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Simplicity and Pulp capping
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john kanca



Joined: 14 May 2005
Posts: 6346

PostPosted: Sat Sep 10, 2005 1:42 pm    Post subject: Reply with quote

1- In all the above, we perform the step "alcohol+ wash off the alcohol" as the 1st step when it comes time to use the Sim?

If you are using NaOCl the alcohol can be discarded. And careful with the alcohol on a pulp.

2- Durelon is the choice material, are any materials acceptable? And your comments on them if so?

There are several materials which are in the literature, but this is the most benevolent for larger exposures, short of MTA. But oyu have to be a rich endodontist to afford it.

3- re Larger exposure, at what point do you say, "endo for sure"?

It's all about history, signs and symptoms. The exposure could be larger but traumatic.

And do you anticipate that changing as you learn over the years that you are getting a superior seal w Sim & related products?

I think the diagnosis screening will remain pretty much the same.
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cool kid



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PostPosted: Sun Oct 09, 2005 8:25 am    Post subject: Reply with quote

this post was so unbelievably helpful to me yesterday that I just want to thank all of you for this great discussion. I had a 7 1/2 mo pg pt in the chair yesterday. she had a very large carious lesion #19. tested vital but she had no symptoms with the tooth up to this point other then getting stuff caught in it. She did not want endo. I got her numb and was going to do a build up and a cerec, but told her that endo was a possibility. I removed the bulk of the decay with a slow speed, btu used a spoon over teh pulp horn. on my last scrape, I got a pin point exposure. it was bleeding a tad and all I could think of was CRAP!!! then this entire thread came up in my head. I got out my NaOCl and placed it on the exposure. stopped bleeding immediately. then sim 1 and 2, flow and composite build up. I then did a cerec and gave her my cell # to call me if she has any pain and I'd come in to do the endo on sunday if necessary. I called her last night about 9 pm and she said she had not 1 lick of sensitivity. I was jumping for joy. Thanks for the info here. Just a great thread!!
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Gerry



Joined: 13 May 2005
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Location: Tarrytown NY

PostPosted: Mon Oct 10, 2005 7:56 am    Post subject: Reply with quote

Nice work! Rather than get the exposure try leaving the last remnant of leathery caries in place. Usually this stuff in "Affected" rather than "Infected" dentin, and the NAOCL will prevent any problems anyway. T. Fusayama did some interesting work on this concept. Dr. III is a proponent of this protocol & I've been doing it for over 40 years. Used to be called "secondary pulp cap".
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cool kid



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PostPosted: Mon Oct 10, 2005 8:37 am    Post subject: Reply with quote

gerry,

I actually though that I was dong that. I was jsut doing one last sweep witht he spoon excavator and bingo, there was the pinpoint exposure. I have been more and more leaving that last little layer of affected dentin with a nice wide rim of solid dentin and enamel. has been working great. This was just one that I didn't think I'd expose with that last sweep. that is why the protocol that was discussed at length was so helpful.
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john kanca



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PostPosted: Mon Oct 10, 2005 9:38 am    Post subject: Reply with quote

That's really great to hear, CK. Thanks for sharing it. I am going to excerpt it and put it in the public section if you don't mind.
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cool kid



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PostPosted: Mon Oct 10, 2005 10:25 am    Post subject: Reply with quote

I'd be honored!!!
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dsg_c1



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PostPosted: Mon Oct 10, 2005 1:33 pm    Post subject: Reply with quote

do you all use caries indicating solution?

how does one tell the difference between "effected" and "infected" dentin?

when i am in doubt i remove decay, but maybe i should be less prudent on removing everything that looks suspicious. i know there has been research for years on leaving the last layer of leathery caries, but i have problems (many that i won't discuss here - flem and ck) with leaving decay - i certainly wouldn't do it on my kid - therefore, when in doubt i remove. by using JK's pulp exposure protocols and now all of his products - i have had little problem with pulp exposures, strangely even when i was doing direct pulpal exposures incorrectly i was having way more success than failures. lately i have really been pushing the envelope with these exposures that would send all endodontis into tizzy fits with minimal issues.

take care,
d
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john kanca



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PostPosted: Mon Oct 10, 2005 1:44 pm    Post subject: Reply with quote

I think it's important that we make clear that what is truly being left behind is caries-affected dentin, NOT carious tooth per se. Even though the literature is supportive of sealed caries not progressing, I do not advocate leaving overt caries in place.

Caries-affected tissue is another matter. That can be left in place when a tooth is aymptomatic and there is a high risk of exposure.
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Gerry



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PostPosted: Mon Oct 10, 2005 4:35 pm    Post subject: Reply with quote

According to Dr. T. Fusayama Infected dentin stains heavily while Affected dentin barely stains if at all when using caries disclosing solution. Even in the presence of ideal isolation it is preferrable to avoid having a frank exposure of vital pulp to the outside environment. I simply tell the patient what treatment I plan on doing and ask them I they would prefer to give it a chance or start endo immediately. For some reason I'm rarely asked to start RCT! BTW, I have done this "secondary pulp cap" procedure on family members with excellent success. When necessary I peform all my own RCT. Sure, with pulp capping I'm not getting the fee for the RCT, which is why I'm discussing this conservative approach here rather than on DT.
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marshall white



Joined: 11 May 2005
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PostPosted: Mon Oct 10, 2005 9:38 pm    Post subject: Reply with quote

hi dsg_c1,

IMHO, caries indicator stains (CISs) are of limited usefulness when attempting to discern betwixt affected and infected dentin. Why?

Like most things, other than congeniality with the young, I learned about it from JK III. Then confirmed it with a little time spent (not that it needs confirmed, mind you, but one can never be too careful ...Laughing )

Even affected dentin has microscopic voids from partial demineralization. These voids in both infected & affected dentin, sometimes called lacunae, are what is penetrated and inhabited by the dyes. Surface tension (capillary action) prevents the dye's rinsing out. Same with enamel lacunae, incidentally. Affected dentin will frequently stain well, but there is minimal bacterial invasion and so it is not INfected. Another confounding factor is the reality that sound and intact deeper dentin will tend to stain and be interpreted as a false-positive for infected dentin. The closer we are to the pulp, the larger are the diameters of the tubuli AND there are more per unit of cut area (they're closer together and fatter).

It depends upon who you talk to, but infected is generally dentin that has sufficient demineralization that tubules are wide open and filled with live bugs. The organic matrix has lost its organization and collapsed. This will either remineralize very poorly or not at all, even if you can truly seal it. Bonding to infected dentin is tenuous at best, and one in vitro study I recall says that resin bonds to infected dentin deteriorate to statistical significance in ~8 weeks.

Affected dentin, on the other hand, has some demin. But the basic latticework of dentin matrix remains relatively intact, so much so that in the right conditions it can remineralize, in a fashion, kind of like in dentinogenesis but nowhere near as well-organized. There is very little bacterial invasion, and tubuli may still be somewhat closed off just as they were left by retreating odontoblastic processes when the 'demineralization front' first imposed lower pH upon the dentin at the leading edge of the carious lesion.

(No, Flem...that's 'DEMINERALIZATION front', not "EMINENCE FRONT")

SSWhite had some studies done when developing the original SmartPrep burs to determine the most reliable way to discern between in- and affected dentin. Once one precisely defines one and the other, turns out that Knoop hardness happens to be the most reliable means of discernment between in- and affected dentin. SO the SmartPrep, which they hoped would just get close to or would maybe at least approximate what stains and microbiology showed to be the difference, well it (the Smartprep) was a much more reliable indicator than any other methods, save for electrical impedance. Its polymer is designed to be harder than infected and softer than affected dentin.

HOWEVER, hands-on comparisons determined that caries-affected dentin feels no different to an experienced clinician using a sharp shepherds hook explorer or a 3ES than does intact sound dentin. There's no "stick" in affected dentin. Kind of ironic that the oldest method is the best way to see if we've left any decay.

The TRICK is to find a way to remove ONLY the INfected dentin, and cease cutting right where the AFfected dentin begins. IOW, it is easy to discern if we've left any INfected dentin, but discerning whether or not we've spared the AFfected dentin is a crap shoot.

Long story short:

Rely on dyes for shallower preps or portions thereof. Trust it with enamel. Let the love end there. Deeper dentin? Trust your explorer to tell you ... the closer you are to the pulp, just remove small amts of dentin at a time over the most pulpal aspect of a deep prep. Then test with your explorer, trust not the stain here.

INfected dentin: massive demineralization; wide open tubuli filled & swarming with viable bacteria; loss of matrix's quaternary stucture; won't remineralize; bonds poorly; sharp explorer will always stick; stains heavily.

AFfected dentin: relatively mild loss of mineral; closed or slightly open tubuli with little or no bacteria; the latticework of the matrix is generally intact; will remineralize more or less under the right conditions; bonds better than infected dentin, but not quite as well as the healthy intact stuff, and bond is relatively stable; feels like healthy dentin with an explorer, so no stick; stains some despite lack of infection.

Sorry so long. But hopefully that's useful ...and correct Shocked

M.


dsg_c1 wrote:
do you all use caries indicating solution?

how does one tell the difference between "effected" and "infected" dentin?

when i am in doubt i remove decay, but maybe i should be less prudent on removing everything that looks suspicious. i know there has been research for years on leaving the last layer of leathery caries, but i have problems (many that i won't discuss here - flem and ck) with leaving decay - i certainly wouldn't do it on my kid - therefore, when in doubt i remove. by using JK's pulp exposure protocols and now all of his products - i have had little problem with pulp exposures, strangely even when i was doing direct pulpal exposures incorrectly i was having way more success than failures. lately i have really been pushing the envelope with these exposures that would send all endodontis into tizzy fits with minimal issues.

take care,
d
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dsg_c1



Joined: 11 May 2005
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Location: mill creek, wa

PostPosted: Mon Oct 10, 2005 11:26 pm    Post subject: Reply with quote

marshall white wrote:
hi dsg_c1,

IMHO, caries indicator stains (CISs) are of limited usefulness when attempting to discern betwixt affected and infected dentin. Why?

Like most things, other than congeniality with the young, I learned about it from JK III. Then confirmed it with a little time spent (not that it needs confirmed, mind you, but one can never be too careful ...Laughing )

Even affected dentin has microscopic voids from partial demineralization. These voids in both infected & affected dentin, sometimes called lacunae, are what is penetrated and inhabited by the dyes. Surface tension (capillary action) prevents the dye's rinsing out. Same with enamel lacunae, incidentally. Affected dentin will frequently stain well, but there is minimal bacterial invasion and so it is not INfected. Another confounding factor is the reality that sound and intact deeper dentin will tend to stain and be interpreted as a false-positive for infected dentin. The closer we are to the pulp, the larger are the diameters of the tubuli AND there are more per unit of cut area (they're closer together and fatter).

It depends upon who you talk to, but infected is generally dentin that has sufficient demineralization that tubules are wide open and filled with live bugs. The organic matrix has lost its organization and collapsed. This will either remineralize very poorly or not at all, even if you can truly seal it. Bonding to infected dentin is tenuous at best, and one in vitro study I recall says that resin bonds to infected dentin deteriorate to statistical significance in ~8 weeks.

Affected dentin, on the other hand, has some demin. But the basic latticework of dentin matrix remains relatively intact, so much so that in the right conditions it can remineralize, in a fashion, kind of like in dentinogenesis but nowhere near as well-organized. There is very little bacterial invasion, and tubuli may still be somewhat closed off just as they were left by retreating odontoblastic processes when the 'demineralization front' first imposed lower pH upon the dentin at the leading edge of the carious lesion.

(No, Flem...that's 'DEMINERALIZATION front', not "EMINENCE FRONT")

SSWhite had some studies done when developing the original SmartPrep burs to determine the most reliable way to discern between in- and affected dentin. Once one precisely defines one and the other, turns out that Knoop hardness happens to be the most reliable means of discernment between in- and affected dentin. SO the SmartPrep, which they hoped would just get close to or would maybe at least approximate what stains and microbiology showed to be the difference, well it (the Smartprep) was a much more reliable indicator than any other methods, save for electrical impedance. Its polymer is designed to be harder than infected and softer than affected dentin.

HOWEVER, hands-on comparisons determined that caries-affected dentin feels no different to an experienced clinician using a sharp shepherds hook explorer or a 3ES than does intact sound dentin. There's no "stick" in affected dentin. Kind of ironic that the oldest method is the best way to see if we've left any decay.

The TRICK is to find a way to remove ONLY the INfected dentin, and cease cutting right where the AFfected dentin begins. IOW, it is easy to discern if we've left any INfected dentin, but discerning whether or not we've spared the AFfected dentin is a crap shoot.

Long story short:

Rely on dyes for shallower preps or portions thereof. Trust it with enamel. Let the love end there. Deeper dentin? Trust your explorer to tell you ... the closer you are to the pulp, just remove small amts of dentin at a time over the most pulpal aspect of a deep prep. Then test with your explorer, trust not the stain here.

INfected dentin: massive demineralization; wide open tubuli filled & swarming with viable bacteria; loss of matrix's quaternary stucture; won't remineralize; bonds poorly; sharp explorer will always stick; stains heavily.

AFfected dentin: relatively mild loss of mineral; closed or slightly open tubuli with little or no bacteria; the latticework of the matrix is generally intact; will remineralize more or less under the right conditions; bonds better than infected dentin, but not quite as well as the healthy intact stuff, and bond is relatively stable; feels like healthy dentin with an explorer, so no stick; stains some despite lack of infection.

Sorry so long. But hopefully that's useful ...and correct Shocked

M.


dsg_c1 wrote:
do you all use caries indicating solution?

how does one tell the difference between "effected" and "infected" dentin?

when i am in doubt i remove decay, but maybe i should be less prudent on removing everything that looks suspicious. i know there has been research for years on leaving the last layer of leathery caries, but i have problems (many that i won't discuss here - flem and ck) with leaving decay - i certainly wouldn't do it on my kid - therefore, when in doubt i remove. by using JK's pulp exposure protocols and now all of his products - i have had little problem with pulp exposures, strangely even when i was doing direct pulpal exposures incorrectly i was having way more success than failures. lately i have really been pushing the envelope with these exposures that would send all endodontis into tizzy fits with minimal issues.

take care,
d


thanks marshall - that was VERY informative. i appreciate all of your time you spent on the reply - this was exactly what i was trying to determine. again - you were the "swami" - actually, you are more like the "human google" - thanks again.

take care,
d
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darren greenhalgh dds
15130 main st suite 210
mill creek, wa. 98012
www.pacificNWsmiles.com
425.357.6400

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frequently a blasphemer of John Kanca III, DMD
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Mark J Fleming DDS



Joined: 11 May 2005
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PostPosted: Tue Oct 11, 2005 3:25 am    Post subject: Reply with quote

Marshall,

Thanks for the info. Especially enjoyed the Who reference! Cool
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satchdds



Joined: 10 Jun 2005
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Location: niagara falls, n.y.

PostPosted: Tue Oct 11, 2005 7:47 am    Post subject: Reply with quote

Thank you Marshall. Great post.
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cool kid



Joined: 12 May 2005
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PostPosted: Tue Oct 11, 2005 8:06 am    Post subject: Reply with quote

marshall,

that was a great post. Here is my question after reading it. If I have a sharp explorer and try to get a "stick" on an area that is VERY thin and right up against the pulp chamber, isn't there a good chance that I may just push right through that thin wall, even if it is affected? how would I then tell if it is affected or infected at that point? I guess just use the protocol that has been discussed here previously?
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marshall white



Joined: 11 May 2005
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Location: Granville, Ohio

PostPosted: Tue Oct 11, 2005 8:30 am    Post subject: Reply with quote

Thanks, all... Embarassed

CK,

Yes, earlier advise is my approach sometimes.

More often though, I just leave whatever is there even if it is a bit of infected dentin. I will have made certain that the pulpal aspect of the prep (where this dentin would be) is surrounded by a wide region of healthy intact dentin from that remnat to the cavosurface margin or DEJ, whichever the case may be. I'd prefer to leave a bit of infected dentin rather than remove too much affected and expose, OR perforate the dentin floor.

M.


cool kid wrote:
marshall,

that was a great post. Here is my question after reading it. If I have a sharp explorer and try to get a "stick" on an area that is VERY thin and right up against the pulp chamber, isn't there a good chance that I may just push right through that thin wall, even if it is affected? how would I then tell if it is affected or infected at that point? I guess just use the protocol that has been discussed here previously?
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