Help with stepwise excavation and calcium hydroxide

[lilodent]

Dear everyone.

Today i had a patient where i had to do a stepwise excavation. It was more like an intermediate restorative material because of lack of time, and so i thought it could as well work as stepwise excavation.

However i ended up forgetting using dycal which is a calcium hydroxide, and i also obviously forgot vitrebond (glas ionomer liner) too since i forgot the dycal. Patient is now home. I am wondering how big of a problem it is to forget these 2 if the patient is going to get a permanant filling made in about 1 month from now?

I guess i will not have any tertiary dentin developement and hence it will be non effective?
Please answer me thank you in advance.

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[FanOfCostco]

How deep is the caries? Are you on affected dentin? How close are you to the pulp?

 

[lilodent]

How deep is the caries? Are you on affected dentin? How close are you to the pulp?

The caries was deep but only mesially though i had to open up from the occlusal part to get there and excavate. The preparation ended up being about 3 mm above the gingiva on the mesial part of the molar tooth and going a bit occlusal since thats where i had to open up from (1/3 of the occlusal surface is now IRM). I didnt go into the pulpa but i guess it was close enough to have to do it with the dycal and vitrebond. And i was on affected dentin, but removed most of the caries and then left it not 100% cleaned since i was getting close to the pulpa so i thought a stepwise excavation would be better to get the nerve a bit further in these next week so we can do a permanent filling then.

However do you know what will happen now for a stepwise excavation?

 

[FanOfCostco]

The caries was deep but only mesially though i had to open up from the occlusal part to get there and excavate. The preparation ended up being about 3 mm above the gingiva on the mesial part of the molar tooth and going a bit occlusal since thats where i had to open up from (1/3 of the occlusal surface is now IRM). I didnt go into the pulpa but i guess it was close enough to have to do it with the dycal and vitrebond. And i was on affected dentin, but removed most of the caries and then left it not 100% cleaned since i was getting close to the pulpa so i thought a stepwise excavation would be better to get the nerve a bit further in these next week so we can do a permanent filling then.

However do you know what will happen now since i forgot? Should i redo it or is it ok since its not a permanent filling or is it a HUGE mistake to forget it for a stepwise excavation?

2 things can happen
1: nothing
2: tooth becomes symptomatic and then needs RCT

Take an radiograph at next appt and see how close you are to pulp.

My suggestion is to wait and see what happens. It will probably need a RCT sometime down the line.

 

[Vicviper]

IRM was created to be the type of material that you can just scoop out gross caries with an instrument and smush it in with your thumb, its very resilient.

The stepwise method you're describing is super old school, but that's what they teach you in dental school! If you were my resident, I would say to wait two months, take a new radiograph, vitality test the tooth, and if it's looking normal, proceed with a final restoration. One option would be to remove most of the IRM / prep to near ideal , and use the IRM as a base (which is what it is), and placing an amalgam - you can't use composite with an IRM base. If you remove all of the IRM, you risk traumatizing the pulp more, but if you want to, use a slow speed and be careful.

I would say you wouldn't notice much of a difference than if you had placed dycal. Many studies are showing that it isn't the best material to use, and often its better to just place Limelight or Vitrebond and place a final restoration. All that said, you'll probably just end up having to do what your instructor that day feels is best Good luck!

***PS, for after your graduate: what I recommend doing in cases of very deep caries that is showing reversible pulpitis is what we call a Seditive Filling at my clinic. We excavate caries, always leaving affected dentin over the pulp, placing either Limelight / Vitrebond, and restoring with Fuji 9 (Glass Ionomer). Wait 2+ months, and if it's asymptomatic, place a final restoration, leaving the Fuji as a base. You'll be surprised at how well indirect pulp caps work, but you always need to inform the patient of RCT risk. If you're planning on doing a crown, it is sometimes better to just go ahead with the RCT depending on vitality testing.

 

[lilodent]

IRM was created to be the type of material that you can just scoop out gross caries with an instrument and smush it in with your thumb, its very resilient.

The stepwise method you're describing is super old school, but that's what they teach you in dental school! If you were my resident, I would say to wait two months, take a new radiograph, vitality test the tooth, and if it's looking normal, proceed with a final restoration. One option would be to remove most of the IRM / prep to near ideal , and use the IRM as a base (which is what it is), and placing an amalgam - you can't use composite with an IRM base. If you remove all of the IRM, you risk traumatizing the pulp more, but if you want to, use a slow speed and be careful.

I would say you wouldn't notice much of a difference than if you had placed dycal. Many studies are showing that it isn't the best material to use, and often its better to just place Limelight or Vitrebond and place a final restoration. All that said, you'll probably just end up having to do what your instructor that day feels is best Good luck!

***PS, for after your graduate: what I recommend doing in cases of very deep caries that is showing reversible pulpitis is what we call a Seditive Filling at my clinic. We excavate caries, always leaving affected dentin over the pulp, placing either Limelight / Vitrebond, and restoring with Fuji 9 (Glass Ionomer). Wait 2+ months, and if it's asymptomatic, place a final restoration, leaving the Fuji as a base. You'll be surprised at how well indirect pulp caps work, but you always need to inform the patient of RCT risk. If you're planning on doing a crown, it is sometimes better to just go ahead with the RCT depending on vitality testing.

But what if i forgot vitrebond?

Is there a difference between vitrebond and limelight? We have never been told of limelight at my dental school.

Ps. Thank you so much for answering me this fast. It is really nice to hear what other dentists know outside ones own dental school.

 

[lilodent]

2 things can happen
1: nothing
2: tooth becomes symptomatic and then needs RCT

Take an radiograph at next appt and see how close you are to pulp.

My suggestion is to wait and see what happens. It will probably need a RCT sometime down the line.

But how long do you suggest before i take the radiograph? And do you mean it needs RCTbecause its the typical outcome usually anyway?

Also is it really bad to remove all of the IRM and just redo it or will it be too big a risk to take in regards to caries and irritating the tooth?

 

[FanOfCostco]

But how long do you suggest before i take the radiograph? And do you mean it needs RCT because of my fault or because its the typical outcome usually anyway?

Also is it really bad to remove all of the IRM and just redo it or will it be too big a risk to take in regards to caries and irritating the tooth?

The outcome usually means rct. Even if it's asymptotic I always tell the patient I recommend a rct because if we crown it, etc it will be harder and decreases integrity if crown (depending how close you are to the pulp)

Removing irm and redoing it probably will cause no issues. Edit unless you really go at it and expose

 

[Vicviper]

Anytime you have deep caries, there is always a possibility of needing RCT, you always need to tell a patient that before starting a deep lesion, and like Costco is saying, sometimes you'll just go ahead and recommend the RCT, especially if it's going to be like a bridge abutment. You didn't put the caries there, needing a RCT will never be your "fault" unless you un-necessarily pulp when caries isn't deep, or somehow fry or cause iatrogeneic damage. Learning this takes a lot of stress out of doing deep restorative.

I don't think the fact that you didn't put in Dycal or Vitrebond is a massive problem (and yes, Limelight is similar, there's a million different products out there). Just be honest with your instructor and do what they say.

 

[lilodent]

Thank you everyone, you definitely taught me alot out of my problem and i really appreciate your help!

 

[Saddleshoes]

IRM was created to be the type of material that you can just scoop out gross caries with an instrument and smush it in with your thumb, its very resilient.

Bingo!!!

A lot of us old timers remember using IRM only for getting military people ready to deploy overseas for a year. Most of them did just fine.
A lot of us old timers remember using IRM only to clean up "rampant caries" in kids in the public health clinics. Most of them did just fine.
A lot of us old timers remember using IRM only to take "Sick Call" patients out of pain in institutional clinics. Most of them did just fine.
lilodent your patient will likely do just fine too.

 

[decent07]

hi i m new to forum and learning a lot in deep caries sometime pt feel a lot of pain during caries excavation although pulp is not inflamed how to deal with such cases shouid we use LA

 

[FanOfCostco]

hi i m new to forum and learning a lot in deep caries sometime pt feel a lot of pain during caries excavation although pulp is not inflamed how to deal with such cases shouid we use LA

Are you sure you have profound anesthesia? (I'm assuming mandibular)
You can try doing PDL.