Thursday, January 19, 2017

Indirect Radiowave Radiosurgery Coagulation--no14

Centers for Oral Care
No. 14 -- 19Jan2017
Fellow of the Academy of Veterinary Dentistry
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Indirect Radiowave Radiosurgery Coagulation
For hemostasis of soft tissue, the Partially Rectified Radiowave Radiosurgery waveform is chosen. It must be remembered that this waveform produces increased lateral heat and tissue shrinkage. It should not be used for coagulation in close proximity to bone or when performing osseous surgery. The Ball Shaped, #135, or Pencil Point, #117, electrode tips, [Ellman International], are commonly chosen for this procedure.
Normally, the area must be free of blood for the coagulation to occur. This means removal of blood or constant daubing or rinsing to keep the blood pool away from the electrode tip during coagulation. With Indirect Radiowave Radiosurgery Coagulation [IRWRSC], a 1"x1' gauze square becomes a sandwich interface between the active electrode tip and the area of soft tissue that needs coagulation. The insert, electrode tip, is placed over the gauze to effect coagulation and acts as a buffer to prevent a pooling of blood from accumulating before the coagulation can be completed.

If using a larger Ball Electrode, it necessitates a higher intensity of power which leads to increased lateral heat. For this reason, it is recommended to utilize the smallest coagulation electrode tip possible [i.e. Pencil Point, #117]. Always wait 10-15 seconds if performing a second coagulation. While waiting, use gentle direct pressure with a saline soaked sponge over the coagulation site. The second coagulation may not be needed. On the other hand, the second coagulation may only require a one second Direct Radiowave Radiosurgery Coagulation [DRWRSC].
Be sure that the passive electrode plate is in position when performing IRWRSC. According to Sherman, "the radiosignal is transmitted from the active electrode through the tissue…being received by the passive electrode and returned directly to the radiosurgery unit. This pathway is the most efficient and produces a more stable and consistent cutting/coagulation current." [Sherman JA, Oral Radiosurgery, An Illustrated Clinical Guide, Chapter 3, P15, Taylor and Francis, 2005].
Before the development of IRWRSC at the CT and NY Specialty Centers for Oral Care, there was no information to show that the radiosignal passes from the active electrode, through a coagulum buffer [i.e. gauze square], to the passive electrode with return to the surgery unit with such efficiency. This break through technique allows the most difficult coagulation procedures to proceed without flaw. Do not overheat the site with continual coagulation. Remember, the Partially Rectified Waveform does produce significant lateral heat. Be patient with a one to two second contact of the tissue at one time. With patience and digital pressure with a saline soaked gauze square, the hemostasis will be achieved in a maximum of two contact times.
The Pulpotomy-Vital Pulp Therapy-Endodontics and IRWRSC

The same IRWRSC technique can be utilized in the Pulpotomy Procedure in the canine or feline. The procedure is initiated with a high speed handpiece to extirpate and expose coronal pulp.
The Fully Rectified Waveform with a U-Shaped, #114, insert is utilized to remove the coronal pulp tissue. Isolated bleeding can continue after this procedure is completed. Because of this bleeding, it is difficult to effect hemostasis with the Partially Rectified Waveform.
IRWRSC can solve the problem. If a wick of gauze or paper point is placed into the canal and the Partially Rectified Waveform with a Ball Shaped, #135, or a Pencil Point, #117, electrode tip is utilized, the bleeding will stop because the electrode tip is not sitting in a pool of blood. [see Illustration]

Again, it is important to only make contact with the pulpal tissue for one second. Wait thirty seconds, if necessary, and repeat. Multiple coagulation attempts should be avoided to prevent pulp necrosis. In permanent dentition, if after two attempts there is still pulpal bleeding, it may be advisable to consider the possibility of advanced bacterial pathology within the pulp. At that point, abort the Vital PulpTherapy procedure and complete a Conventional Root Canal procedure. Intraoral radiology must always be used to confirm that the Vital Pulp Procedure or the Conventional Root Canal are indicated.

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