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Testing temperatures of heat carriers for accuracy
The opinions within this web page are not ours. Authors have been credited for the individual posts where they are

Testing temperatures of heat carriers for accuracy You can go on and on
about obturation being unimportant and if youíre only worried about
following your cases for a couple of years; youíre right obturation
probably isnít that important for short term success.  If you donít
want your cases to become as septic and a Shell gas station toilet in a few
years you have to worry about the obturation and the coronal restoration.

For years Iíve suspected that the System B is a terrible heat delivery device. The temp always seems inconsistent and I only used it because it was the only device with a temp gauge supposedly telling me what the tip temp was. This is important to for heat transference through the gutta percha as the material appropriately deforms apically within the desired temperature range to affect deformation but not overheat cause molecular phase transformation, excessive shrinkage, and leakage. A few weeks ago I finally decided to get a heat calibrator/measuring device with a K-Type thermocouple (info gained from Khademi) and actually test whether the temps were the same as on the digital display. THEY ARE NOT! Iím putting my System BS devices on Ebay for sale and buying the Kerr Touch n Heat . The tip temps were no where close to where they were supposed to be even testing with several different tips. The Touch n Heat was the only device that got the tip to the desired 330 degree level. - Terry Terry, Was there any correlation between the gauge an the real temp? As the Sys B goes up to the 600s on the gauge,and starts at 100,then surely it must be 330 somewhere in between? Did tip size make a difference in your test?- Bill Tip size didnít seem to make a difference and the results were the same. I just go off the phone with Khademi and we brainstormed some ideas to verify that my results were an accurate reflection. Iím going out to get some copper wire to really wrap these things and see if the results change. The feeling is that the System Bís were only made to be accurate up to 200-250 degrees centigrade which really sucks if you understand rheology and know what you should be doing - Terry Terry, Does the heat carrier need to be at 330 degree to transfert heat through gutta percha and softened it enough to get proper deformation apically? Any danger to the PDL? Any research to support it? I have touch & heat units which I use at level 6 usually... what is the temperature then?? Is it enough? Thank you - Vince This has been extensively studied at Boston U. The science has been there for years. No one pays attention to it and yes it needs to be up to 330 and it wonít be deformed adequately otherwise. Iíve posted my arguments against the scientific validity of the continuous wave technique in the past. There have been countless bastardizations of the vertical compaction of warmed gutta percha technique described by Schilder. Schilderís technique was studied thoroughly. The polymer chemistry of gutta percha was meticulously analyzed through heating cycles by Alvin Goodman. The external root temperatures were not at a level that would harm the PDL. Jim Stephens wrote an excellent thesis describing adaptations and settings required of the Touch n Heat to reproduce the Goodman thermal profiles and yet 20 years later we have dumbed-down ineffective copy-cat techniques promoted to sell profits and speed at the expense of a quality result. Even Iíve been duped by the faulty digital temperature display. If the science isnít paid attention to you are only getting a single cone stuck in a pool of sealer at the apex. Now that Iím extracting quite a few teeth for implants, I get a chance to look at the forensics. Below is one I believe represents something like the continuous wave technique. Radiographically, you have what would be viewed by many as a so-called perfect apical prep. Well if you look at the Hess apices, rarely do the root ends have a Tulsa Shape and there is no technique of cleaning and shaping that would make them look like the end of an Autofit gutta percha cone taken straight out of the box unless it was actually radiographic representation of cone placed into the canal without deformation, straight out of the box. Below is the telling forensic section I looked at a few weeks ago.
So, Terry, at level 6-7 on the T&H, what is the temperature at the tip of the smallest heat carrier available? If it is not the desired temperature (330 deg), what should be the setting then? -Vince Vince, I canít tell you because I donít know the consistency of manufacturing and the variability from one specific unit to the next, cut judging from the one unit I tested today Iíd crank it up to the max as the best guess. Until we have some quality assurance from the manufacturers, Iíd buy your own tester and make sure. Iíve always suspected that the System B was one of the worst products and Iíve routinely had inconsistent heating experiences with it in my practice. - Terry No thanks after you found that out. Have you had an opportunity to test the elements unit from sybron Iím currently using? How about parkellís unit. Iíd love to know how accurate they are - gary Btw, if you are referring to my statements on obturation, my point was not that it is unimportant. But if Iím going to screw something up, Iím not going to screw up disinfection and shaping. I have zero chance then. My point was good people are getting good results with both gp and with the nasty stuff from the dark side of Connecticut - Gary Gary,Well, Iím not going to buy them to find out. Itís pretty cheap to buy the temp calibrator/tester. It was about $80 online for the unit and $20 for the two K-type thermocouples. Iíd do it yourself. Itís well worth it. Iím heading off to hardware store to buy some very fine copper wire so I can wrap the tip to the thermocouple and get the most accurate reading. Iím certain that the readings I got today are in the ballpark, but I want them exact. -Terry Yep, I was thinking of them. The problem is the perceptual and human motivational aspect of thinking that obturation is not important. It fails to instill a motivation to achieve the highest level of success. I want to scream every time I hear someone rationalizing their mucked up endo case with the excuses offered by the literature, that obturation doesnít matter anyway. For one thing these same people that fill short, fail to coronally flare, fail to extend accesses, and fail to trough grooves; are the same people whose cases I constantly retreat that . In a theoretically controlled environment a librarian that only reads literature and doesnít treat endo will think that obturation is unimportant because the statistics and studies tell them so, they take pride in knowing the literature and take no pride in completely finishing an endo case. Debridement is accomplished through shaping and flushing irrigants and obturation cannot be accomplished properly without the cleaning and shaping. Itís all related and to comment that one is less important than the other is not productive, doesnít instill clinical excellence and serves to motivate one to perform inferior treatment. In the lab obturation is not important in practice it is.- Terry We are in total agreement my friend. We simply choose to use different media to achieve the same goal. Where do I get ahold of a thermalcouple? - Gary Iím at home now, but I think the company name that I googled was Technika and the model number of the K-type thermocouple accessory was 800060.- Terry There are some issues. Terry and I talked and he's solving them. In a nutshell, I expect the SystemB to be accurate in the range it is "designed" to be used in, namely 200 or so to about 250. Above that, or with larger tips, it does not have enough grunt to get to and hold the higher temps.It's kinda like the speedometer in your Toyota. It goes to 140mph, but will the car really go that fast? - John A Khademy> John & Terry, I have literally spent years looking at this problem...without using a thermocouple in the tip and calabrating it....the temperatures seen on the unit will never be reflective of what's dialed in. - Joey D Terry, I agree on long term follow ups, however, you keep saying about 2 years success being unimportant, do you have any reference or anything to back up statements like that or could you explain how healing of the periradicular tissues could take place and then suddenly bacteria could regain nutrients to cause the disease again?. What is the exact time frame in which we could really say you have success and according to What?. Kuttler followed many of his cases for more than 20 years, some up to more than 30, he would call it a failure when he found a LEO after that long of a time. Disinfection is the key to get healing my friend, show me a study that shows an hermetic seal anywhere no mater what the technique used to fill.- Jorge For years, Iíve retreated cases, pulp chambers corroded with silver points in a slurry of a pus filled soup, single uncondensed gutta percha cones sticking half way down canals with neighboring untreated MB2ís, and every other type of septic stew that obviously was brewing in a root canal system for decades while only eliciting a mild periapical reaction, usually with an inflammatory effect like resorption on the root apex. Some people donít mind sleeping an unmade hotel bed where the previous guest crapped in it, but some people do. The literature calls these successes, I donít and it depends on your tolerance for filth. - Terry Terry,Here are two papers ( I know you don't love too much that kind of research ;-) ) that show also the difference between what SysB displays and the real temperature. I attach the full text papers but for those of you who are busy and don't have time to read all I just cut the interesting parts. On the second image you can read that actually SysB is estimated to have an accuracy of +/- 10 degrees, but they found differences of about 50 degrees (which is still optimistic regarding the results of the first study, which shows differences of more than 100-150 degrees) Hmmm...I hope we won't get anyone too mad on us with what we are showing here .- Roberto
    

System B temperature Paper 1 System B temperature Paper 2 Great read - Terry
I find these numbers worse than shocking. That kind of quality control is like having no control at all. +/_ 10 % is 20 degrees at 200, not 50 or 100. Iím going to beat up on some of my local engineers, get a hold of a thermalcouple and test all 4 of my units. - Gary Terry, The testers are relatively inexpensive (the one in your picture goes for US$88) and worth having for checking System B and Touch and Heat units on a regular basis ... akin to having a curing light testing unit, only much cheaper. Would it be possible to expand on the testing protocol? eg, how do you rig the tester's probe to the heating tip? Perhaps a photo would explain everything nicely. - Michael Moran PS: For those wanting a Technika link, go to http://www.technika.com/Sper/s800010.htm Iím definitely going to look into this more and recommend others do the same.- Terry I have tried the sys b with narrow posterior heat carrier and temp setting 600. It was cherry red . I think that this is not only 200 at the tip.... Camil The System B is calibrated for centigrade, so the tip was a lot hotter than 200. DougR .and there seems to be an initial spike in temp then it cools down. I find the temp readings all over the map with the System B. Iíll do some more tests once I wrap it with copper wire, but Iím convinced the System B is not as consistent as other units and the temp gauge is way off - Terry Terry, Do you think the initial spike could be to do with the " Separation burst" that is promoted for the continuous wave technique? I presume you will be repeating the test with the TNH and letting us know what sort of settings that gives us? What heat source did Goodman use in his Thesis? Was touch n heat out in 1973? - Bill Goodman used Bunsen burner which heated the heat carrier cherry red but as it was transferred to the canal and plunged into the gp pad would dissipate heat. Stephens wrote a very detailed thesis that correlated the Touch n Heat setting of a specific model available in 1984 to the research done by Goodman with the Bunsen burner. You shouldnít think that the 330C is the exact temp that it has to be because there is a buffer range that is acceptable and will not overheat the gp apically. One thing is very clear: IF YOU DONíT GET THE HEAT TO AT LEAST 330C THERE WILL BE NO APICAL DEFORMATION AND YOU ARE JUST PLACING AND SINGLE UNMOLDED CONE INTO THE APEX. I want to laugh every time I hear people brag about their nice tiny smooth apical preps. They donít understand Schilderís concepts at all. Small as practical is not Small as possible and if you donít have a properly shaped root canal system you wonít be able to achieve the objectives of obturation; it will not be 3-dimensionally molded and the nice tiny smooth tapering shape these people are bragging about are nothing better than a silver point floating in a pool of sealer. Itís about time some dispels the myths propagated by the Schilder Imitators. A VW is not a Porsche. Quick and dirty, all-rotary endodontics does not clean out a root canal system or adequately explore lateral anatomy. The concept of a continuous wave does not create the thermal profile required to deform apical gp because the temp is too low and the compaction is not created in the sequential waves of heating-cooling cycles that elevates the apical gp temp to the thermal plateau of 43.5 C required to deform the gutta percha and create appropriate apical obturation. If you donít get the temp up to at least 330C you have a problem, if itís a little higher it probably isnít a problem and still creates the same thermal profile: - Terry P.S. The big problem is that the Schilder Imitators promote junk science and the product industry follows suit and creates junk products. If I get a reading of 330C I expect it to be 330C, not 220C. At least the Touch n Heat gives you no information rather than false information. Iíll take the Touch n Heat any day. I hate being lied to. In my opinion, this is part of the problem with the classic Schilder technique. It is very technique sensitive, too sensitive for the wide range of operator variability to be reliable and predictable. It does work for some operators but the classic technique is too complicated. According to the graph there are 5-8 heat applications necessary for each canal and there is no way of knowing just what temperature was achieved in the GP at the apex. It's guesswork. The apical GP temperature should also be affected by the diameter of the root, the diameter of the apical preparation, the length of the root, the temperature of the condenser, the speed with which the condenser was advanced apically, the diameter or volume of the GP in the coronal 1/3, the diameter or volume of the GP in the middle 1/3 . Too many variables to get consistent results for most operators. IMO there are better and easier ways to accomplish a consistently high quality obturation than the classic Schilder technique. To those who can do it consistently congratulations. - Randy Hedrick Thanks. Thatís the one I ordered they had a little better meter available for 146 that has a software interface, that will let me record in real time the entire heating and dropoff event. For instance, Sybron claims the elements unit will cook for 4 seconds then auto shut down. Iím going to check to see how accurate the display is, but also evaluate the timing of max temp and minimum temp. Iíll try to do this on 4 units: Sybron elements, touch and heat, system b, and parkellís thermique. Iíll post the data when I get it. Should have it on Tuesday This could be interesting. - Gary There should be an initial spike to around 300 for about a second or so, then the temp should settle in at the dialed in temperature subject to some of the constraints we discussed. You may not see the initial spike to 300 due to heat capacity, conduction and latency in the system.- John A Khademy Bill: Supposed the dial temp is above 300, does the spike still stop at 300 or does it go up to the dialled temp? As Terry's described technique only applies the heat for a couple of seconds, it's pretty important. I suppose you could activate without touching the gp, and after a couple of seconds apply to the gp to get round the spike. Terry: You need the tip to be heated to at least 330C apply it for 3 seconds and remove it. If the damn instrument is spiking up and down from 330C to 220C it ainít happening. The System BS is useless for the Schilder technique. Philippe: Sorry to jump in,,we have been teaching the Schilder technique for over 10 years at the University as THE obturation technique for undergraduate students, it is a sensitive techinque true, bit with proper initiation they were able to handle it beatifuly. Terry I know that you are a warm gutta percha Fan, try the RCPSL ( root canal plugger sleiman) from Hu_friedy and give me your opinion. Thanks Philippe, I will try it and let you know. - Terry In my opinion, this is part of the problem with the classic Schilder technique. It is very technique sensitive, too sensitive for the wide range of operator variability to be reliable and predictable. It does work for some operators but the classic technique is too complicated. According to the graph there are 5-8 heat applications necessary for each canal and there is no way of knowing just what temperature was achieved in the GP at the apex.It's guesswork. The apical GP temperature should also be affected by the diameter of the root, the diameter of the apical preparation, the length of the root, the temperature of the condenser, the speed with which the condenser was advanced apically, the diameter or volume of the GP in the coronal 1/3, the diameter or volume of the GP in the middle 1/3 . Too many variables to get consistent results for most operators. IMO there are better and easier ways to accomplish a consistently high quality obturation than the classic Schilder technique. To those who can do it consistently congratulations. - Randy Hedrick Wrong, itís simple and the temp buffers out at 43.5C - Terry If System B units are having problems with indicated and true temperature discrepancies, how do Obtura II units perform in this respect? Wouldn't temperature accuracy be critical for the Squirt Technique? - Michael Moran Allow me to chime in for a moment:The Obtura temperature is calibrated by the internal temperature of the heater chamber, at a specific location along its length. The temperature of the GP as it's extruded will be as much as 100 C lower and that depends on the rate it is extruded and the size needle as well. The GP carries most the heat to the end of the needle If you want more data, let me know & I'll see what I can come up with. - Steve Conger Steve, My testing with thermocouples showed it was within 10% and typically within 1-3% of the set temp - Joey D, "This was measured at the nut....not the tip of the needle" Was not bad at all - I just wanted to clarify where we take our measurement from so the comparisons are valid. The other problem is when measuring external surfaces you need to turn your year round air conditioning off or at least make sure you're not setup under a vent! ;-) - Steve Conger Thanks for your input - You need to measure it inside the chamber to replicate what we do here. We set it at the hottest point of the heater chamber and claim we heat the GP up to 200 C, not that it exits the needle at that temperature. We do have a tolerance of + - 5 deg C but set it on the mark, or on the high side rather than the low. We recognize that a lower temperature may cause some issues with handling. Some of the older units vary a little more but we recalibrate those of course when in for any repairs and they've shown to stay within specs for a remarkable number of years.- Steve Conger That seems more reasonable in the sense that chamber temp what you expect to be measured and itís known that gp is a very poor conductor of heat and that it would cool off rapidly. Itís a little different than a metal tip that is supposed to be a certain generated temp. No temp display is better than a wrong temp display. If I am told something, I expect it to be correct or Iím going to scream if itís bogus. - Terry As I understand it, the T & H and B tips heat from the point back, so the measurements would need to be taken from there. The further away from the end you place your thermocouple the cooler it will be. - Steve Conger Steve:Can you find what temperature in the chamber and then the projected temps at the tip, and how much the rate of extrusion and needle size effect it. Iíd like to know the numbers for resilon as well. - Gary I'll look in to it - this won't be real easy or accurate since the tip & GP will begin to immediately cool after you stop extruding it. There is a delay (I'm not sure how long) between the temp and the reading on the digital thermometer that it gets from the probe. What I'm saying is, I'm not sure we have the equipment to give you those kinds of accurate results. They way the units are tested now is by placing the probe in the heating chamber for 10 minutes in order to verify the temperature stability. If it's off, the units are adjusted and it's given another 10 minutes to stabilize. That doesn't mean you need to leave the unit on for 10 minutes prior to use, it's just the timeframe we've identified over the years. They take longer at times to cool down than they do to heat up. I'll toss this at engineering as see what they say. - Steve Dr. Henkel, Out of curiosity, what temperature do you use Resilon at with what gauge needle? This seems to vary widely by user from 120 C up to 200 C. Thanks for your time, - Steve In looking through the literature on the temperature concept I found this related article. Related literature Terry, you have mentioned needing to get to 331 c several times in this thread. On what is that based. Iíve looked at several studies, this is the first of 4 where they took the temp up to 300, most being at 200-250. - Gary 330C based on Jim Stephens thesis. 200-250C is based on junk science and has nothing to do with the true thermal profiles that occur. - Terry > Another footnote regarding the Sweatman study is the probable difference between in vitro and in vivo study models. Like the Goodman and Stephens work youíre looking at a lab set up that doesnít necessarily account for the heat dissipation that occurs in an actual clinical case. The surrounding PDL and bone draws heat away from the tooth surface unlike the lab apparatus that wonít as efficiently conduct the heat away.Multiple interrupted waves are safer in that they allow the temp to peak and drop in multiple applications allowing a steady plateau of peaks leveling off at the 43.5C level apically and dissipation of thermal energy laterally. Basically it is hard to overheat and easy to underheat leading to incomplete apical deformation. The likely error is underheat the apical gutta percha by failing to deliver an adequate number of cycles at an inappropriately low temp. Thereís nothing technique sensitive about this but you have to know the rheology and understand the appropriate temp settings and delivery sequence. Iím pretty POíd that Iíve had units with bogus temp gauges. Iíve always felt a need to hold the compaction pressure longer than required and now that I know it wasnít the right temp, I understand why. - Terry OK folks. There is some HARD evidence from Terry . Not just opinion. Thanks Terry. The facts are that the displays (either on EPTs, EFLs or Systems B heating units) are simply WRONG and INNACURATE.Total Bullshit. But they look nice. I've been using my Touch N' Heat (M2005) units for 20 years and I'm always tweaking them for proper heat? Why? Cuz the tips wear out,lose conductivity with time, some tips heat more easily than others etc. For proper classic warm vertical technique you must constantly be watching how the material reacts to your heat. Too much heat and the material "melts"- becomes soupy and is actually more difficult to pack properly. That's not "the technique". Not enough heat and you don't get adequate plugger compression into the material - hence proper deformation is impossible. (That's also why you need properly sized preps so the heat can be transferred to the mass o gutta percha.) You can usually tell you have the right amount of heat when the heat carrier is placed into the GP AND IT REMOVES THE RIGHT AMOUNT of GP UPON WITHDRAWL. Too much heat and you get nothing removed cuz its soup. Too little heat and you get minimal amount cuz its too cold. The right amount?...Walls are clean upon removal, you can clearly easily see the remaining GP and its EASY to pack. You can see the GP as it is deformed with the piston-like compressions of the plugger especially if you use a scope. That's one of my favorite reasons for using a scope now- packing cases with a scope is SO COOL!! Sometimes you have to vary the temp ( depending on whether you use "thick" anterior or posterior tips). The point is that you need to know how the material handles - in order to get a good result. That's one of things I've never liked about pure System B. As my friend Donald Yu has been known to say , it's the "Fake Orgasm" of Schilder Warm vertical endodontics. The criticism that "The Schilder warm GP technqiue sensitive is too technique sensitive" is so much BS. What is DOES require is attention to prepping the canal. That's the hard part. That's why some of us hate Thermafil so much. It the lazy persons filling technique - for people who wouldn't know a well shaped canal I've got nothing against Resilon but it simply doesn't heat like GP. I have 25 years of experience knowing EXACTLY how much I can move a GP cone. With a larger apex, I can (and often do) fit a cone shorter than normal and then "Sit on it" with a plugger and get it to exactly the location I want. My staff see me moving GP in this way every day especially with necrotic cases that have resorbed apices. In other cases with especially tough anatomy, I'll squirt. I'm simply not ready to give up that kind of material control with a material that has produced reliable results and has a proven track record. And as for the coronal leakge issue - I suggest that Orifice Bonding offers a reasonable alternative with materials that the average dentist ALREADY HAS in his op. He's much more likely to do that rather than trying a material and technqiue that he is totally unfamiliar with. - Rob Have not posted much,,,but Rob gets my juices flowing ;-) I love the literature and spent 40+ years reading it.... but nothing beats clinical experience. I enclose my references collection ( most with abstracts ) on the subject. But Rob's post right here is more relevant. - Ben Liviu, beautiful as usual. tell me, how did you control the soft tissues when placing the composite? the fractures appear to go subgingivally to quite a degree. Would an instrument such as a Zekrya margin protector have helped, or did you pack cord? - Bill Thanks Bill,I have indeed packed cord and used the Zekrya margin protector. 0:))))) - Liviu Hi Liviu, Beautiful recovery! Any rads? - Marga Well done Liviu.....it is always wonderful to see your cases.What is the likelihood of the pulp staying vital. Secondly, in a case like this when do you offer more permanent restorations. Thanks - Glenn Tahnk you Glenn! (G) What is the likelihood of the pulp staying vital. (L) Chances are far higher than 90%. (G) Secondly, in a case like this when do you offer more permanent restorations. (L) At a later age as the young lady was just below 14 years. - Liviu Liviu, the 90% pulpotomy success is trauma induced teeth with open apices or closed? and how long are these recalls for? Cvek's studies are on immature teeth, I believe.. i personally would have done endo on teeth with closed apices.. fantastic restorative result....you are an artist.- Sashi Nallapati Thank you Sashi for your words! I doubt if this was to be your daughter, the root canal treatment would have been your treatment of choice? The only addition you might have been done than would have been to apply Emdogain on the pulps!Here is some literature to the topic. - Liviu Effectiveness of 4 pulpotomy techniques--randomized controlled trial. Huth KC, Paschos E, Hajek-Al-Khatar N, Hollweck R, Crispin A, Hickel R, Folwaczny M. Department of Restorative Dentistry & Periodontology, Dental School, Ludwig-Maximilians-University, Goethestrasse 70, 80336 Munich, Germany. Pulpotomy is the accepted therapy for the management of cariously exposed pulps in symptom-free primary molars; however, evidence is lacking about the most appropriate technique. The aim of this study was to compare the relative effectiveness of the Er:YAG laser, calcium hydroxide, and ferric sulfate techniques with that of dilute formocresol in retaining such molars symptom-free. Two hundred primary molars in 107 healthy children were included and randomly allocated to one of the techniques. The treated teeth were blindly re-evaluated after 6, 12, 18, and 24 months. Descriptive data analysis and logistic regression analysis, accounting for each patient's effect by a generalized estimating equation (GEE), were used. After 24 months, the following total and clinical success rates were determined (%): formocresol 85 (96), laser 78 (93), calcium hydroxide 53 (87), and ferric sulfate 86 (100). Only calcium hydroxide performed significantly worse than formocresol (p = 0.001, odds ratio = 5.6, 95% confidence interval 2.0-15.5). In conclusion, calcium hydroxide is less appropriate for pulpotomies than is formocresol. J Clin Pediatr Dent. 2005 Summer;29(4):307-11. Success of mineral trioxide aggregate in pulpotomized primary molars. Farsi N, Alamoudi N, Balto K , Mushayt A . Pediatric Dentistry Division, Department of Preventive Dental Sciences, Faculty of Dentistry King Abdulaziz University, Jeddah, Saudi Arabia. N_Farsi@yahoo.com The aim of the present study was to compare, clinically and radiographically, the mineral trioxide aggregate (MTA) to formocresol (FC) when used as medicaments in pulpotomized vital human primary molars. METHODS: The sample consisted of 120 primary molars, all teeth were treated with the same conventional pulpotomy technique. Sixty molars received FC and 60 received MTA throughout a random selection technique. RESULTS: At the end of 24-month evaluation period, 74 molars (36 FC, 38 MTA) were available for clinical and radiographic evaluation. None of the MTA treated teeth showed any clinical or radiographic pathology, while the FC group showed a success rate of 86.8% radiographically and 98.6% clinically. The difference between the two groups in the radiographic outcomes was statistically significant. It was concluded that MTA treated molars demonstrated significantly greater success. MTA seems to be a suitable replacement for formocresol in pulpotomized primary teeth. Dent Traumatol. 2005 Aug;21(4):240-3. Related Articles, Links Vital pulp therapy with mineral trioxide aggregate. Karabucak B, Li D , Lim J, Iqbal M. cSchool of Dental Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA. bekirk@mac.com> The present case report describes the treatment of complicated crown fractures using mineral trioxide aggregate (MTA). MTA was used as pulp-capping material after partial pulpotomy to preserve the vitality of the pulpal tissues in two cases. Follow-up examinations revealed that the treatment was successful in preserving pulpal vitality and continued development of the tooth. Dent Traumatol. 2003 Dec;19(6):314-20. Comparison of bioactive glass, mineral trioxide aggregate, ferric sulfate, and formocresol as pulpotomy agents in rat molar. Salako N , Joseph B , Ritwik P , Salonen J, John P, Junaid TA. Faculty of Dentistry, Kuwait University, Kuwait. Bioactive glass (BAG) is often used as a filler material for repair of dental bone defects. Although there is evidence of osteogenic potential of this material, it is not clear yet whether the material exhibits potential for dentinogenesis. Hence, the aim of the present study was to evaluate BAG as a pulpotomy agent and to compare it with three commercially available pulpotomy agents such as formocresol (FC), ferric sulfate (FS), and mineral trioxide aggregate (MTA). Pulpotomies were performed in 80 maxillary first molars of Sprague Dawley rats, and pulp stumps were covered with BAG, FC, FS, and MTA. Histologic analysis was performed at 2 weeks and then at 4 weeks after treatment. Experimental samples were compared with contra-lateral normal maxillary first molars. At 2 weeks, BAG showed inflammatory changes in the pulp. After 4 weeks, some samples showed normal pulp histology, with evidence of vasodilation. At 2 weeks, MTA samples showed some acute inflammatory cells around the material with evidence of macrophages in the radicular pulp. Dentine bridge formation with normal pulp histology was a consistent finding at 2 and 4 weeks with MTA. Ferric sulfate showed moderate inflammation of pulp with widespread necrosis in coronal pulp at 2 and 4 weeks. Formocresol showed zones of atrophy, inflammation, and fibrosis. Fibrosis was more extensive at 4 weeks with evidence of calcification in certain samples. Among the materials tested, MTA performed ideally as a pulpotomy agent causing dentine bridge formation while simultaneously maintaining normal pulpal histology. It appeared that BAG induced an inflammatory response at 2 weeks with resolution of inflammation at 4 weeks. Liviu, the first two studies you referenced are in primary molars the third, is a case series of two cases in immature (open apices) teeth where pulpotomy is the treatment of choice to facilitate apexogenesis. the last study merely compared, if you decide to do a pulpotomy , what material is best... Cvek's classic studies of pulpotomy were very successful in traumatised teeth with open apices, which is a different ball game. AAE guidelines for teeth with closed apices that undergo trauma with fractures and pulpal involvement is pulp cap/pulpotomy OR RCT. my opinion ( and strictly an opinion) is, pulpotomy in a vital tooth with closed apices (trauma/caries) is ,at best, a temporary measure than a final, definitive and predictable (over a long period of time .over 25+ years) treatment option. for my daughter , i would do endodontics to maintain periapical health with out any hesitation.- Sashi Nallapati Sashi, thank you very much for your point. I understand where you are coming from. I understand that still my treatment plan was conform the AAE guidelines! :0)) Indeed as you remember from the words I addressed to Glenn, the treatment is to be considered a temporary one. :0))) But I do understand and appreciate your worries still I do not share your treatment opinion. Time will show! The patient is now in recall, ....and yes I am fully behind my treatment plan selection! - Liviu Partial pulpotomy healing: Cvek 1982: 178 cases--95% success Fuks 1987: 63 cases--94% success - Fred average recalls of what period ? was the Cvek study in 1982 done in humans? can you give me a full reference? thanks... Sashi Nallapati re: Emdogain is not better than Ca(OH)2 for pulp capping. Int Endod J. 2005 Mar;38(3):186-94. Dental pulp capping: effect of Emdogain Gel on experimentally exposed humanpulps.Olsson H, Davies JR, Holst KE, Schroder U, Petersson K.Department of Endodontics, Faculty of Odontology, Malmo University, Sweden. helena.olsson@od.mah.seAIM: To investigate the effect of Emdogain Gel (Biora AB, Malmo, Sweden),consisting of a enamel matrix derivative (EMD) in a propylene glycol alginate (PGA) vehicle, on experimentally exposed human pulps and to register postoperative symptoms. METHODOLOGY: Nine pairs of contralateral premolars scheduled for extraction on orthodontic indications were included. Following a superficial pulp amputation performed with a small (016) diamond bur, either EMDgel or a mix of calcium hydroxide and sterile saline was placed at random incontact with the pulp wound. The subjects made records of symptoms and were also interviewed about pain/discomfort by a blinded examiner. After 12 weeks the teeth were extracted, prepared and subjected to light microscopic examination inwhich the inflammation and newly formed hard tissue in the pulp were analysed. Immunohistochemistry was performed using affinity-purified rabbit anti-EMD polyclonal antibodies. RESULTS: Postoperative symptoms were less frequent in theEMDgel-treated than in the calcium hydroxide-treated teeth, especially during the first six weeks. In the EMDgel-treated teeth, new tissue partly filled thespace initially occupied by the gel and hard tissue was formed alongside theexposed dentine surfaces and in patches in the adjacent pulp tissue. EMD was detected in the areas where new hard tissue had been formed. The wound area ofthe EMDgel-treated teeth exhibited inflammation in the majority of the teethwhereas less inflammation was seen in the calcium hydroxide-treated teeth where the hard tissue was formed as a bridge. CONCLUSIONS: In the EMDgel-treatedteeth, postoperative symptoms were less frequent and the amount and pattern ofhard tissue formation were markedly different than in the teeth treated with calcium hydroxide. However, the operative procedure and the formulation with EMDin a PGA vehicle do not seem to be effective for the formation of a hard tissuebarrier.- Fred re: Emdogain is not better than Ca(OH)2 for pulp capping. Fred,this is true. Emdogain is also in Perio not considered to be better than classical techniques but it is liked as it enhances a nice wound healing. - Liviu Liviu, Amazing case! One doubt, Is it possible in these kind of cases to use calcium hydroxide Ca(OH)2 (Dycal) instead of MTA? Which is the different? I have read that the only different is in the physics properties, Is this true? - Marcela Absolutely beautiful, Liviu. I hope the caps work. Guy

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Ahmad Tehrani
Fred Barnett
Glenn Van As
Jorg
Marga Ree
Mark Dreyer
Noemi Pascual
Sashi Nallapati
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Winfried Zeppenfeld

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