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Let's discuss this! II.

 
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john kanca



Joined: 14 May 2005
Posts: 6345

PostPosted: Sat May 21, 2005 9:26 am    Post subject: Let's discuss this! II. Reply with quote

From another post:

I'm a new associate at this practice (6 months). In late October I saw a 16 yr old girl who needed an occlusal resin on #3 (her first ever). No big deal, I thought. Initial prep was fine, maybe a little deep. I placed a little dycal and moved on with restoration. Her mom called about 3 wks later and said the daughter was a little sensitive. So we got her in and adjusted the bite (wasn't high, though). She called back a couple of weeks later still sensitive. Another occlusal adjustment. I did not need to anesthetize either time and she reported improvement of her symptoms both times. After the second time, I told mom that this was unusual for a small occlusal resin to be giving her any trouble, but we would wait and see and place an IRM if symptoms continue. Sure enough, She came back a third time and we removed the resin (she did need 3 carps of citanest, though), I noticed what looked like a small crack on the distal (took intraoral pic) and moved on. Two months later she called back and I got my senior doc to look at her. He removed everything (after another 3 carps) and saw nothing wrong, so he filled it with resin again. Now the girl is being referred for endo eval. I feel bad, because she is not really a complainer according to the staff (who've known her for many years) and the family are all good patients. Looks like she'll need endo and crown after that, and she's only 16. I know I didn't do anything wrong and I feel vindicated that my partner saw nothing wrong (nicked pulpal horn or the like), but it sure doesn't help the patient. The mom has been nice so far, but you never know in this situation. Any thoughts?
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Ekrause



Joined: 11 May 2005
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PostPosted: Sat May 21, 2005 9:55 am    Post subject: Reply with quote

Which Dycal?? Any GI placed over it?? Can you bond to Dycal??

Parafunction contributory perhaps?
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Ekrause



Joined: 11 May 2005
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Location: I'm here now.

PostPosted: Sat May 21, 2005 10:10 am    Post subject: Reply with quote

How was the tooth sensitive?? Cold? Heat? Biting? Release?
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john kanca



Joined: 14 May 2005
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PostPosted: Sat May 21, 2005 10:16 am    Post subject: Reply with quote

This is good. I am soliciting other comments as well. Then we'll mash it up. Smile
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Gerry



Joined: 13 May 2005
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Location: Tarrytown NY

PostPosted: Sat May 21, 2005 11:29 am    Post subject: Reply with quote

I have a feeling that JK would agree that if there was no indication of function or parafunction interference the initial restoration probably had a sub-filling gap and should have been replaced.

At one point you mention that you removed the filling and "moved on". Does that mean IRM or some other concoction containing eugenol? If so endo consultation is probably now a good idea.
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drhal35



Joined: 11 May 2005
Posts: 41
Location: Niskayuna, NY

PostPosted: Sat May 21, 2005 12:36 pm    Post subject: Reply with quote

poor bond to pulpal floor due to contamination with dycal.
are they still teaching dycal under restorations?
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rajeev2003



Joined: 14 May 2005
Posts: 57
Location: WETHERSFIELD, CT

PostPosted: Sat May 21, 2005 9:55 pm    Post subject: Reply with quote

16 year patient.Will have large pulp chamber/ horns.
Pre-treatment presenting features were....no discomfort,a simple one surface cavity.
Guy admits to prepping deep inadvertently.
As a precaution he placed dycal.
Patient was relived of sensitivity 3-4 times post occlusal adjustments.
No IRM was ever placed.
The cause for sensitivity was iatrogenic.
Relief of symptoms after occlusal adjustments shows a state of acute pulpits initiated initially by the resin and deep fill,slowly becoming chronic (more anesthesia required) with the tooth in clear definate Hyperocclusion/hyper-erruption from the increasing level of inflammation.
At each stage,patient felt better after relieving the inflammatory hyperoccln,but tooth was never given a chance to recover by the resin being placed right back in the cavity,re-initiating the inflm process.No bonding agent was used to seal the dentine.
I would have placed IRM after releiving the bite.Leave it in for 8 weeks minimal and evaluate for symptoms .
Chances favor a recovery and reversal of inflammation.
Post recovery of tooth,leave irm as base and do restoration
Question i ask in this case are:
1)what did both dentists do to allow and help the tooth recover from the iatrogenic trauma?NOTHING.Infact they increased the insults repeatedly.

I understand from some research articles that using and doing a good dentine bond to seal the iatrogenically exposed horns, placing a temp and taking this tooth completely out of acclusion would have also allowed recovery after 8-10 weeks.
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john kanca



Joined: 14 May 2005
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PostPosted: Sun May 22, 2005 4:59 pm    Post subject: Reply with quote

I'm a new associate at this practice (6 months). In late October I saw a 16 yr old girl who needed an occlusal resin on #3 (her first ever). No big deal, I thought. Initial prep was fine, maybe a little deep. I placed a little dycal (FIRST AND BIGGEST MISTAKE) and moved on with restoration.

Now up to here we don't even know if was an amalgam.

Her mom called about 3 wks later and said the daughter was a little sensitive. So we got her in and adjusted the bite (wasn't high, though).

Then why adjust it?

She called back a couple of weeks later still sensitive. Another occlusal adjustment. I did not need to anesthetize either time and she reported improvement of her symptoms both times.

Well, let' s see. It's biting sensitive and he keeps taking it out of occlusion....hmmm.....

After the second time, I told mom that this was unusual for a small occlusal resin to be giving her any trouble, but we would wait and see and place an IRM if symptoms continue. Sure enough, She came back a third time and we removed the resin (she did need 3 carps of citanest, though), I noticed what looked like a small crack on the distal (took intraoral pic) and moved on. Two months later she called back and I got my senior doc to look at her. He removed everything (after another 3 carps) and saw nothing wrong, so he filled it with resin again. Now the girl is being referred for endo eval.

LESSON: Virgin dentin is one of the toughest substrates to bond, especially deeper dentin.

I feel bad, because she is not really a complainer according to the staff (who've known her for many years) and the family are all good patients. Looks like she'll need endo and crown after that, and she's only 16. I know I didn't do anything wrong and I feel vindicated that my partner saw nothing wrong (nicked pulpal horn or the like), but it sure doesn't help the patient. The mom has been nice so far, but you never know in this situation. Any thoughts?

There is nowhere near enough information provided to make any conclusions, but it is my opinion that if resin was inserted that this was a gap between the resin and the tooth. Class I's are the most sensitive to contraction stress, and this one hit the jackpot.
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