Thursday, November 2, 2017

Two Great Ways to Remove Moisture from Cleansed Root Canals

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The past ten years have seen some incredible advances in the field of endodontics.  One of the greatest, in my opinion, has been advances in obturation.
We no longer have the singular option of mixing up some type of “glue” and then placing multiple fibers of gutta percha in it.  Instead we have things that range from gutta percha and sealer, to obturators (gutta percha on a stick), to bondable resin sealers and obturating fibers.
I have chosen to utilize bondable obturation for a variety of reasons.  When the first possibilities of bonded obturation became available in the early 2000’s I was fascinated by the possibilities.  As a general dentist I immediately understood & appreciated the logic & science behind the bonded concept.

Many studies, going back over 20-30 years have shown that root canal systems can be contaminated by bacteria in as little as 30 days.  Placing a temporary material in the access over a non-bonded obturation is not sufficient.  Bacteria can quickly penetrate the temporary material down to the pulpal floor and than navigate the root canal system to the apex in a month or so.  The unfortunate reality of this all too common clinical situation is that the spaces previously occupied by infected pulp that have been meticulously cleansed can return to their uncleaned state quickly and without symptoms.  Unfortunately, without that knowledge a dentist can, with the best of intentions, then place a permanently cemented or bonded crown on this tooth.  This means that the bacteria are now sealed from the occlusal side, but the bacteria is still within the canal system and has the possibility of causing a recurrent infection at any time.

The reason for this is because the most commonly used access prep temporary materials such as IRM and Cavit are porous and offer no resistance to bacterial penetration.  However, what if you could make the root canal system impervious to this bacterial penetration?  By using a bondable point and a resin based duel cure sealer that bonds to the canal walls, this is exactly what bonded obturation does.

However, the bonded obturation process is a bit different than the standard sealer and gutta percha process.  The main difference being that traditional sealers require a dry canal while any type of a bonded process requires a bit of moisture remains in the canal system.  Frequently ethyl alcohol (ETOH) is the last irrigant used in standard obturation as it evaporates extremely fast and takes any remnants of moisture with it, leaving a dry canal to place the sealer in.

For bonded obturation it’s required to do “wet bonding” and in my protocol the last irrigant is chlorhexidine because of its residual bactericidal effects.  The main question in bonded obturation becomes “how to remove the chlorhexidine without over drying the canal?”  The easiest way I have found to do this is by using some type of capillary tip that can be introduced into the canals and then removed before over drying can occur.

The  photos above are the 2 best products I’ve found to accomplish this.  The first tip is from Coltene (the ROEKO Surgitip-endo) and available through your current dental supply company.  The second tip is from Ultradent (Luer Vacuum Adapter & Capillary Tips) and can be purchased directly from the company.  They are both highly flexible and easy to place.  The technique involves bending the tips to provide straight line access and then sliding the tip into the prepared canal until it binds against the prepared canal wall.  At that point, the tip is quickly withdrawn and removes the majority of the moisture with it.  However, by quickly removing the tip and not allowing air to circulate around it, it does leave the canal walls with adequate moisture to facilitate bonding of the hydrophilic EndoRez Sealer which is purchased from Ultradent.  Cones are then placed in the manner which is most comfortable for the operator.  

My one complaint on the Coltene tip is that it is opaque and you cannot see the chlorhexidine moving through it.  Instead you need a quiet environment where one can *hear* the process.  The Ultradent capillary tip is translucent which allows for the operator to actually see fluid movement through it.

Both products are *highly* recommended.

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