SURGICAL RETREATMENT
For additional FAQ’s related to Surgical Retreatment, please refer to the "Special Note Re: Surgical Retreatment" posted to the main Frequently Asked Questions page of this site.
What materials do you recommend for hemostasis during surgery?
I have three recommendations for hemostasis during surgery:
- Anesthetics that contain a vasoconstrictor;
- Cut-trol (Ferric Sulfate) very sparingly; and/or
- Calcium Sulfate
For a tooth with pulpal pathosis with an intraoral sinus tract, do you recommend surgery? If so, when would surgery be performed?
In general, I recommend conventional treatment (Shape, Clean, Pack) first, followed by a 30-day check to see if the fistula has closed. If the sinus tract persists, then a regimen of antibiotics. If the sinus tract persists further, then a surgical approach may be considered.
Clinical question regarding local anesthesia in surgery. Do you use long acting local like Marcain? I got some but have been scared by a story that in some patients it can cause cardiac problems with no known antidote. Thus I have not used it and it is sitting on my shelf. I find mostly that I have enough time to complete the job using xylocaine 1:80000 for regional anesthesia, 1:50000 local infiltration, however some patients seem to metabolize this pretty quickly. Then I find additional palatal anesthesia helps but is infrequently profound in its anesthetic effects.
I routinely use 2-4 carpules of 1:50,000 xylocaine when performing surgery. Block anesthesia gives you patient comfort, but is not so good at hemostasis; therefore, infiltrating in the apical regions of the teeth included in the incision will provide powerful hemostasis and enhanced vision during surgery. In 25 years I have found this to be most effective. Obviously, certain patients' metabolic rate necessitates supplemental support anesthesia which tends to never be as effective as the original battery of injections. I use Marcaine (1:200,000) infrequently for out-of-town patients following suturing to bridge the time interval between the surgery and the patient's return to their home. Since the adrenal medulla produces endogenous epinephrine, there's no such thing as a patient allergic to adrenaline, although there may be some undesirable non-threatening cardiac events.
During apical surgery, ultrasonic retro tips work well in medium sized roots; however, in canals with larger cross-sectional diameters, the ultrasonic instrument tends to smear gutta percha around the walls. My problem is that when I condense the gutta percha off the walls the retro cavity is shallower. Any helpful suggestions please. Also what do you find is the best instrument for packing Super EBA.
Using abrasive coated tips (Dentsply Tulsa Dental) goes a long way towards eliminating gutta percha adhering to prepped walls. Additionally, prep slightly deeper than your intentions so when and if you need to condense gutta percha coronally, the depth of your prep is ideal. For packing EBA, I make all of my own pluggers from old endo explorers and customize them to address any clinical situation.