Getting to the Root of Endo

This month’s column is going to have a few old sayings, but I think when you get to the end you’ll understand why.

There is an old saying that I really love: “No good deed goes unpunished.” I have a sneaking suspicion that the person who came up with it was a dentist—or at least had a background in health care. I feel that way because of what let’s call… ahem… “life experience.” In my career, I’ve had more than a couple of instances where I started out trying to do the right thing for a discounted fee and then ended up asking myself why I ever started the situation in the first place.

Here is an example. Once upon a time in the not-too-distant past, I saw a patient in my practice’s clinic. He came in with an initial complaint of pain to biting pressure in the lower left quadrant. He’s been a patient for almost 2 decades. He is a good, low-key, honest individual who works hard but is not in a career where he has a lot of disposable income. Over the years I’ve done some procedures for a reduced fee, or even no fee, simply because I felt it was the right thing to do. I truly feel that we are put here to help others and this nice gentleman is the living embodiment of the type of individuals I feel inclined to help.

I isolated the problem to tooth #19’s mesiobuccal cusp with a Tooth Slooth (Ocean Microendodontics) and I made a diagnosis of cracked tooth syndrome. I explained the problem to the patient and we discussed potential solutions. At that point in time, his financial situation did not allow him to afford to pay for a new crown. In the past, I had done some fixed prosthetics work for him for only the lab fee, but even that wasn’t feasible for him that day.

The tooth had a large occlusal amalgam restoration that occupied a good deal of the previous clinical crown and had weakened the cusps. I suggested a direct bonded composite restoration to help reinforce the tooth structure, hoping that would get him by until we could get a crown scheduled.

I removed the existing amalgam restoration and underneath it found a calcium hydroxide base material. Due to the age of the restoration, I guessed it was Dycal, but that was pure speculation. Since it was a very old restoration, I anticipated that the original treating doctor had likely used Copalite varnish as well. Varnish interferes with bonding, so I felt it was necessary to remove the base material as well as a small amount of tooth structure from inside the prep to ensure fresh dentin and enamel for bonding.

Next came the “good deed” that was about to be “punished.” I carefully removed the calcium hydroxide base, and as I flicked away the last crumb from the deepest area…I learned that the material had been used for a direct pulp cap.

I know that most of you have been in a similar situation, but if you haven’t yet, you will. And let me tell you, it is not a fun place to be. So, I took an intraoral photo of the situation and then began to explain to the patient that had just told me he cannot afford a crown that now he will most likely need a root canal AND a crown. Fortunately, the patient and I had a long record together and he understood that sometimes things like that happen. It also helped that I had been taking intraoral pictures of his teeth for years and I could quickly and easily show him the image of the situation.

Pulp Therapy

Over the past 20 or so years, endodontic treatment has gotten a lot easier; thank goodness. But what has gotten even better is the fact that we have more and better ways to avoid it when possible.

It used to be that if there was an exposure or a near exposure, most doctors would default to the diagnostic choice of just doing the root canal. Heck, I even remember an instructor of mine in dental school who frequently advised students to do endodontic therapy prophylactically if the case was questionable. His philosophy was that it was easier to perform the treatment at the beginning of a treatment plan than at the end. Considering the choices and technologies available at that point in time, even now I could not argue with the concept.

However, now we have a good number of choices for when a potential endodontic clinical situation presents that might help avoid the dreaded root canal. Many doctors are now going so far as to leave small amounts of caries that are in close proximity to the pulp and attempting to harden the dentin and kill the bacteria with some amazing products.

As I routinely tell patients, root canals are a lot like getting married. By that I mean, it’s a whole lot easier to not do it than to do it and then wish you hadn’t. Normally patients laugh when I tell them that, but they also immediately know the message I am trying to convey. The other thing I regularly tell patients is that the longer I practice, the more of a John Lennon fan I become which leads to my philosophy of “Give teeth a chance.”

So with the concept of trying to avoid endodontic therapy, let’s take a look at some product options.

Base Materials

As mentioned above, calcium hydroxide has been the go-to base product for decades. However, straight calcium hydroxide does have limitations, the biggest of which is the set time, followed by its solubility. A material that does not set quickly means that either the operator waits until the material is set (which isn’t an option) or the restorative material is placed directly on top of the base, which causes it to be displaced and moved by the pressure. This removes the calcium hydroxide from the area, which decreases its effect.

To overcome those limitations, the smart folks at several materials companies developed specialized versions of base materials. These materials are light cured, which means they can be placed directly onto the area where it is needed and then set immediately with a standard curing light. The material is set within seconds and once it is set the solubility decreases appreciably. None of these requires etching or bonding agent placement prior to application. They give the pulp the opportunity to recover from insult and help, over time, determine whether the problem is reversible pulpitis or irreversible pulpitis.

BISCO TheraBase®

The smart minds at BISCO have come up with an amazing base/liner. Like its sister product TheraCal, TheraBase® releases calcium but it also releases fluoride. Plus, it is also a dual cure material that can have its cure initialized by a curing light and then continue to polymerize to a full set with an autocure component. This means TheraBase can be used with confidence in any preparation that needs it, regardless of the prep depth or location. Because it has a robust dual cure component, it will fully set even without a curing light.

The calcium and fluoride ions are released and recharged throughout the life of the restoration. It is stronger and more durable than other base materials while also being radiopaque for easy identification on radiographs.

TheraBase is delivered via an automix syringe with an intraoral tip. This allows the operator to get the small tip into the exact spot and then dispense it easily in correctly mixed increments.

TheraBase generates an alkaline pH of approximately 11. It contains the adhesion-promoting monomer MDP, which helps the material create a predictable and solid bond to the prepared dentin.

Pulpdent Activa™ Bioactive—Restorative™

Pulpdent has done a great job in the past decade in the arena of bioactive materials, especially their line of Activa™ products. I bring this up because, although in this section I’ll be discussing Activa Bioactive—Restorative, there are other products in the Activa line and they all work very well.

ACTIVA Bioactive Restorative from Pulpdent.

Activa Bioactive-Restorative is a composite with bioactive properties. We are beginning to see more composites with similar properties, and I am excited about the future they promise.

This material has good esthetics, and it holds up well in the oral environment. It is more bioactive than the glass ionomers the profession currently uses while also being more fracture resistant than traditional composites. Those factors are important to me in pediatric cases, and I find myself reaching for this material more and more when treating children in need of direct restorations. We all know that because of skeletal growth children’s occlusion can change rapidly. That means that a restoration that has perfect occlusion today may be in a malocclusion in 60 days. That can lead to either fracture and loss of the restoration or a fracture only, but neither is a good result.

I am more concerned about fractures that allow pathogens to easily penetrate under the restoration and rapidly cause breakdown of the underlying dentin, which can result in pulpal pathologies. Knowing that the restorative material I am placing is fracture resistant helps me lay my head on the pillow with a little more confidence at night.

Thermal Pulp Testing

My last piece of advice is one that gives my geeky heart a small pitter-pat of pride. For cold testing, most offices keep a can or 2 of chemicals to spray on a cotton-tipped applicator or cotton pellet. Once the cotton is saturated, the cotton can be pushed against the tooth to create an isolated cold test that tells the doctor if the tooth has a response to cold.

I discovered one day that a spray can of electronic component cooler contains the same chemical we dentists use to do our cold testing. The only difference appears to be the cost. Check for yourself, but you might be able to save a few dollars by purchasing electronic component cooler spray instead.

Conclusion

I love dentistry, I love endodontics, and I love helping people. I am so excited to see the profession continuing to improve and evolve. I also love having options and giving patients choices.

We have plenty of opportunities to help others throughout their lives. By helping the body to repair itself we are giving patients a tremendous gift. I like to tell patients that “modern medicine can do amazing things, but nothing we do is better than what God put in at the factory.” By helping our fellow human beings maintain their “factory equipment” we are helping them to proceed better equipped into the future.