Prophylactic Endo vs Preventive Endo, what's the difference? (CBL 42!)
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- čas přidán 22. 07. 2024
- Dr. Nasseh shares a recent clinical case from the office where his preventive endo tx. had turned into prophylactic endo treatment when the patient ended up seeking care at a local dental school.
When you evaluate every pros an cons, make a great decision and someone else ruins it, lets the pacient go through 9 hours procedure that could have been avoided, doesnt even find all canals and separates an instrument. Gotta love that!
I know. It was so frustrating.... but on the bright side, it motivated me to make this video and share the experience! ;) But I was thinking to myself that sometimes, getting less expensive treatment (going to place where the procedure is cheaper) can backfire by getting over treated! But again... it's all on a case by case basis as many school treatments are actually good quality. It seems like so much of treatment is just day to day dependent... who's looking at the x-ray and what kind of mood they're in!!! LOL! Thanks for the comment! 👍
Humour in uniform😎
Loved the included footage of the procedure and imaging, we appreciate it!
Thanks Dr.Nasseh 🙌🏻
Prophy endo can often be the result of collaborating with a below average lab which asks for excessive reduction of the tooth structure. The risks related to pulp sensitivity and pulp heating during preparation become too great and you find yourself doing the endo on a healthy upper lateral because of it.
This is an excellent point. Not only an inferior lab but also old school thinking by using Porcelain bonded to metal that requires significant reduction for proper esthetics. This makes for a good conversation or interview if I can find a couple of pros people who're willing to go on the record discussing it. Cheers!
Very interesting subject. Being an endo resident I was once just helping some general dentistry students to prepare a 3.7 for a bridge. The hygiene of the patient coming from a rural area was not satisfying but the tooth had no symptoms. The tooth had a deep caries which was removed and I verified myself that there was undeniably hard substance after the caries removal. The prosthetics professor forced a prophylactic endo on that tooth. Until today I still wonder if it was the right thing to do.
I agree that every case is different and should be evaluated taking in consideration several factors.
Also in your case there were more than one doctors involved, looks like the students unfortunately didn't reach the original doctor before they proceed and they had lack of information, probably they didn't see the CBCT.
Excellent points. I agree that it's done too easily and can be avoided in a certain number of cases. Part of the problem is restorative dentists often realize the limitations of their own ability to fabricate a crown that doesn't leak and is seated properly, so that it doesn't cause dentinal sensitivity and discomfort afterwards. This limitation alone is part of the reason why they request RCT. My theory is that many request prophy endo so they can get away with a lower quality restoration in the short run!!! All of us have to raise our game if we want to provide the most appropriate treatment to our patients. Thanks for sharing your experience here! :)
What a shame! I guess part of our post-op instructions after VPT should include “don’t let anyone else do a root canal on the tooth!”When the students are taught that it is ok to over treat in school to meet their requirements, they are more likely to continue over treat in practice. Great case for discussion!
Dentistry aside, that intro, editing and music choise were cool!
I do vital pulp therapy with BC sealer and BC liner all the time and I have had great success. I am confident enough in these materials that I have no problem pacing full coverage restorations on top of them. Another thing to consider is provisional cementation of your definitive full coverage restoration and allowing the patient to live in their crown for several weeks and closely monitor them for symptoms of pulpitis. If you have Cerec this is even easier because you can make the crown the same day and temporarily cement it. If they remain asymptomatic for several weeks then you can remove the crown and cement or bond it on. I haven’t had to drill holes in many crowns using this method. If signs of irreversible pulpitis begin then I can then remove the crown and complete the endodontic treatment. In my opinion root canal treatment should be avoided unless there are clear indications for it. We also have to define success and failure. If a tooth receives vital pulp therapy and remains asymptomatic for 10 years and eventually needs endodontic treatment I define that as successful vital pulp therapy! I had vital pulp therapy done on myself (on tooth #31) as a 17 year old. The tooth needed root canal treatment 12 years later. To me, that was successful!
If you use temp bond original (with Eugenol) to temporarily cement a crown I would consider mixing the absolute tiniest amount of Vaseline into it to make removal of the crown easier.
Thanks again for the great video. I really enjoy your content and the thoughtful discussion it provokes.
Great points about the definition of success for VPT. That’s an astute point most people don’t keep in mind. A hip replacement lasts about ten years. It’s best to use your own hip until it’s time for it. Keeping your own hip for another ten years before getting hip replacement is not considered a failure either!
The Vaseline trick is important as most of the time I’ve asked a GP to cement the crown with provisional cement they have had difficulty removing it! Good points.
Even if that is a rough estimate more than 75% of cases that some colleagues referred to me for an endo where reversible pulpitis cases wrongly assessed. 4 5 years later the pt doesn't have any symptoms and we saved him from an endo. I always always give
It a go after talking and informing the pt.
Honestly we have a problem in preventive dentistry as a whole. I've seen a lot of unnecessary procedures done to a fairly easy to fix teeth. Just sad. Let's give the patients and their teeth a chance before doing extractions and RCTs.
I agree. We need to make sure we prevent procedure since there's risk to doing procedures and once done it's irreversible. At the same time, we need to try to avoid pulpal necrosis. So, it's a balancing act that's best addressed through strict follow up. Thanks for the comment. 👍
Since you mentioned calcium hydroxide, do you think it's still has a use when the obturation is done with bioceramic?
Given that bioceramic do release calcium hydroxide, i imagine this would be a discussing of concetrations. Curious to here your thoughts
Good question. To be honest, whether Ca(OH)2 is necessary or not is somewhat argumentative. But whenever you can't do a procedure in a single visit it is advised to leave Ca(OH)2 dressing in the canal. For cement, obviously, having an antimicrobial sealer is better than an insert sealer. So, whether BC Sealer helps you do single visit is not the right question, since single visit is fine as long as the objectives for the full RCT is achieved during the time allowed for a single visit. I should probably do a video on this question! Cheers! :)
Good to see that in the times of drill&fill approach you really stressed upon the real conservative dentistry subject. I think every situation is different and needs a customised treatment plan
Thank you and yes, we need to customize treatment for our patients in their own unique way; but I'm trying to figure out if we can have first principles or real values that should guide our decisions in a more objective manner than mere knee jerk reactions based on simplified decisions. Thanks for the comment.
the only Root canal that is can't fail is the root canal that isn't done. If the tooth is asymptomatic and you don't have a frank exposure don't do the endo. the endo will make the tooth more likely to fracture in the future. If you end up needing a post fracture is even more likely. With the advent of MTA and bioceramics vital pulp therapy has a much better success rate.
That's absolutely taking this video's objective to the next level. Conservative prosthodontics is all about this exactly. Pathology weighs higher than prophalytic endontics
Yes. It’s about risk assessment. We should always focus on saving the pulp whenever possible unless the price of endo failing is too high to pay(big bridge, survey crown, etc.) or the patient shows signs of irreversible pulpitis and tooth needs a crown. Asymptomatic teeth may at best require long term provisional (3-4 weeks with follow up.)
@@AANasseh well reflected doc. How do we convincingly enlighten on conservative approach to the patient is the challenge ahead.
Спасибо за видео.
I’ve seen this a lot- the idea that, if the Caries is too close to the pulp, you “might as well do the endo” or “it will eventually need it anyway”- it’s certainly not evidence based- old school dentists or recent grads taught by said old schoolers are hyper conservative in the sense of not wanting to miss treatment that “needs” to be done, but not conservative at all in the sense of avoiding unnecessary treatment- btw what are your thoughts on leaving caries under a well sealed restoration? Always a no no?
As I mentioned in the previous comment this is a controversial area and there are cardiologists and pulp biologists who have different opinions on this matter. The current acceptable theory by the AAE is to remove all Caries as it’s usually the source of failure for the Direct pulp cap. But if there are no symptoms and one’s trying to do indirect pulp cap then at least something has to be done to the Carie’s to deactivate it, whether silver fluoride or whatever else.. I wouldn’t just think that sealing it will kill the decay since unless you only have a mix of strict aerobes then your facultative anaerobes can still survive. They need to be disinfected/inactivated before coverage. Whether Ca(OH)2 is enough is also another point of contention among experts.
Thanks for the reply- reasoned and thoughtful- appreciate your vids
@@kavityphiller4891 I was just reading my reply and I really should consider re-reading before pressing "reply!" LOL! So many autocorrect issues... For example, the controversy is between pulp biologists and "cariologists", not cardiologists as recommended by autocorrect! LOL! Cheers!
Nice theme doctor. My opinion is that we must be as minimally invasive as possible. In my practice, if there are no signs of irreversible damage to the dental pulp, I only perform conservative restorative treatment. It involves MTA, glasionomer cement and composite. I have not had long-term failures. I perform endodontic treatment only when necessary, in apical abscesses, apical periodontitis or when the coronary destruction is extensive, when the pulp chamber is open or when I have only 1 or 2 good coronary walls. In my opinion, if I have the possibility to make retentions so that the composite fixes well to the tooth, there is no point in endodontic treatment. A procedure may need to be created when the endodontic treatment needs to be performed and when not, as well as with the indications for tooth extraction.
I agree. Based on what you saw, do you think a bonded composite would have lasted long enough? Some people are saying even a crown did not seem necessary. Do you think a bonded composite would not chip off on that buccal cusp?
@@AANasseh My opinion is that if we follow Black's rules in preparing the cavities, we will have no problem fixing the composite to the tooth.
@@reli-dent-implantreli-dent5881 But I thought GV Black principles of retention were less important in the era of adhesives. Do you mean in less retentive cases like this one?
@@AANasseh I do not dispute the quality of the adhesives. Achieving composite retention increases the strength of the joint between the composite and the tooth. The temporo-mandibular joint is not a simple hinge joint. Her movements are complex. The way chewing is done differs from person to person. The muscles develop differently depending on the patient's habits. Some patients eat only on one side (left or right) we rarely see patients who chew food on both sides. We also have patients who have edentulous or carious lesions, in which the chewing undergoes changes in the sense that they can eat avoiding certain areas. I make retentions in any situation, in the idea that if during chewing there may be premature contact between the food (which in some cases the food may be harder) and the teeth. In this case, the composite filling can come off the tooth, due to the force that will act at a single point. I had patients who came to my office with composite fillings detached from the tooth, who did not have these retentions. I always made retentions and had no problem with the composite fillings coming off the tooth. I'm not saying that without retention a composite filler will have a short life or that it's wrong that no retentions were made. They can last over time. I mean, we don't know what the patient's chewing habit is and how hard the food they eat is.
@@reli-dent-implantreli-dent5881 definitely if you place retention undercuts on that buccal prep a composite restoration would’ve stayed & no need for a crown. I do them all the time. Again why not explain to patient & try it, but I am positive it would’ve worked.
I honestly don't think that there was a need for a crown since the seal is fine and there was no post-VPT symptoms. Too bad
Yes. But I had BC Miner on top… this is not a final. So, someone should have prepped into the Blue sliver and created a retentive surface to put a strong composite. Do you think that would be enough considering shear forces for a mere composite to stay?
@@AANasseh I can't really say definitively but I do believe in the power of rigorous adhesive protocol and their excellent result .. what's your opinion on this doctor ?
@@saladinhierosolyma8738 I don’t know. I think adhesive dentistry in this place as a big wall would work… but not sure for how long. An Onlay should obviously last longer but hard to argue a counter factual at this point. It’s anyone’s guess to be honest.
@@AANasseh Generous bevelling into enamel on all of the applicable line angles should provide excellent longevity. Unless the patient is a monstrous bruxer it should work for many years without issue. I'm skeptical as to the benefits of small onlays with just single cuspal coverage - seems more financially driven than patient outcome driven).
@@meowymeow282 Very interesting. So, you feel the longevity of a long beveled direct composite to cover a couple of buccal cusps is as high as that of a cast restoration. I don't do these so I'll have to take your word for it. Any specific type/brand of composite you think can do the job better?
40 Minutes for a whole 4 canal RCT? Damn, I'm slow 😄
No worries... you'll be faster if decide to be faster too. It does take practice for sure. After 28K cases I've gotten fast just through experience.
When I was young doctor I did 3 canal for 20 min. +survey, x-rg, fill the card, а сup of tee and one checkers game.
Why patient wanted a crown on this tooth at first place ?
I agree... I think they should have just done an onlay or something. Either way, the Blue Liner had to be replaced and since it included the buccal wall... they had to do something stronger as it would have likely chipped otherwise. What would you have placed, just replace the BC Liner with composite? Or would you have done a partial casting?
Crown is fine in this case- a ton of the tooth is already compromised
Prophy Endo, crown everything is the dental school mentality. You probably could’ve just left that tooth with the composite restoration you did since it was likely a nonfunctional cusp. A lot easier to keep clean a tooth without a crown versus a tooth with a crown. The academic world is out of touch with clinical real life practice.
It's true that much of the feedback is practical clinical opinions from thirty years ago. But besides that, how long can we realistically expect a bonded composite restoration in that location with lat large of a size last? What would you quote as expected lifespan of such restoration before leakage sets in and starts to act on the pulp?
@@AANasseh see restorations like that last years and some less. I think a lot depends on the age of the patient. In a case like that where you can see the pulp so high up in the coronal aspect of the tooth maybe less, however I think the crown will make worse & more likely cause the tooth to need Endo quicker & then presents more of a challenge in terms of access through a zirc crown.
No symptoms for that patient, probably should’ve left the tooth alone, no crown. See if the patient oral hygiene can improve because to get a cavity like that it’s typically awful homecare or diet or potentially drugs. Crowning that tooth is gonna create Endo or tooth loss quicker & cost the patient a lot $$$. Amalgam back there could’ve been another option, however how dare you ever use amalgam haha. Great work, just shows how out of touch the dental schools are in USA still.
Don’t forget crowning lengthening as well since probably short clinical crown since second molar. Patient probably wasn’t even presented with option of gold so you don’t need to reduce the hell out of the tooth. I bet the dental student had to cut a heavy chamfer margin all around rather than knife edge and minimal reduction gold crown. So much wrong with our dental education system. 3 different opinions from a Prost faculty resident who just started the program who has prepped 10 crowns his whole career & paying $100,000 a year in tuition….. joke
@@celts03 I agree... especially since a crown is much more technique sensitive and I second your statement about amalgam. It was such a long lasting material for situations where you needed something long lasting instead of a crown. Here there's not enough retention, unless one uses pins.. which then may actually accelerate pulpitis. It's a tough case but I agree that a crown should be avoided in maxillary second molars unless really necessary due to its technical necessities. Doing the endo before the crown is just a lazy move to get away with the. potential open margins that will ensue!
@@AANasseh you should do a talk on how “every Endo tooth needs a crown.” Another completely outdated idea. #21 small occlusal access for Endo & tooth needs crown. Or even do I dare #19 MO decay to the pulp Endo treated needs a crown. The dental schools need to go back & rewrite the “recipe” book they created. Get some advice from GP observations worldwide. As soon as you crown the tooth the quicker you’re to lose the tooth in a lot of ways.
@@celts03 Gordon Christiansen tried to say that and they jumped on him! I think it's the unspoken truth that there are too many crowns being made, and probably too many prophy endos too.
Thanks Dr.Nasseh 🙌🏻