branislav Andrijevic Joseph replies >1. what if there is no change in the lesion after a year, but the tooth is >asymptomatic? Would you still not obturate? Yes - Joseph Check out this article: Orstavik in IEJ 1996 _Time-course and risk analyses of the development and healing of chronic apical periodontitis in man._ "Complete healing of preoperative CAP [chronic apical periodontitis] in some instances required 4 years for completion, while signs of initiated, but incomplete, healing were visible in at least 89% of all healing roots after 1 year." This implies that the remaining percentage of cases required more than 1 year to demonstrate signs of healing radiographically. - H Anthony > > 2. Radiographic changes can be because of angulation differences. The > "slightest" change in a radiographic lesion does not necessarily mean that > healing has taken place. As long an clinical symptoms supercede radiographic findings IMHO - Joseph So this goes to my point. If the tooth is asymptomatic, lack of lesion size reduction may not be relevant to definitive completion of endodontic therapy. Your differential diagnosis of apical lesions should include (from an endodontic stand point): apical periodontitis, radicular cyst, and apical scar. If the lesion is a cyst, it may never resolve non-surgically. Apical scars will remain asymptomatic and never fill in with bone. If the endo was done to the best of your ability, residual apical periodontitis may need to be treated surgically. Therefore, I suggest you obturate the case after 1 week of calcium hydroxide placement intracanal (Sjogren showed that 1 week was enough to disinfect canals) then surgery if symptoms develop or continue. - H Anthony From: "Dr. Neil Pande" Sent: Thursday, May 03, 2001 2:13 PM Subject: CaOH I leave Ca(OH)2 for 3 weeks to 1 month and change subsequently until the radiolucency disappears considerably. I have one question though, why is there a flare up, especially in a Chronic case once you give a closed dressing with Ca(OH)2 as an intracanal medicament. Is it that due to the property of inducing inflammation or some enzymatic action. Whatever it is, Cheers to Calcium Hydroxide!!!! - Neil From: Jack Rigby Sent: Friday, May 04, 2001 10:08 PM Hello I am looking for a creamier CaOh mixture. One that I can place with a lentuo spiral thanks - Jack Rigby Judy replies... Calcicur by Voco By the way - I rarely use lentulos except in wide straight canals because of risk (! and experience!!) of fracture. I now use a hand reamer and find the results pretty good - just takes a fraction longer. Regards, - Judi Thanks judy I'll use the reamer. I don't think I have ever seem voco here. = Jack Rigby Its easier to prepare the mix by mixing saline or anaesthetic solution with a powder that you can buy at any chemist store or pharmacy. In this way you can control the consistency and the amount and it is much much les less pensive. If you want to have a ready mix there are a lot of vehicles that the CaOH is mixed with like methyl cellulose, saline, quaternary ammonium, iodine, silicon oil etc. Brand names are Vitapex, TD, Calxyl, and there are lot more. From: "tomhagen" Sent: Friday, May 04, 2001 11:04 PM Check out Ultracal XS from Ultradent (1 800-552 5512) or Temp-Canal by Pulpdent (available at Henry Schein). Both come with syringes for use in canals, but I find them easier to use if expressed onto a slab and spiraled into the canal with a lentulo. Don,t waste your money on the refill needles, just buy the syringe refill of the CaOH material. Hope one of those helps. Regards, Tom Hagen DDS Sunny Port Ludlow From: "Joseph A. Belsito" Sent: Tuesday, May 08, 2001 6:01 PM Agreed..... Orstavik 's article is what I had in mind. The reason I wait 5-6 weeks after CaOH placement is simply for scheduling, even though Sjogren showed CaOH effect after only 1 week. - jab From: "Murat AYDIN" Sent: Tuesday, May 15, 2001 1:26 PM Here another case. 24 yof. Asymtomatic lover incisor with open apex. She remembers trauma when she was 10. Canin and other incisor vital. How long time do you leave CaOH for apexification ? I guess at least 1 month? Many thanks for your helps - Murat From: Jack Rigby Sent: Tuesday, May 15, 2001 7:11 PM I have taken several months on various college students over the years. They only come in while they are home at breaks. 1 month may be fine but 4 months doesn't hurt either. Jack Rigby DDS, Hudson Ohio

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