In an ideal world, we'd love to remove the entire restoration,
remove any carries access for cracks. But when our 20 minutes,
we need to get in, go for the kill. Is that okay? Can you forgive us? Yeah.
No, it is at the end of this is about patient.
This is about getting the patient out of pain. Okay?
And you just need to get in there. I used to call it ninja endo. Get in there,
get the job done, get out before that patient realizing it.
That's my principle at Endo. Whether it's emergency or or endo,
you wanna stealthy? Stealth. Stealth. Okay.
.
Welcome to group function where the prot true serrate work together to find good
solutions to worthy problems in dentistry with your host jazz gulati.
What is your current protocol for exta patients?
So let's say you made a diagnosis of irreversible pitis.
Your patient is in raging pain and you have to squeeze in this pain relieving
treatment ATA patient probably of a lower mo or something in five minutes.
What are you gonna do? Well,
some of you will listen to this and it'll be validation and revision and you'll
be thinking, Wow, I've been doing it right all this time,
even though I thought maybe I was taking shortcuts,
but actually I've been doing it right all this time. And others will be like,
Whoa, this is so much easier compared to what I'm doing at the moment.
Because the big hint I can give you is that you don't even need a K file for
your molar expeditions anymore after today. Cause I've got Dr.
Sanger specialist and Adonis to talk us through what is the right way,
the proper way to do an extra patient of your patient who is in pain.
And there are just so many gems from pain relief, diagnosis,
isolation. And,
and what I love about sang in this episode is that he's not dogmatic. Yes,
he's a specialist and Adonis and it's so easy for him or anyone say you must
always use rubber dam. But he actually does discuss a scenario that, okay,
if for reason you had to do it without rubber dam,
how can you optimize the isolation?
How can you reduce this saliva getting inside the tooth?
So I really appreciated that about this episode. I'm sure,
I hope you will as well. It's very much in tune with the real world. And lastly,
we do cover his step by step,
what is the right and proper way to do an expectation without wasting time and
without actually making things worse for future treatment.
So hope you enjoy a episode and I'll catch you in the outro. Dr. Sandra Bender,
welcome to the Protrusive Dental Podcast. How are you my friend? I'm.
Very well, thank you, Jazz. Thanks for the invitation.
Excited not done one of these before, .
Oh, well I, I'm amazed at your first time and uh, it is, you,
you're a real hero of mines cuz I dunno if you remember 10 years ago I met you
at the uh, British Endodontic Society. Can you believe it was, Is that long ago?
God, 10 year. You know, everything's a blur nowadays at my age.
could been yesterday. It will be still, still seem the same,
but no thank you. It's, it's lovely to have to be here. Thank you.
Jess. Thank you so much.
And I remember your lecture even then and I remember some of your lecture,
the BDA and probably cuz our paths haven't collided. I haven't seen you,
I knew you're very active with your teaching,
but our paths haven't collided since then that much. But it's,
it's great to have you on to talk about a very important topic, which is how to,
to get a patient outta pain in terms of your diagnosis, irreversible pitis.
And we're gonna talk about what is the optimum and best sang approved way of,
of dealing with that that you wish your referring dentist would do.
And the other one we'll talk about is post-op pain.
But before we dive into the nitty gritty details,
just please tell us listening to an international audience in terms of where is
it that you work, what got you into Endo, a bit of your background.
Sure, yes. I've been in this game in Endo anyway for,
well dentistry I suppose We go all the way back.
It's gonna be our 30th anniversary next year. So, uh,
which is a bit bit frightening. So now qualified in London, actually in London.
But I now live in Manchester and I've sort of wormed my up north to the
northwest, uh, mainly by accident really. And just,
just hospital jobs initially came up. Then I did my postgrad training up here.
I mean back in those days, 1995 there was no,
there were only three postgraduate ended programs outside the hospital training
pathway. And I was either London or Manchester.
I happened to be at the right place at the right time in Manchester.
I got onto the Masters quite young, actually quite early.
I think it was the first one in our batch in our year at guys.
And I wasn't a high flying student at all.
I managed to first one to get an MSC and then I stayed in Manchester at that
time in the mid nineties. I d if you're too young to remember jazz.
But it was quite a good university simply. And uh, it was uh,
I think I had a better student life as a postgrad than I did in London. But, uh,
no, it was things were changing in Manchester. The dental school was good.
I was teaching, there were not many endodontists.
One of the reasons I stayed up north, actually, uh,
because I knew the job prospects would be better.
This is before Endo became really popular and I could see it. In fact,
it's by accident. I fell into Endo.
It was gonna be either implants at that time. There was an implant,
See there was an Endo MSC because that was one of the only endo MSC in the
country. I was too young. I would never go on.
The people that got onto that were experienced practitioners and I'd really had
no chance. But I, that's where I was gonna go, ironically, the opposite way.
And I ended up doing Endo and it sort of taken off from there and I just got
into Endo and I stayed in Manchester job offers and I pretty much been fulltime
endo day one from finishing the masters. So since 97.
So how many days are you clinical at the moment in terms of doing your, um,
endodontics, uh, you know, referral practice?
Yeah, so I'm pretty much now full, full-time. As in I was full days,
I'm down to three days now and I've gone an associate role,
Rob Jacobs who covers me. So, uh,
so I'm down to three and a half days and teaching now just in private courses,
uh, up and down between London and Manchester with a couple of friends.
So that keeps me outta the practice. But pretty much I've always been a,
a hands on clinician.
So you're very wet fingered, very clinical. You,
you've got a great name in the UK as a, the person for Endo. So again,
it's a privilege to have you on.
The reason I have you on is because extra patients,
I speak to different colleagues and we all kind of do it differently.
So I wanna find out what is it that you recommend.
And I remember asking an endodontist some years ago what they recommended and I
got interesting answer from the endodontist. He said that, you know what,
as an endodontist,
I rarely get to see the emergency extra patient cases anymore.
Cuz usually by the time they've come see me, there's a sinus track,
there's a per endo lesion and they're really complicated.
So firstly I'm just being nosy. Uh, how much emergency expectations do you,
do you get, how many of those phone calls do you get?
How many do you actually treat in that regard.
In terms of the practice? You are absolutely right being an end dontist, we, we,
by the time they get to us, they're the non-it previously root failed or the um,
or the dentist has had to go doing it.
We get a lot of phone calls and mainly from dentists. What do I do?
How do I numb the tooth up? And this sort of thing. We'll talk about that um,
shortly. But in that way I'm kind of slightly lucky,
although I know how to deal with it. And we have to back in the training,
working in dental school, you're in the emergency, the dental casualty,
whatever they call it nowadays. So you had to deal with that.
You had to learn pretty quickly. One of the reasons I went into endo is just,
okay, it is not just about the white lines at the end of the endo treatment,
right in the beginning, getting patients out of pain,
immediately out of pain just until they relax and you get them back into the
proper endo. That is really important. And,
and in that way I'm kind of shielded being in specialist practice cuz my general
dental colleagues there at the cold face and they've gotta deal with that stuff
on a Friday afternoon just before they close. Patient wore rocks in, you know,
and never slept for a week. And they're anxious and they're nervous.
They've never been to a dentist sometimes.
And you've got all that to deal with and you gotta get 'em out of pain and you
can't fo 'em off with antibiotics. It's just not appropriate nowadays medically.
It's not. You could get into water if something happens.
So you've gotta be able to get in there and deal with it efficiently as
painlessly as possible.
And that's the challenge cuz the tooth is extremely inflamed and,
and just stabilize everything so you can get them back in when you've got plenty
of time, we'll get someone else to do it.
Whatever the protocols are for that is important. Yeah. Um.
But before we go in for the,
for the kill and talk about the exact protocol that you would recommend to
alleviate someone out of pain. Let's talk a little bit for the,
for the younger audiences saying maybe students who are listening right now, uh,
just coming up with a,
a diagnosis of when it is appropriate to give antibiotics because perhaps the
necrotic infected and really it might already be root filled or whatever.
And then what kind of history and clinical findings are are leading you to,
towards a diagnosis of irreversible popit that needs that intervention that
wouldn't settle with antibiotics. Can you just, uh,
give a distinction between the two different types of patients?
Okay, so you've got two different situations. You've got the,
the root fill and non root fill tooth. I won't talk about the root fill tooth.
Yeah. Cause that's a different, slightly different scenario,
but on a tooth that's either potentially vital or semi vial
or parro or completely nero. Okay. So you start from the,
the pro the disease process obviously starts at the top.
The pulp typically carries tooth fractures.
Bugs have gotta get into that pulp.
Now sometimes the patients will have very low grade symptoms and a
ni a du lake, maybe a bit of thermal sensitivity. And they, they,
they kind of put up with it and sometimes those pulps will die,
but it's the ones that don't die or die painfully. And they,
they go through an acute phase. What we describe as irreversible pulpit. Uh,
they're the ones at the challenge because, because the, the top of the pulp,
the, the, the pulp that's most in inflamed,
closest to the insult could be carries or a fracture.
That bit of the pulp will be difficult to nichetize. So the whole,
when you give a block, uh, typically for a lower tooth,
you'll give a block anesthesia, you'll give an infiltration,
the anesthesia will not penetrate up the id, um, nerve,
you won't get into the poll, it'll get into the pulp aly,
maybe curricular area, but it won't get to that point,
which is the closest to the insult, the most inflame.
That's the challenge getting from the, where I describe it to the patients.
I show them the x-ray, this is your tooth, that's the top.
You got all filling there.
We need to go from the top thesal surface down to that pulp chamber bit.
We're gonna go down to there. Now a lot of it's patient management,
it's preparation. Okay. Because we'll go through the anesthetic protocol,
which hopefully will work, but sometimes you're just not going to work.
But you need to know that.
And you know that from the patient's symptomology where they walk in,
you just know that as a hot pole, there's a chance that they're not,
you're not gonna be able to anize it doesn't matter what you hit them with. Um,
there are a few things we'll talk about how to prep that. If you,
if if they aren't walked in off the street,
if you know there's a pulpit coming in you,
there's a few things you can ask them to do before they come in just to,
to help the anesthesia process. And then when they get them in, in the chair,
it is management's a lot of good anesthesia, multiple techniques, uh,
different agents and then going in carefully and managing the patient,
being empathetic,
but up to a point if they can't tolerate it or their anxiety levels is too much,
you sometimes have to do in stages. Sometimes you've gotta gotta go for it.
And it's sometimes you've gotta be cruel to be kind, but in,
in the appropriate patient mm-hmm. , you can't just dive in and,
you know, you lose a patient and it's just not nice.
You've gotta imagine yourself in that position,
but equally you wanna get 'em out of pain. So it's a balance,
it's a real fine balance. Yeah.
Based on just, just the other day I saw, um, an acute, a patient in acute pain,
uh, and, uh, after getting somewhat good anesthesia, you know, objective,
you know, I, I tried with endo frost my degrees beforehand,
managed to elicit an aquatic response compared to others actually.
But he had recent symptoms of eros ptu, so it was probably mostly necrotic,
but there's still, uh,
some element of vitality to it based on his symptoms he was presenting with. Uh,
and so when I did manage to reach the pulp chamber of this lower molar,
he placed a file just into the distal. Now this wasn't bleeding,
so it confirmed my diagnosis of necrotic, but I saw the,
the white pulpal tissue. Uh, so soon I put my um, uh,
K file into the dis he, he pretty much jumped out the chair.
So I gave the intra pple and that that just settled him.
So it kind of leads communis and like you said,
I had to be cruel to be kind for that patient.
Now what could I have done had I known, I didn't know who was coming in,
but what kind of anesthetic supplement or advice could I have given on,
on the phone as you alluded to,
to help achieve better success rate of anesthesia? Yeah.
I'm, it its about reducing the,
the inflammatory status that pulp is as best you can and systemically, I mean,
and there's plenty of evidence to say that loing them up with
anti-inflammatories. Nonsteroid also four to 600 ibuprofen with or without,
uh, paracetamol if they,
they can't tolerate anti-inflammatory asthma or stomach issues. Tramadol,
something like that. A codeine paracetamol not as good as an anti-inflammatory,
but it's better than nothing that will just physiologically reduce the
inflammatory stages.
It doesn't guarantee that that tiny bit of the pulp that's inflamed will
completely anesthetized. But it'll definitely,
there's plenty of evidence saying it will help The anesthesia anesthetic process
in terms of the actual local anesthesia for the lower teeth always
is notoriously the worst teeth mo teeth first.
Second mo is dose teeth are really difficult to numb and it's because they've
got accessory nerve supply as well often. And, and for me the,
the baseline technique is Id do you doing an ID block,
I don't mess out with intra PDLs and this sort of thing. And you know,
just need to knock, knock that nerve out.
Not as much as you can supplemented with buckle infiltrations of an agent
that's, that absorbs well, and for me it's aade. So if my ID block, um, I,
I would give li can as, as a start,
this is an acute emergencies I don't use Nick can often actually, yeah,
I'll tend to fall back on, can talk that later on.
Why use prefer came for routine endo,
but for hot teeth you need profound anesthesia. You don't need longevity.
But Li Canin works pretty well as an id.
I'm not a fan of giving I id blocks to the heart cane,
but I know the evidence suggests it is very good and there's controversial about
the risk of paraesthesia and it may not be anything to do with the agent,
it's probably to do with the fact it's trauma from the needle,
but I'd rather not if, if there's an alternative and it,
which works just as well.
So Id li can wait for that to be to work completely work.
So we're talking, the lip is completely numb.
The lingual muco are completely numb. Not even the patient can't feel a thing.
Then arca buckle infiltrations,
it tends to absorb better through the buckle plate. It's pretty thick, you know,
especially in the sixth and seminary.
And then I might give PDLs as well or lingual under pressure.
I've got an intra periodontal device called the wand that are few other devices
and now available, which do the same sort of thing.
They're basically under high pressure with a short needle.
They can deliver the anesthetic through the pdl.
And the theory behind that is a PDL is almost as good as an in ous
SIS is the other mechanism.
You can drill a hole into the bone through these self drilling devices,
which has a, a pretty good effect. I've never got a used to those devices,
but some people swear by them.
But you need to get that profound anesthesia in there. Uh,
and you just gotta wait mention, just make sure that the anesthetics work,
don't just dive in and then your ation management.
Mm-hmm. well with the busy lives of general dental practitioners,
uh, juggling at getting these patients in,
making the diagnosis can take in a 15,
20 minutes sometimes to take a radiograph. Then giving them the block,
let's say an infiltration,
getting 'em sit outside while you see a few more patients.
I'll see you in my lunch breaks, Mrs. Smith or whatever.
Then the lunch break comes, your nurses rolling our eyes, they swap nurses.
And so it's all, it's all happening in, in busy practice.
Now let's say we made our diagnosis of iritis and we know we need to extricate,
We have a given sufficient anesthesia and the patient loaded up with ibuprofen
and all the stars aligned. When we are dealing with such teeth,
they usually have large mod amalgams or something like that. Right?
So my first question in terms of making it very tangible for, for,
for general busy general dentist is in an ideal world,
we'd love to remove the entire restoration,
remove any carries access for cracks. But when our 20 minutes,
we need to get in. Go for the kill. Yeah. Is that okay? Can you forgive us?
Yeah, no, it is at the end of this is about patient,
This is about getting the patient out of pain. Okay.
And you just need to get in there. I used to call it ninja endo. Get in there,
get the job done, get out before without patient realizing it.
That's my principle at endo, whether it's emergency or or endo,
you want stealthy? Stealth. Stealth, Okay, . And it,
the first part is get, get into the pulp. You're releasing the,
by going into the pulp, you also actually release pressure.
There's pressure buildup. That's the number one proative inflammation, isn't it?
Then you need to set,
basically you are applying a set to material to relieve the inflammation.
The most common, uh, and popular products that steroid.
Based. No, but before we talk about ments and stuff, Yeah.
Before we talk about the predicaments, I,
I'd just love to ask some real world questions. Like let's say you go in,
you open up the pop chamber,
do you think is desirable for the practitioner who's gonna refer to you in the
future?
Should we be also removing the roof of the pulp chamber as much as possible?
So let's say that lower molar saw the, the other day had four canals,
mis buckle melenal, two distals. So four canals. And I did,
I opened it all up as much as I could to to, to visualize those four canals.
And it was mostly restorative material I was removing at this point at now,
is it okay in that short appointment to just literally go in,
see the pop chamber and then proceed to predicaments?
Or would you recommend to open it? Or does it depend on any factors?
Okay, in short, forget about the root canals job is get in there,
relieve the pressure, open the pulp space up and apply the dressing.
That's simple. Like that's all you have to do on a Friday afternoon.
Even even like three or four millimeters in, in the middle, that's sufficient.
That's tissue. Because what then tends to happen is,
so the inflamed part is the,
the al pulp or in fact just the top bit of the pulp horn.
You'll find once you've though, in those cases, you've gotta game in chipo and,
and intra pulp. Going back to that,
essentially all you're doing is crushing the nerves.
It doesn't matter what agent. You could use sterile water,
but the pressure crushes the nerve in that inflamed part,
you'll often find the rest of the pulp. Okay? It might be hyper emmic,
it might be bleeding a lot, but they won't feel that.
Remove the cor pulp if you can, if you know if the, it's not painful.
And then just dress it. Don't worry about the root canals at this stage,
that's not the priority. In fact,
if you then start fishing around the root canals,
you're gonna start shredding pulp tissue.
And unless you get the rest whole pulp out,
that pulp tissue you lead behind in the ale or mid third it's gonna be inflamed.
And then the patient just, you get equals other problems. Mm-hmm. .
So the pain's coming from the al pulp deal with that dress it and,
and going back to the restoration, unless there's a gaping hole underneath the,
the, the, the ODM album or it's clearly this care, you know,
it's just this saliva coming in. Don't worry about this stage.
You can temporarily seal that off with cavitt or cows on or whatever you're
gonna use. Just close the tooth, sedate it, close it,
and then get them back in for, to then strip the tooth apart if you have to.
And it'll be easy to numb up. You can then doability assessment. If it's not,
if it's too knackered from the outset, then you just refer for an extraction or,
or booking for an extraction. But if you, if you're not sure,
then don't worry about that.
You can assessability and then treat and plant endo, uh,
once the patient's out of pain. And they're easy toti.
So don't miss about the po root canales at this stage.
This is about dressing and getting out of pain.
Don't fish around the root canales.
Endo. There's gonna be enlightening san there's gonna be absolutely enlightening
because I know plenty of colleagues who have advised me in the past and they
swear by this san, they said,
You won't get the patient out of pain until you file all the way through the
apex. Now is that a myth? Largely.
Yes. It's a myth because.
Have you had this.
Vital, So the pain is coming from that top bit. It's not the rest of the pulp.
In fact, we'll come onto this. We get time. We,
things are slightly changing now the way we treat vital pulps. Okay,
this is an interesting conversation where we are now,
I think this is too early to bring this in.
So we're in the realms of what's called vital pulp therapy,
where maybe we don't need to extricate pulps at all or the
root canal.
We can do the cro pulpotomy as we used to do for kids in immature teeth.
Remember the Shrek pulpotomy back in the day. That concept is now coming in,
in adult teeth, not just immature adult teeth molars, for example,
even in mature teeth. And this comes, this is the,
the kind of crossover between cardiology,
the caries management and restorative dentist coming in.
And they've been doing this kind of stepwise technique and all that.
But at the end of, we've always been aware,
not been happy with that because it's been unpredictable.
Materials haven't been appropriate.
And the risk is the patient could come back in acute pain,
they'll come back with advanced disease, endo disease,
which then therefore the prognosis lowers. Um,
all the pulps completely obliterate.
And then when you have to do the endos a nightmare,
things are changing a little bit with the new materials. But, but at this stage,
in terms of emergency management, it's enough just to deal with the,
the criminal part of the pulp, the rest of the pop.
Often you'll stay vital whether you then take the do the full root. This.
Is music to everyone's a this is music.
So whether you then go and do root canal. Yeah. So yeah,
whether you go do the full endo or you don't,
you apply these new vital pulse therapies. That's the,
that's the next interesting question. Cause endodontics is changing.
Now we didn't prevent Adon, if you like it.
Very good, very good. I think, I think that'll be a whole new episode.
But just to, to continue on the reign of the emergency management,
I think what you said is gonna be music to the ears of all the GDPs listening
who perhaps had this thought that,
and they're gonna spend this extra time and extra risk in opening up all
the individual canals, filing all the way to the apex.
So really what I'm hearing is to get sufficient anesthesia, get in there,
open up the pulp chamber just enough to get your SIV in and we'll talk about
assertive in a moment. Now my, and don't go sticking your K file,
so in fact your nurse now knows not even to give you a Kal for this emergency
expectation, which, which is brilliant. Would you recommend using HypoChlor?
Now, before we get to that, let's take one step back. I personally,
I I would always use rubber damm, you know, with your influence on, under B Bs.
I can't go to a BS conference and then not use rubber dam for anything like
this. So I always use raam, but I've got some colleagues, uh,
little bit more experience and they say jazz,
it's okay cuz we're killing the nerve anyway.
The endo don Endos will sort the bugs out afterwards. So just get, go in,
put some ve in and come out.
We don't need to irrigate and we don't eat rubber dam.
What do you think on that? What is best practice?
What do you want from your referring practitioners?
Okay, but I mean, best practice is you've gotta isolate the two properly,
both from a safety point of view and know also from micro biological point of
view. Now, okay, the end, that person dentist may not be doing the endone,
it's not their problem. It'll go to the endo Dons.
The problem is if bugs get in there, Sali gets in there,
it'll kill the rest of the pulp. Okay, fine. The plan is to do endo.
But the problem is, if in reverse pulpit actually is a,
apart from that inflamed bit, it's actually a sterile situation,
which is where pop therapy comes in. So you,
you don't want to introduce bugs there because you don't,
you don't know when that prevent patient's gonna get to the endodontist or when
they're gonna have the endo might be weeks, it might be months.
And if they get an infection and it gets into the aprille,
then you're into a different ballgame in terms of prognosis and treatment.
So isolation still is important. Now whether you rubber down or you compromise,
depending on the clinic and if you're working in the emergency department,
I know other factors is easy for me to say in my every tower of
dental school or or endo practice, you have rubber dam there and then,
but get good isolation. Your nurse is there, good aspiration, open the PU pub,
give it an irrigation. Remember it's only the AL bar.
You're not messing about the root canals. You don't,
you just need to bathe the area. HypoChlor.
Or coril or whatever. What do you, what do you recommend HypoChlor?
Now what do you think about people who,
because maybe they're not using rubber dam, they're then using, um,
chlorhexine 2% maybe, or, or, or, or.
It's kinda than nothing. They won't be using 2%. They're using mouthwash,
which is useless to be honest. It's the surface. It's.
True, it's.
True.
It won't be using 2% for sure cause that's quite expensive and most people don't
even then doners don't use that. Why not many do.
Even if it's as simple as open the Polk Chamber, you've got isolation, suction,
stop and I getting in there,
dipping a cotton pledge it in hyperly and squashing in there. So at least it's,
it's bathed, then dress and close. That's fine. Just be quick.
If everything's efficient, you know what you're doing. Hence, keep it simple.
You don't need endo files. The, the aim is all you need is your high speed,
ideally rubber down, but all good isolation. Um, you need your,
you in arrogant even to dip into whether you injecting to see if there's another
issue. You'll send the material and close.
But are you happy for us to use a hyper and,
and use a maybe whole syringe of HypoChlor to irrigate the superficial pulp?
It's, yeah,
it's not a problem whether you're gonna do vital pop theory or do endo,
it doesn't matter for the fus for a minute or two or 30 seconds,
you're gonna do it. It doesn't make a difference. It's not gonna do anything,
any damage.
But again, we don't need to go into the canal.
It's just staying very superficially in the, in the, in the pulp chamber, right?
Yeah.
That's all you're trying, trying to do. Get some hemostasis if you can.
If you can't get hemostasis, the agent you're gonna use will hopefully, no,
it'll kill the pulp off. So when you go back and it'll be less messy next time.
Mm-hmm . But it's good to have some disinfectant within there.
Remember the dressing material will probably also have disinfectant effect,
so that's fine. But ideally, yes, get good isolation especi, you can.
And for the sake of a 30 seconds or a minute, it's not the end of the world.
You know, you can, you can be careful enough,
I think you can be careful enough to use hypocrite. You don't need much,
you don't need a syringe. That's foro.
Just in a co p as you said is, is a real gem right there actually, yeah.
Just so can then close in.
There. I I really respect you sound Jen.
I'm not saying I really respect you because what you've given is you really
respected the, the plight of the GDP there and you haven't been dogmatic.
And I really, it's so easy for you as an say no, you absolutely must.
You're committing a cardinal in which we know we are if we don't.
But sometimes you only got five minutes and you are already 45 minutes into it,
whatever, right?
So therefore I really respect that you've given us guidelines in terms of best
practice. But you've said that, okay, if we have to compromise,
let's do it in this fashion, which is gonna help us either way.
So really good suction dip your cotton palette in hypochlorite and those
guidelines you gave.
So I really respect you for considering our position sometimes.
So thank you for that.
Now the last question in this segment for emergency acute situations before we
talk about post-op pain is,
which is your sedative of choice and which is your temporary restoration of
choice.
Sensitive choice. Very popular one.
And I still like it if you can get a hold of it is leix,
this is purely for a corona poly otomy. It's not for sticking down root canals.
Okay? It's got a steroid in it. So naturally it is anti-inflammatory.
The antibiotic component is broad spectrum.
That's neither he inal there to be honest. But it might have some effect.
This is the fact it's sve. You just wanna get the patient outta pain,
but you need to go back in. You can't leave emix for long because it it,
it does its thing and it, it doesn't do much after that. And the,
if there's any pulp beyond that, it'll start getting inflamed.
The PU will become inflamed deeper down. So if you're using leix,
it'll keep it quiet for two to four weeks maybe.
But you need to go back in there and do the full expectation,
do the full endo quickly. The alternative,
and it's still the gold standard is calcium hydroxide, onsetting, um,
it hasn't got any direct anti-inflammatory properties,
but it's a necrotizing agent. It's antibacterial.
So kind of indirectly it'll disinfect the environment.
It'll necrotizing the pot cause it's pretty caustic.
Calcium hydroxide is pretty caustic stuff. It'll fry the pulpit,
comes in contact with very alkaline and it'll do the job.
So when you go back in, you've then got the choice, whether you do end,
it will go down and keep preserve the rest of the pub.
But council drop side's fine.
Non setting councilman drop side if you can't get a hold of . Mm-hmm.
Cause I know.
How, how much do we need here because you know, sometimes nurses,
depending on which dentist they work with, they've got previous biases.
Sometimes give you a huge splodge of it and they give you a file cuz they expect
you to take it all the way to the apex cuz that's what they're used to with the
dentist they work with.
Or sometimes they give you like the tiniest bit and a and a cotton pellet.
Now personally mes i, I like to use PTFE instead of cotton nowadays.
We can hear your thoughts about that. But then how do you best apply that?
And then how much do you put and how do you seal over that?
Okay, so what I do is once you've got hemostasis or relative hemostat,
if you have, if you've got hemostasis, I literally inject the cre. It's cre,
it's like cream, I've got it. Calcium oxide cream into say this over the pole,
chamber floor, a third of the PO chamber floor. Very gently. I you can use ptfe.
The only problem with ptfe,
and I know a lot of Adonis and everyone goes on about ptfe,
the problem is if you put that into place, you roll it into a bull,
you have to roll into a bull and you squash it in,
it displaces the councilman oxide, it just squirts back out.
So you haven't got the volume. So a better material. And you write Carlton woo,
there's plenty of evidence saying you shouldn't use cotton woo because um,
you can't,
you often can't see the fibers and they sometimes petree three and you're gonna
get an infected. It'll just penetrate through the temporary material on the top.
A better alternative I use as sponge Ps. These, the sponge pelles, um,
either endo pellets or um, voco pellets,
they're better because they're compressible the poorest.
So they'll hold the calcium drug side or whatever agent you're in and it just
holds a bit bigger volume of dressing material and like,
well the problem with PTFE is you push it in,
you meant to display it and it's good because it's antibacterial.
And when I say antibacteria, because it's ptfe,
nothing bugs don't stick to the material,
which is great as an inter appointment between root canal treatment is great
for that or postoperatively, uh, we need before you send back. But uh,
for the dressing you just end up displacing it out and you want the dressing
material to soothe the tooth. Mm-hmm. . So, um, sponge, okay,
fair point. In terms of material on harp, it it, again,
it depends on how when the patient's gonna come back. It, the options are, um,
cows and all traditional reinforcing car or cows and all.
If you think the patient's not gonna go see a dentist for a long time,
either GI or irm.
IRM is my favorite because it's super reinforced cows and it's rock hard.
And in fact it was designed. Do you know the history of IRM where it came from?
Uh, no I don't, I don't.
It was developed this, I'm not sure this quite, but it was developed by the,
I think it was the US Navy. So they used doing the Vietnam war.
So what they used to do is they,
they found a material where that they'd do address again, emergency dressings,
get the the soldiers out of pain and they knew they wouldn't come back for
months on end. And that's where our aim was developed. They used it there.
So it's a long term. It's really, it's quite hard.
It's not as hard as a will composite, but it's pretty rare.
The other property's got that original component. It's slightly antibacterial,
which is why a lot of endodontics love it. Um,
it's got that long term antibacterial and it sort of deflects biofilm and
bacteria. So iron's great,
but otherwise GI encapsulated bo standard GI is hard enough,
is resistant enough and is easy, easily accessible for the of the fine endo.
They're the choice ca.
Quite soft. Is that okay for, for a short term?
Short term is fine. It depends on the cavity. If it's an enclosed cavity,
you'd literally, and the clues or access cavity,
you need depth and bulk of Cabot. It is not very, it is quite,
it's pool wear resistance,
but it's okay for no more than two to three weeks and it depends on the
patient's occlusion as well. So mm-hmm it's okay. It's okay.
Sure. Okay. But we do favor counsels on even more IRM and then user GIC if,
if if appropriate as well. So, but that's good.
If I was just summarized because the reason I've done a whistle stop straw this
because I also wanna talk about postop pain perhaps after doing RT and while
I've got this precious time, for those who don't know,
we've been months in the waiting to, to sync our diaries.
So I've got this very valuable specialist,
precious time to extract everything out of your brain and distribute it to a
producer rti. So just to summarize so far guys, we need to uh,
get profound anesthesia.
We don't need to explore in that emergency appointment to get to every single
canal. We certainly don't need to file into every single canal.
If you open up the pulp chamber,
place a sedative like letter mix or a onsetting, calcium hydroxide,
a foam on top, put some cows or GI for good measure irm,
maybe if you want something longer lasting and, and that should work.
Do we have any data on how, Cause sometimes I've done it maybe some years ago,
just patients call calls up next day and say I'm still in pain. But,
but most of the time I'd say 95% plus patients are out of pain the next day.
Cuz I, I did for, for a while do an audit the day after,
especially when I worked at guys in the emergency department. Uh,
do we know how successful it is or has that not been studied? The.
You mean the emergency dressing protocol?
Yes, the emergency dressing protocol. Yeah.
I'm not aware of any specific studies on that,
but it anecdotally from when patients car had the dressings done,
it seems to, within a couple of days,
most patients are outta pain once the dentist's been in there. Yeah.
Yeah. What advice would you give to a patient in terms of, you know,
give it a couple of days and analgesics,
Let's just finish off with what advice you'd give before we talk about post-op
pain. Yeah.
I'd warn them if almost suddenly get, get better. So give it a couple of days.
I ask them to continue the ibuprofen. If they can take ibuprofen or paracetamol,
it was acute pain, then tramadol or something like that. And I,
one thing I also do is just to, in terms of just symptomatic relief, I just,
I'll flatten the occlusion,
get all the deflected contacts out just so there's no,
most of the pain is often non lateral percussion. Uh, so just,
just flatten the tooth,
the teeth probably gonna be indirectly restored probably anyway. So just,
just relieve an ear. Uh, the tooth will be high hyper occlusion anyway.
If there's any acal involvement as well. You never in multiple teeth,
in multitude teeth, one pop could be vital inflamed,
the other part could be dead.
So you might have also a combination of ale inflammation.
You don't really know that immediately.
So just relieve the tooth out of occlusion, all that exclusion and,
and then yeah, postoperative antis, it should settle within a couple of days.
Should do. And sell 'em to go to the dentist, not your patient. You must,
they must follow this up and warn them what could happen. Because if they,
again, medical legal hat on, if you haven't warn them this, it kicks off,
they'll say you didn't warn them. And you know, just to prevent a complaint,
he needs to warn them, put in the notes, this is the advice given.
If you're not gonna come back to your clinic, uh, this needs to be done.
So you just protect yourself for the future.
Yeah, warn them.
And also make an entry into the notes that patient warn that needs to,
this is not the final treatment. You know, some people just assume that, oh,
I've done my root now and I take a radiograph. There's no root filling material.
You've seen, obviously he's been dressed at some point probably five years ago,
whatever. So yeah, good point. Well made. So thanks. Let's,
let's switch gears a little bit. I recently treated a, a gentleman,
Well there we have it guys,
you don't need to find and open up every single canal. Just get in there,
relieve the pressure, place your predicament.
And we also talked about what kind of materials we can use afterwards.
So I feel like we covered a fair amount in this group function. Listen,
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