Retreatment Success Without Apical Patency? CBL Vlog from Algarve Portugal
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- čas přidán 8. 07. 2024
- Dr. Nasseh shares a recent case with patency questions during his trip to Algarve Portugal.
0:00 Barcelona
0:37 Wedding
1:35 Porto
2:16 Ferdinand Magellan's House
2:40 Algarve
4:00 Clinical Case of Patency issue with follow up
10:00 Post Op and Case conclusions
Hope you enjoyed the video. Please let me know where you stand on the topic of patency and if it does matter for you on every case or not. Also, don't forget to like the video to help the CZcams Algorithm! :)
Yes, ive experienced in some of my cases, where i spent lot of time in trying to achieve the patency & remained unsuccessful. But, at the same time irrigation with ultrasonic activation, cycles of EDTA, heating NaOCl in composite warmer, with a hope the biofilm disruption & elimination, while informing the patient & with consent, on followup, the lesions tend to heal, and became asymptomatic.
You've absolutely made the point, its not just mechenical but mostly chemical cleaning...
Dr. Nasseh, highly appreciate your effort in contemporary endodontics.
Love your endodontic vlogs...
Glad to hear you’ve had a similar experience… it seems like there’s more to successful than meets the eye. ;)
I just have to say it, when I started watching your videos, the quality of production, editing was and still is just stunning! The intro in this video is such beautifly made, capturing the moment like that!. Incredible. It is like you also wanted to be a movie maker or something 😀 Of course the endo part is superb also, I have learned a lot!
Thanks! The moviemaking part of it is the main challenge and why I do these videos... I'm glad to hear it's helping out as well! Cheers! :)
What are the cameras and other equipments that are part of your filming gear?
Yes, He is a great movie maker. Sometimes I thought better for him to work in Hollywood.
If you can have it, that's great. If you can't have it, there's nothing you can do about it. That's life!
Hello Dr. Nasseh
It is important in this case to understand what is happening at the apical level of the root, at the level of the bone. What we see on the x-ray is the RESULT... (the response of the human body to the action of bacteria but also to the toxins produced by bacteria). We have to ask ourselves what exactly is apical periodontitis visible on radiographs. The human body tries to defend itself against bacteria and especially against their toxins. Bacteria use toxins to gain ground and penetrate the human body more easily. The human body tries to defend itself, and at the apical level it tries to isolate or seal.
It is also possible that the root canal was blocked (at the first treatment attempt) with debris that blocked the canal.
Exotoxins are secreted by the bacterium and sent to the outside constantly, not just after the death of that bacterium. Their structure is protein and their action is enzymatic, very active, they have a very high toxicity. The protein structure gives them an antigenic character, causing a strong immune reaction from the body. Returning to the situation presented by you. By washing with irrigating and surfactant substances and using ultrasonic activation, a large part of the bacteria, bacterial remains, and exotoxins were removed, giving the body the opportunity to return to normal. If we did a study on the presence of bacteria at the apical level in apical periodontitis, I think we would be surprised by their absence or a reduced number depending on the clinical situation.
Phenomenal and very useful, as always, Dr. Al!
I remember Dr. Buchanan arguing in a video posted on his website that patency is required because the dentinal debris acumulated at the terminus cannot be removed coronally, so it's better to push it apically and allow the immune system to take care of it periapically.
Obviously, mechanically, it might be possible to do so if you prep beyond the confines of the root canal (which I don't advocate, but to each their own), but I think that with negative pressure irrigation, it's a moot point anyways; I love NPI with irriflex/EDDY/Trunatomy canulas!
Eradicating the critical mass of biofilm in the main canal most of the time could be enough for healing to happen in a healthy patient as long as there are good coronal and apical sealing. That would be my opinion. Great video Dr. Nasseh.
Agree completely! 👍
Excellent
I have had several re-treatment cases like the one you just exposed Dr. Nasseh. What I try to do if I don't obtain patency, is try to finish the case anyway in that one appointment. Except of course if drainage is high or highly symptomatic. Sometimes I feel that with good irrigation techniques you can erradicate the biofilm that kept causing the lesion. We all have that gut feeling to try and obtain patency in these cases but if I see that my cones fit very close to what it would be "the perfect WL" and the canals are clean of old guttapercha I just finish the case.
Also, I feel that the patient will feel much more confortable if in one appointment, the treatment is finished instead of two appointments in which no one can guarantee that you can obtain patency.
Thank you for your super informative videos.
Greetings from the super lovely city of Barcelona, Spain!
You got it!!! The key to the whole thing is good irrigation … and it doesn’t have to be crazy expensive gadgets either!
I had a great time in Barcelona! Take care! Cheers!
Amazing Video as usual Dr allen, I think the idea always about disinfection the activation process let the solution reach areas in root canal system maybe it doesn't appear on radiography but if we got these tooth a section it we will find the effect of good activation protocol that lead to this healing
Exactly. Macroscopic patency might be a whole different concept than microscopic and molecular patency, the level at which most chemical interactions occur. Cheers!
I feel patency is crucial to obtain for every case but, anatomy is diverse, so best possible try is all what we can do to achieve it. Additionally, the gutta percha cutting instrument is amazing! I guess a ball burnisher can also serve some purpose till this comes out in the market!
Regarding patency, I've had a few cases that shaped my worldview: being inspired by Schilder-inspired endodontists (Mainly Buchanan and Ruddle) I used to perform apical patency for all cases. Years later, I've been inspired by the biologically driven endos, such as yourself and Riccuci to prep the canal to (not into) the constriction and I'd establish working length when my small hand files would reach "the intersection of the blue and green scale on the Morita Apex locator".
But I had more than one case in which I did so, took a file shot and was short. WAY short; Like 4 mm short! Because there was a large-enough lateral canal, 4 mm away from the apex, my Morita ZX Mini device got fooled.
Only when I took the file 4 mm apically, allowing the file to go into the "apex" indicators on my apex-locator, did I become confident in what the working length should be.
After such experiences, I'm now more inclined to allow patancy, to get my bearings, and prep coronal to that.
Also, I feel patency is useful in cases where there are abrupt impediments/curves in the last 1-2 mm, to make sure I don't lose working length. This, though, might be an "educational hang-on" from my schilder endo days, and I might need to revise this particular recommandation.
All excellent points, including the patency's role in maintaining the curve vs. transporting and zipping. It's definitely interesting and we still don't have a proper scientific study to put an end to this debate. Like one of the other commenters said, if I have it I use it and if I don't have it I don't. I don't lose sleep over it too much. Main point is follow up! That's something I constantly advocate for. Cheers Michael!
This is beautiful! I’d love a video on your camera set up with in depth settings.
Thank you. It's a good idea; but there's really more than just camera settings in filmmaking.. It's like managing a 3 canal, curved, mandibular premolar and then sharing the file/handpiece setting! LOL!!!
Enjoyable presentation. I see that the time line is important. With patamcy I find bone fill tales longer, but hopefully lasts longer. Achieving patamcy is not always seen when the tooth is disected afterwords, regardless of what one sees on the X-ray. Your comment ?
Altimately it’s about biofilm disruption and removal of the pathogenic microbes: disinfection. I think patency or no patency whichever way that goal is achieved the proof is in the pudding and if it heals and is asymptomatic we should focus on the main cause of success rather than controversial means to it. Cheers!
On one of your previous videos you and your guest mentioned that minimum apical size should be 30. Does it still hold true esp for a case like this?
That’s a great question! I think the Apical size, in these situations, is important where it allows you to place your negative pressure suction tip or ultrasonic/sonic tip fairly close to the apex. This will help the agitation of the chemicals. So, I would say it does matter even more than a vital case without a lesion.
Hello Doc, a few months ago I retracted a molar: there was an apical reaction on the mesial root in which a false path had been created more than a millimeter from the apex. I have not been able to recover the false path, however after a long cleansing I have managed to obtain an excellent recovery. Lately I've been working trying to close the apical constriction without forcing patency and pushing hard on cleansing: the results are exciting especially in cases with lesions. 👋🍀
What camera do you use to film? Amazing quality
I use a variety of cameras but my Sony A1 is my favorite. Of course, there’s more to it that the camera. Professional cameras are like blank canvases. You have to know how to set the right setting for the environment you are in. I also shoot in either Log or RAW; so the footage has to be worked to be color balanced and graded. It’s a long process. That’s why I don’t post every other day. I should just relax and post more often with cheaper cameras and easier workflows but I enjoy the filmmaking part more than the content, which is why I’m always behind schedule… but I do make less formal stuff in my social, like Instagram etc. cheers!
Can the software use AI to work out how long each canal is from the CBCT?
Yes. It’s possible to get a fairly accurate estimate. But keep in mind it’s an estimate as the actual reference point you choose clinically may vary from AI or the angle of view may be different. Furthermore, unless you have a digital impression on top of your CBCT info there’s often cuspal and crown shape inaccuracies as a result of the Compton effect, beam hardening, and scatter caused by coronal restorations. So the crown part is not so accurately visualized in many CBCT images and that could slightly change the working length. But I would trust it’s length as a fairly accurate (probably within 1-2mm) of an estimated length that you should validate with an EAL. Cheers!
One of my professors in residency (who did not think patency was necessary) would always point out that there is, more often than we like to think, more than one apical foramen (ex lateral canals, furcal canals, apical deltas, etc) and he would always question why, if apical patency was so important, would we only get patent at one of these foraminas and not the others? And why, if we had not achieved patency in all of these foraminas, would we get healing of furcal/lateral lesions and healing of lesions around apical deltas. That always stuck with me, because he was right. So I (like one of the other viewers who posted a comment) try to achieve patency so that my morita Alex locator will not be “fooled”. But if I can’t get it despite valid attempts than what other option do we have than to complete the case without it.
Also this brings me to a question for you Dr. Ali. Do you routinely complete retreatments in a single visit? (If you have criteria for this please let me know) and in cases if retreatments where we cannot achieve patency, should we perhaps consider placing an intracanal medicament and bring the patient back for a second visit?
Sorry for the long comment, but as always thank for your great videos Dr. Ali. Can’t wait for the next one! 😊
Your professor was right and that is exactly the cognitive dissonance in the concept of patency: the fact that cases heal without it. You can also make the same argument for the people who believe in filling lateral canals; the fact that all out cases do not look like Hess Plates, and yet, cases heal is enough of an indication that success is not based on these proxies. Regarding single visit rex. Yes. I've done single visit Retx. all my career. There are a certain number of cases that heal and 5-10% of them that need apico. I have not found that doing it in a single visit actually increases that number. Once again, I feel there are other mechanisms that regulate into these lesions not healing and requiring apicoecotmy. Of course, the use of a calcium silicate type cement will be highly helpful as it does release calcium hydroxide for about a week, peaking at about 3 days post op (Hapossalo). So, while there's no study that shows that is enough to replace Ca(OH)2 therapy, it follows logically that the release of Ca(OH)2 is in line with those who believe in Ca(OH)2 therapy. But to make short answer long, yes, I do almost all my retx. cases in a single visit. The only ones I do in two visits are those that have active drainage, or are highly symptomatic, and even in the latter, I don't really have a good explanation why I do them in two visits. As far as I'm concerned, if retx. cases fail 5-10% of the time, I'm not going to explode 90% of people to two visits unnecessarily where as I can just do the apico on the second visit of 5-10% of the patients at a much reduced cost. That's a better management tactic that doing everything in two visits that hasn't been proven to have a higher success rate, especially in the calcium silicate area. Cheers!
@@AANasseh thank you for your reply. It is much appreciated!
Dear sir. in my opinion and practice, i see alot of teeth which didn’t fill to apical but they have a long term: no pain, no periapical imflamation or abscess. Can i send u some x ray film one of cases
Yes. As long as it’s clean it will heal. You can post to social and then share the link here?
Dr...is there any reason for not giving calcium hydroxide dressing...and will there be any adverse effect if calcium hydroxide dressing is given for long term i.e weakening of radicular dentin... thanks in advance.
That’s certainly an option. Many people believe it can help. I’m not sure the evidence is definitive on it, or else, it would have been the standard of care. One could further argue that BC Sealer releases Ca(OH)2 and has a similar pH profile as Calcium Hydroxide for the first few days to week. That may be another reason why it worked (possibly). So, Ca(OH)2 would have been another reasonable approach. I should have mentioned in the video… I was sitting there on that beach with people literally five yards from me sitting on the beach… it was so awkward and I was trying to stop talking about teeth on the beach ASAP!! So I missed a bunch of details!! LOL! Thanks!
Hi Doctor, in such cases where patency has not been achieved, how do you manage patients expectation ?
I think the key is having enough recalls and follow up. Then you’ll know before further investment. Also, knowing the salvageability of a tooth surgically if problems arise is another important factor.
Sir can we do obturation at same visit if we used chloroform or we should delay till next visit ? Thanks in advance
Of course you can. That’s what I have done for the past 30 years. If you run a large volume of irrigants and then dry with palate pin ya profusely you will remove all the remaining chloroform.
In my practice i got the best results (post-op pain, faster resolution of symptoms and healing)
when i stay inside the canal, Patency is desirable for better evacuation of debris and of course AL readings. In majorities of cases i obturate the system on second appointment with no anesthesia so i guess if the canal is clean and the length is right there will be no pain.
So no anesthesia gives me important information if there is pain i guess im wrong in my lenght or i have pulp residual. Im not scientist it is just my practice so dont take my advice.
Why we get healing with no pateny, well we have healing when we have lateral canals, multiple exits and so on. Ultrasonic activation i guess.
Dr. Can you make video on ultasonic activation in curved canals i always wonder how far we can reach activating( i notice u are using ultrasonic tip that can reach depth of 3-4mm. Using u files is bit challenging they lack power and ledges are problem. Discussion on US activation will be awesome.
Sry for the long post.
I would stay away from not anesthetizing. I think a video on that concept of not anesthetizing during the second visit would be a good idea. :)
Regarding ultrasonics, they only work when you have a stiff tip. So in order to get deeper sonic might be a better approach for that. But it’s important to know that ultrasonics do cause an increase in kinetic flow much deeper than the tip of the instrument. I really should make a video about it. Thanks! 🙏
@@AANasseh Yes how far from the tip we get adequate activation, strong enough to disrupt biofilm.
Thank you Dr.
@@kiossov Direct strong activation is only a few millimeters; but there's caustic streaming and increase in the kinetic energy of the fluid far longer down the canal. Sonic is another option to go deeper. I've been working in this domain and interesting, but most importantly inexpensive, ideas will be shared soon. Stay tuned! :)
Hi Dr Nasseh- you did this in a single sitting?
Yes.. single visit. :)
Endo is so deep. metaphysics😂