1 00:00:00,050 --> 00:00:02,720 In an ideal world, we'd love to remove the entire restoration, 2 00:00:02,720 --> 00:00:06,360 remove any carries access for cracks. But when our 20 minutes, 3 00:00:06,360 --> 00:00:09,840 we need to get in, go for the kill. Is that okay? Can you forgive us? Yeah. 4 00:00:09,840 --> 00:00:11,600 No, it is at the end of this is about patient. 5 00:00:11,600 --> 00:00:13,600 This is about getting the patient out of pain. Okay? 6 00:00:13,600 --> 00:00:17,400 And you just need to get in there. I used to call it ninja endo. Get in there, 7 00:00:17,400 --> 00:00:20,520 get the job done, get out before that patient realizing it. 8 00:00:20,520 --> 00:00:24,000 That's my principle at Endo. Whether it's emergency or or endo, 9 00:00:24,000 --> 00:00:26,840 you wanna stealthy? Stealth. Stealth. Okay. 10 00:00:27,360 --> 00:00:27,970 . 11 00:00:27,970 --> 00:00:32,920 Welcome to group function where the prot true serrate work together to find good 12 00:00:32,920 --> 00:00:37,680 solutions to worthy problems in dentistry with your host jazz gulati. 13 00:00:42,250 --> 00:00:45,460 What is your current protocol for exta patients? 14 00:00:45,460 --> 00:00:48,420 So let's say you made a diagnosis of irreversible pitis. 15 00:00:48,420 --> 00:00:52,980 Your patient is in raging pain and you have to squeeze in this pain relieving 16 00:00:52,980 --> 00:00:57,180 treatment ATA patient probably of a lower mo or something in five minutes. 17 00:00:57,410 --> 00:00:58,540 What are you gonna do? Well, 18 00:00:58,540 --> 00:01:02,540 some of you will listen to this and it'll be validation and revision and you'll 19 00:01:02,540 --> 00:01:04,380 be thinking, Wow, I've been doing it right all this time, 20 00:01:04,380 --> 00:01:06,420 even though I thought maybe I was taking shortcuts, 21 00:01:06,420 --> 00:01:10,020 but actually I've been doing it right all this time. And others will be like, 22 00:01:10,020 --> 00:01:13,620 Whoa, this is so much easier compared to what I'm doing at the moment. 23 00:01:13,620 --> 00:01:17,980 Because the big hint I can give you is that you don't even need a K file for 24 00:01:17,980 --> 00:01:20,900 your molar expeditions anymore after today. Cause I've got Dr. 25 00:01:21,050 --> 00:01:25,740 Sanger specialist and Adonis to talk us through what is the right way, 26 00:01:25,760 --> 00:01:29,620 the proper way to do an extra patient of your patient who is in pain. 27 00:01:29,720 --> 00:01:33,700 And there are just so many gems from pain relief, diagnosis, 28 00:01:34,020 --> 00:01:35,020 isolation. And, 29 00:01:35,020 --> 00:01:39,260 and what I love about sang in this episode is that he's not dogmatic. Yes, 30 00:01:39,260 --> 00:01:43,100 he's a specialist and Adonis and it's so easy for him or anyone say you must 31 00:01:43,100 --> 00:01:46,100 always use rubber dam. But he actually does discuss a scenario that, okay, 32 00:01:46,100 --> 00:01:48,820 if for reason you had to do it without rubber dam, 33 00:01:48,820 --> 00:01:51,220 how can you optimize the isolation? 34 00:01:51,220 --> 00:01:54,180 How can you reduce this saliva getting inside the tooth? 35 00:01:54,180 --> 00:01:56,540 So I really appreciated that about this episode. I'm sure, 36 00:01:56,540 --> 00:02:00,380 I hope you will as well. It's very much in tune with the real world. And lastly, 37 00:02:00,380 --> 00:02:02,780 we do cover his step by step, 38 00:02:02,780 --> 00:02:07,620 what is the right and proper way to do an expectation without wasting time and 39 00:02:07,620 --> 00:02:10,500 without actually making things worse for future treatment. 40 00:02:10,550 --> 00:02:14,180 So hope you enjoy a episode and I'll catch you in the outro. Dr. Sandra Bender, 41 00:02:14,180 --> 00:02:17,700 welcome to the Protrusive Dental Podcast. How are you my friend? I'm. 42 00:02:17,700 --> 00:02:19,780 Very well, thank you, Jazz. Thanks for the invitation. 43 00:02:19,830 --> 00:02:22,980 Excited not done one of these before, . 44 00:02:23,510 --> 00:02:26,620 Oh, well I, I'm amazed at your first time and uh, it is, you, 45 00:02:26,620 --> 00:02:30,260 you're a real hero of mines cuz I dunno if you remember 10 years ago I met you 46 00:02:30,260 --> 00:02:34,060 at the uh, British Endodontic Society. Can you believe it was, Is that long ago? 47 00:02:34,280 --> 00:02:37,460 God, 10 year. You know, everything's a blur nowadays at my age. 48 00:02:37,860 --> 00:02:41,820 could been yesterday. It will be still, still seem the same, 49 00:02:41,820 --> 00:02:44,860 but no thank you. It's, it's lovely to have to be here. Thank you. 50 00:02:44,860 --> 00:02:45,940 Jess. Thank you so much. 51 00:02:45,940 --> 00:02:48,340 And I remember your lecture even then and I remember some of your lecture, 52 00:02:48,340 --> 00:02:51,420 the BDA and probably cuz our paths haven't collided. I haven't seen you, 53 00:02:51,420 --> 00:02:52,740 I knew you're very active with your teaching, 54 00:02:52,740 --> 00:02:55,460 but our paths haven't collided since then that much. But it's, 55 00:02:55,460 --> 00:02:59,060 it's great to have you on to talk about a very important topic, which is how to, 56 00:02:59,080 --> 00:03:02,440 to get a patient outta pain in terms of your diagnosis, irreversible pitis. 57 00:03:02,580 --> 00:03:07,040 And we're gonna talk about what is the optimum and best sang approved way of, 58 00:03:07,040 --> 00:03:09,440 of dealing with that that you wish your referring dentist would do. 59 00:03:09,440 --> 00:03:11,280 And the other one we'll talk about is post-op pain. 60 00:03:11,280 --> 00:03:13,280 But before we dive into the nitty gritty details, 61 00:03:13,280 --> 00:03:17,200 just please tell us listening to an international audience in terms of where is 62 00:03:17,200 --> 00:03:20,360 it that you work, what got you into Endo, a bit of your background. 63 00:03:20,590 --> 00:03:23,680 Sure, yes. I've been in this game in Endo anyway for, 64 00:03:23,790 --> 00:03:26,320 well dentistry I suppose We go all the way back. 65 00:03:26,320 --> 00:03:29,640 It's gonna be our 30th anniversary next year. So, uh, 66 00:03:29,640 --> 00:03:33,520 which is a bit bit frightening. So now qualified in London, actually in London. 67 00:03:33,580 --> 00:03:37,880 But I now live in Manchester and I've sort of wormed my up north to the 68 00:03:37,960 --> 00:03:40,400 northwest, uh, mainly by accident really. And just, 69 00:03:40,400 --> 00:03:44,760 just hospital jobs initially came up. Then I did my postgrad training up here. 70 00:03:45,030 --> 00:03:48,040 I mean back in those days, 1995 there was no, 71 00:03:48,240 --> 00:03:52,560 there were only three postgraduate ended programs outside the hospital training 72 00:03:52,560 --> 00:03:54,760 pathway. And I was either London or Manchester. 73 00:03:54,760 --> 00:03:57,040 I happened to be at the right place at the right time in Manchester. 74 00:03:57,310 --> 00:04:00,000 I got onto the Masters quite young, actually quite early. 75 00:04:00,270 --> 00:04:03,720 I think it was the first one in our batch in our year at guys. 76 00:04:03,720 --> 00:04:05,400 And I wasn't a high flying student at all. 77 00:04:05,550 --> 00:04:09,920 I managed to first one to get an MSC and then I stayed in Manchester at that 78 00:04:09,920 --> 00:04:13,160 time in the mid nineties. I d if you're too young to remember jazz. 79 00:04:13,160 --> 00:04:17,720 But it was quite a good university simply. And uh, it was uh, 80 00:04:17,720 --> 00:04:22,080 I think I had a better student life as a postgrad than I did in London. But, uh, 81 00:04:22,080 --> 00:04:24,960 no, it was things were changing in Manchester. The dental school was good. 82 00:04:24,960 --> 00:04:27,120 I was teaching, there were not many endodontists. 83 00:04:27,120 --> 00:04:29,360 One of the reasons I stayed up north, actually, uh, 84 00:04:29,360 --> 00:04:31,080 because I knew the job prospects would be better. 85 00:04:31,150 --> 00:04:34,680 This is before Endo became really popular and I could see it. In fact, 86 00:04:34,680 --> 00:04:36,200 it's by accident. I fell into Endo. 87 00:04:36,210 --> 00:04:39,400 It was gonna be either implants at that time. There was an implant, 88 00:04:39,720 --> 00:04:43,600 See there was an Endo MSC because that was one of the only endo MSC in the 89 00:04:43,600 --> 00:04:45,800 country. I was too young. I would never go on. 90 00:04:45,800 --> 00:04:48,760 The people that got onto that were experienced practitioners and I'd really had 91 00:04:48,760 --> 00:04:52,560 no chance. But I, that's where I was gonna go, ironically, the opposite way. 92 00:04:52,560 --> 00:04:56,000 And I ended up doing Endo and it sort of taken off from there and I just got 93 00:04:56,000 --> 00:05:00,960 into Endo and I stayed in Manchester job offers and I pretty much been fulltime 94 00:05:00,960 --> 00:05:04,240 endo day one from finishing the masters. So since 97. 95 00:05:04,810 --> 00:05:08,120 So how many days are you clinical at the moment in terms of doing your, um, 96 00:05:08,120 --> 00:05:10,320 endodontics, uh, you know, referral practice? 97 00:05:10,670 --> 00:05:14,240 Yeah, so I'm pretty much now full, full-time. As in I was full days, 98 00:05:14,240 --> 00:05:16,760 I'm down to three days now and I've gone an associate role, 99 00:05:16,760 --> 00:05:18,840 Rob Jacobs who covers me. So, uh, 100 00:05:18,850 --> 00:05:23,480 so I'm down to three and a half days and teaching now just in private courses, 101 00:05:23,570 --> 00:05:26,440 uh, up and down between London and Manchester with a couple of friends. 102 00:05:26,490 --> 00:05:29,280 So that keeps me outta the practice. But pretty much I've always been a, 103 00:05:29,430 --> 00:05:30,640 a hands on clinician. 104 00:05:30,770 --> 00:05:32,760 So you're very wet fingered, very clinical. You, 105 00:05:32,760 --> 00:05:36,240 you've got a great name in the UK as a, the person for Endo. So again, 106 00:05:36,240 --> 00:05:37,240 it's a privilege to have you on. 107 00:05:37,300 --> 00:05:39,720 The reason I have you on is because extra patients, 108 00:05:40,110 --> 00:05:42,520 I speak to different colleagues and we all kind of do it differently. 109 00:05:42,650 --> 00:05:45,120 So I wanna find out what is it that you recommend. 110 00:05:45,120 --> 00:05:49,000 And I remember asking an endodontist some years ago what they recommended and I 111 00:05:49,000 --> 00:05:52,040 got interesting answer from the endodontist. He said that, you know what, 112 00:05:52,040 --> 00:05:52,873 as an endodontist, 113 00:05:53,150 --> 00:05:56,200 I rarely get to see the emergency extra patient cases anymore. 114 00:05:56,200 --> 00:05:58,720 Cuz usually by the time they've come see me, there's a sinus track, 115 00:05:58,720 --> 00:06:00,880 there's a per endo lesion and they're really complicated. 116 00:06:01,130 --> 00:06:05,440 So firstly I'm just being nosy. Uh, how much emergency expectations do you, 117 00:06:05,440 --> 00:06:06,920 do you get, how many of those phone calls do you get? 118 00:06:06,920 --> 00:06:09,120 How many do you actually treat in that regard. 119 00:06:09,130 --> 00:06:12,960 In terms of the practice? You are absolutely right being an end dontist, we, we, 120 00:06:13,290 --> 00:06:17,720 by the time they get to us, they're the non-it previously root failed or the um, 121 00:06:17,720 --> 00:06:19,320 or the dentist has had to go doing it. 122 00:06:19,330 --> 00:06:22,160 We get a lot of phone calls and mainly from dentists. What do I do? 123 00:06:22,160 --> 00:06:25,400 How do I numb the tooth up? And this sort of thing. We'll talk about that um, 124 00:06:25,400 --> 00:06:28,360 shortly. But in that way I'm kind of slightly lucky, 125 00:06:28,680 --> 00:06:31,680 although I know how to deal with it. And we have to back in the training, 126 00:06:31,770 --> 00:06:35,360 working in dental school, you're in the emergency, the dental casualty, 127 00:06:35,520 --> 00:06:37,640 whatever they call it nowadays. So you had to deal with that. 128 00:06:37,640 --> 00:06:40,920 You had to learn pretty quickly. One of the reasons I went into endo is just, 129 00:06:41,230 --> 00:06:44,520 okay, it is not just about the white lines at the end of the endo treatment, 130 00:06:44,520 --> 00:06:46,320 right in the beginning, getting patients out of pain, 131 00:06:46,420 --> 00:06:50,440 immediately out of pain just until they relax and you get them back into the 132 00:06:50,440 --> 00:06:52,560 proper endo. That is really important. And, 133 00:06:52,560 --> 00:06:57,480 and in that way I'm kind of shielded being in specialist practice cuz my general 134 00:06:57,480 --> 00:07:00,680 dental colleagues there at the cold face and they've gotta deal with that stuff 135 00:07:00,690 --> 00:07:04,400 on a Friday afternoon just before they close. Patient wore rocks in, you know, 136 00:07:04,400 --> 00:07:07,800 and never slept for a week. And they're anxious and they're nervous. 137 00:07:07,800 --> 00:07:09,400 They've never been to a dentist sometimes. 138 00:07:09,400 --> 00:07:12,480 And you've got all that to deal with and you gotta get 'em out of pain and you 139 00:07:12,480 --> 00:07:16,520 can't fo 'em off with antibiotics. It's just not appropriate nowadays medically. 140 00:07:16,520 --> 00:07:18,600 It's not. You could get into water if something happens. 141 00:07:19,010 --> 00:07:22,320 So you've gotta be able to get in there and deal with it efficiently as 142 00:07:22,320 --> 00:07:23,440 painlessly as possible. 143 00:07:23,440 --> 00:07:26,920 And that's the challenge cuz the tooth is extremely inflamed and, 144 00:07:26,920 --> 00:07:29,840 and just stabilize everything so you can get them back in when you've got plenty 145 00:07:29,840 --> 00:07:31,080 of time, we'll get someone else to do it. 146 00:07:31,520 --> 00:07:34,800 Whatever the protocols are for that is important. Yeah. Um. 147 00:07:34,980 --> 00:07:36,120 But before we go in for the, 148 00:07:36,120 --> 00:07:39,920 for the kill and talk about the exact protocol that you would recommend to 149 00:07:39,920 --> 00:07:42,880 alleviate someone out of pain. Let's talk a little bit for the, 150 00:07:42,880 --> 00:07:45,720 for the younger audiences saying maybe students who are listening right now, uh, 151 00:07:45,720 --> 00:07:46,720 just coming up with a, 152 00:07:46,720 --> 00:07:50,920 a diagnosis of when it is appropriate to give antibiotics because perhaps the 153 00:07:50,920 --> 00:07:53,720 necrotic infected and really it might already be root filled or whatever. 154 00:07:53,720 --> 00:07:58,560 And then what kind of history and clinical findings are are leading you to, 155 00:07:58,650 --> 00:08:02,760 towards a diagnosis of irreversible popit that needs that intervention that 156 00:08:02,760 --> 00:08:04,720 wouldn't settle with antibiotics. Can you just, uh, 157 00:08:04,720 --> 00:08:07,480 give a distinction between the two different types of patients? 158 00:08:07,750 --> 00:08:09,960 Okay, so you've got two different situations. You've got the, 159 00:08:09,960 --> 00:08:13,040 the root fill and non root fill tooth. I won't talk about the root fill tooth. 160 00:08:13,040 --> 00:08:14,920 Yeah. Cause that's a different, slightly different scenario, 161 00:08:14,920 --> 00:08:19,720 but on a tooth that's either potentially vital or semi vial 162 00:08:19,770 --> 00:08:23,880 or parro or completely nero. Okay. So you start from the, 163 00:08:23,880 --> 00:08:26,240 the pro the disease process obviously starts at the top. 164 00:08:26,240 --> 00:08:29,520 The pulp typically carries tooth fractures. 165 00:08:29,910 --> 00:08:31,480 Bugs have gotta get into that pulp. 166 00:08:31,700 --> 00:08:36,640 Now sometimes the patients will have very low grade symptoms and a 167 00:08:36,640 --> 00:08:40,840 ni a du lake, maybe a bit of thermal sensitivity. And they, they, 168 00:08:40,840 --> 00:08:43,560 they kind of put up with it and sometimes those pulps will die, 169 00:08:43,620 --> 00:08:46,960 but it's the ones that don't die or die painfully. And they, 170 00:08:46,960 --> 00:08:51,040 they go through an acute phase. What we describe as irreversible pulpit. Uh, 171 00:08:51,040 --> 00:08:54,280 they're the ones at the challenge because, because the, the top of the pulp, 172 00:08:54,280 --> 00:08:57,280 the, the, the pulp that's most in inflamed, 173 00:08:57,280 --> 00:08:59,840 closest to the insult could be carries or a fracture. 174 00:09:00,190 --> 00:09:03,520 That bit of the pulp will be difficult to nichetize. So the whole, 175 00:09:03,520 --> 00:09:05,920 when you give a block, uh, typically for a lower tooth, 176 00:09:05,920 --> 00:09:08,360 you'll give a block anesthesia, you'll give an infiltration, 177 00:09:08,460 --> 00:09:12,320 the anesthesia will not penetrate up the id, um, nerve, 178 00:09:12,340 --> 00:09:16,000 you won't get into the poll, it'll get into the pulp aly, 179 00:09:16,000 --> 00:09:19,200 maybe curricular area, but it won't get to that point, 180 00:09:19,200 --> 00:09:21,440 which is the closest to the insult, the most inflame. 181 00:09:21,440 --> 00:09:24,960 That's the challenge getting from the, where I describe it to the patients. 182 00:09:24,960 --> 00:09:28,200 I show them the x-ray, this is your tooth, that's the top. 183 00:09:28,200 --> 00:09:29,160 You got all filling there. 184 00:09:29,160 --> 00:09:33,600 We need to go from the top thesal surface down to that pulp chamber bit. 185 00:09:33,680 --> 00:09:37,480 We're gonna go down to there. Now a lot of it's patient management, 186 00:09:37,480 --> 00:09:41,960 it's preparation. Okay. Because we'll go through the anesthetic protocol, 187 00:09:41,960 --> 00:09:44,880 which hopefully will work, but sometimes you're just not going to work. 188 00:09:45,540 --> 00:09:46,680 But you need to know that. 189 00:09:46,680 --> 00:09:49,360 And you know that from the patient's symptomology where they walk in, 190 00:09:49,500 --> 00:09:52,560 you just know that as a hot pole, there's a chance that they're not, 191 00:09:52,560 --> 00:09:55,640 you're not gonna be able to anize it doesn't matter what you hit them with. Um, 192 00:09:55,640 --> 00:09:58,440 there are a few things we'll talk about how to prep that. If you, 193 00:09:58,440 --> 00:10:00,080 if if they aren't walked in off the street, 194 00:10:00,080 --> 00:10:02,280 if you know there's a pulpit coming in you, 195 00:10:02,280 --> 00:10:05,240 there's a few things you can ask them to do before they come in just to, 196 00:10:05,240 --> 00:10:09,240 to help the anesthesia process. And then when they get them in, in the chair, 197 00:10:09,240 --> 00:10:13,080 it is management's a lot of good anesthesia, multiple techniques, uh, 198 00:10:13,080 --> 00:10:17,720 different agents and then going in carefully and managing the patient, 199 00:10:17,720 --> 00:10:18,920 being empathetic, 200 00:10:19,420 --> 00:10:23,040 but up to a point if they can't tolerate it or their anxiety levels is too much, 201 00:10:23,040 --> 00:10:26,520 you sometimes have to do in stages. Sometimes you've gotta gotta go for it. 202 00:10:26,520 --> 00:10:29,800 And it's sometimes you've gotta be cruel to be kind, but in, 203 00:10:29,890 --> 00:10:32,760 in the appropriate patient mm-hmm. , you can't just dive in and, 204 00:10:33,020 --> 00:10:35,680 you know, you lose a patient and it's just not nice. 205 00:10:35,680 --> 00:10:37,240 You've gotta imagine yourself in that position, 206 00:10:37,260 --> 00:10:39,800 but equally you wanna get 'em out of pain. So it's a balance, 207 00:10:39,830 --> 00:10:41,480 it's a real fine balance. Yeah. 208 00:10:41,480 --> 00:10:45,280 Based on just, just the other day I saw, um, an acute, a patient in acute pain, 209 00:10:45,290 --> 00:10:49,280 uh, and, uh, after getting somewhat good anesthesia, you know, objective, 210 00:10:49,280 --> 00:10:51,920 you know, I, I tried with endo frost my degrees beforehand, 211 00:10:52,290 --> 00:10:55,560 managed to elicit an aquatic response compared to others actually. 212 00:10:55,720 --> 00:11:00,080 But he had recent symptoms of eros ptu, so it was probably mostly necrotic, 213 00:11:00,080 --> 00:11:00,800 but there's still, uh, 214 00:11:00,800 --> 00:11:04,000 some element of vitality to it based on his symptoms he was presenting with. Uh, 215 00:11:04,000 --> 00:11:07,080 and so when I did manage to reach the pulp chamber of this lower molar, 216 00:11:07,130 --> 00:11:09,600 he placed a file just into the distal. Now this wasn't bleeding, 217 00:11:09,600 --> 00:11:12,480 so it confirmed my diagnosis of necrotic, but I saw the, 218 00:11:12,480 --> 00:11:15,800 the white pulpal tissue. Uh, so soon I put my um, uh, 219 00:11:15,800 --> 00:11:19,480 K file into the dis he, he pretty much jumped out the chair. 220 00:11:19,480 --> 00:11:22,120 So I gave the intra pple and that that just settled him. 221 00:11:22,120 --> 00:11:24,520 So it kind of leads communis and like you said, 222 00:11:24,520 --> 00:11:26,640 I had to be cruel to be kind for that patient. 223 00:11:26,740 --> 00:11:29,520 Now what could I have done had I known, I didn't know who was coming in, 224 00:11:29,520 --> 00:11:33,360 but what kind of anesthetic supplement or advice could I have given on, 225 00:11:33,360 --> 00:11:34,600 on the phone as you alluded to, 226 00:11:34,610 --> 00:11:37,440 to help achieve better success rate of anesthesia? Yeah. 227 00:11:37,440 --> 00:11:39,200 I'm, it its about reducing the, 228 00:11:39,200 --> 00:11:44,000 the inflammatory status that pulp is as best you can and systemically, I mean, 229 00:11:44,000 --> 00:11:46,920 and there's plenty of evidence to say that loing them up with 230 00:11:46,920 --> 00:11:51,520 anti-inflammatories. Nonsteroid also four to 600 ibuprofen with or without, 231 00:11:51,770 --> 00:11:53,040 uh, paracetamol if they, 232 00:11:53,080 --> 00:11:57,120 they can't tolerate anti-inflammatory asthma or stomach issues. Tramadol, 233 00:11:57,120 --> 00:12:00,800 something like that. A codeine paracetamol not as good as an anti-inflammatory, 234 00:12:00,800 --> 00:12:04,800 but it's better than nothing that will just physiologically reduce the 235 00:12:04,800 --> 00:12:05,400 inflammatory stages. 236 00:12:05,400 --> 00:12:08,800 It doesn't guarantee that that tiny bit of the pulp that's inflamed will 237 00:12:08,800 --> 00:12:10,440 completely anesthetized. But it'll definitely, 238 00:12:10,570 --> 00:12:14,680 there's plenty of evidence saying it will help The anesthesia anesthetic process 239 00:12:15,330 --> 00:12:20,160 in terms of the actual local anesthesia for the lower teeth always 240 00:12:20,160 --> 00:12:23,000 is notoriously the worst teeth mo teeth first. 241 00:12:23,000 --> 00:12:26,360 Second mo is dose teeth are really difficult to numb and it's because they've 242 00:12:26,360 --> 00:12:30,760 got accessory nerve supply as well often. And, and for me the, 243 00:12:30,940 --> 00:12:33,760 the baseline technique is Id do you doing an ID block, 244 00:12:33,910 --> 00:12:38,040 I don't mess out with intra PDLs and this sort of thing. And you know, 245 00:12:38,190 --> 00:12:40,200 just need to knock, knock that nerve out. 246 00:12:40,200 --> 00:12:44,960 Not as much as you can supplemented with buckle infiltrations of an agent 247 00:12:44,960 --> 00:12:49,160 that's, that absorbs well, and for me it's aade. So if my ID block, um, I, 248 00:12:49,190 --> 00:12:51,440 I would give li can as, as a start, 249 00:12:51,440 --> 00:12:54,360 this is an acute emergencies I don't use Nick can often actually, yeah, 250 00:12:54,360 --> 00:12:57,720 I'll tend to fall back on, can talk that later on. 251 00:12:57,720 --> 00:12:59,880 Why use prefer came for routine endo, 252 00:12:59,880 --> 00:13:04,480 but for hot teeth you need profound anesthesia. You don't need longevity. 253 00:13:04,540 --> 00:13:06,640 But Li Canin works pretty well as an id. 254 00:13:06,940 --> 00:13:09,720 I'm not a fan of giving I id blocks to the heart cane, 255 00:13:09,720 --> 00:13:14,200 but I know the evidence suggests it is very good and there's controversial about 256 00:13:14,200 --> 00:13:17,560 the risk of paraesthesia and it may not be anything to do with the agent, 257 00:13:17,560 --> 00:13:20,160 it's probably to do with the fact it's trauma from the needle, 258 00:13:20,160 --> 00:13:22,760 but I'd rather not if, if there's an alternative and it, 259 00:13:22,760 --> 00:13:23,600 which works just as well. 260 00:13:23,600 --> 00:13:28,360 So Id li can wait for that to be to work completely work. 261 00:13:28,360 --> 00:13:30,560 So we're talking, the lip is completely numb. 262 00:13:30,560 --> 00:13:34,400 The lingual muco are completely numb. Not even the patient can't feel a thing. 263 00:13:34,590 --> 00:13:37,520 Then arca buckle infiltrations, 264 00:13:37,850 --> 00:13:41,400 it tends to absorb better through the buckle plate. It's pretty thick, you know, 265 00:13:41,400 --> 00:13:42,560 especially in the sixth and seminary. 266 00:13:42,820 --> 00:13:46,840 And then I might give PDLs as well or lingual under pressure. 267 00:13:47,190 --> 00:13:51,160 I've got an intra periodontal device called the wand that are few other devices 268 00:13:51,160 --> 00:13:53,440 and now available, which do the same sort of thing. 269 00:13:53,600 --> 00:13:55,920 They're basically under high pressure with a short needle. 270 00:13:55,920 --> 00:13:58,280 They can deliver the anesthetic through the pdl. 271 00:13:58,280 --> 00:14:02,400 And the theory behind that is a PDL is almost as good as an in ous 272 00:14:03,000 --> 00:14:04,120 SIS is the other mechanism. 273 00:14:04,180 --> 00:14:07,480 You can drill a hole into the bone through these self drilling devices, 274 00:14:07,480 --> 00:14:11,080 which has a, a pretty good effect. I've never got a used to those devices, 275 00:14:11,080 --> 00:14:12,280 but some people swear by them. 276 00:14:12,460 --> 00:14:16,000 But you need to get that profound anesthesia in there. Uh, 277 00:14:16,000 --> 00:14:19,680 and you just gotta wait mention, just make sure that the anesthetics work, 278 00:14:19,680 --> 00:14:22,000 don't just dive in and then your ation management. 279 00:14:22,000 --> 00:14:25,800 Mm-hmm. well with the busy lives of general dental practitioners, 280 00:14:25,890 --> 00:14:27,920 uh, juggling at getting these patients in, 281 00:14:27,920 --> 00:14:29,760 making the diagnosis can take in a 15, 282 00:14:29,760 --> 00:14:32,800 20 minutes sometimes to take a radiograph. Then giving them the block, 283 00:14:32,800 --> 00:14:34,080 let's say an infiltration, 284 00:14:34,080 --> 00:14:36,040 getting 'em sit outside while you see a few more patients. 285 00:14:36,070 --> 00:14:38,120 I'll see you in my lunch breaks, Mrs. Smith or whatever. 286 00:14:38,150 --> 00:14:41,000 Then the lunch break comes, your nurses rolling our eyes, they swap nurses. 287 00:14:41,000 --> 00:14:43,200 And so it's all, it's all happening in, in busy practice. 288 00:14:43,200 --> 00:14:47,760 Now let's say we made our diagnosis of iritis and we know we need to extricate, 289 00:14:48,090 --> 00:14:51,960 We have a given sufficient anesthesia and the patient loaded up with ibuprofen 290 00:14:51,960 --> 00:14:54,920 and all the stars aligned. When we are dealing with such teeth, 291 00:14:54,920 --> 00:14:57,680 they usually have large mod amalgams or something like that. Right? 292 00:14:57,890 --> 00:15:01,040 So my first question in terms of making it very tangible for, for, 293 00:15:01,040 --> 00:15:04,000 for general busy general dentist is in an ideal world, 294 00:15:04,000 --> 00:15:05,720 we'd love to remove the entire restoration, 295 00:15:05,720 --> 00:15:09,360 remove any carries access for cracks. But when our 20 minutes, 296 00:15:09,360 --> 00:15:12,720 we need to get in. Go for the kill. Yeah. Is that okay? Can you forgive us? 297 00:15:12,720 --> 00:15:14,680 Yeah, no, it is at the end of this is about patient, 298 00:15:14,680 --> 00:15:16,720 This is about getting the patient out of pain. Okay. 299 00:15:16,720 --> 00:15:20,680 And you just need to get in there. I used to call it ninja endo. Get in there, 300 00:15:20,680 --> 00:15:23,520 get the job done, get out before without patient realizing it. 301 00:15:23,520 --> 00:15:26,960 That's my principle at endo, whether it's emergency or or endo, 302 00:15:26,960 --> 00:15:31,960 you want stealthy? Stealth. Stealth, Okay, . And it, 303 00:15:32,340 --> 00:15:35,760 the first part is get, get into the pulp. You're releasing the, 304 00:15:35,930 --> 00:15:38,120 by going into the pulp, you also actually release pressure. 305 00:15:38,120 --> 00:15:41,200 There's pressure buildup. That's the number one proative inflammation, isn't it? 306 00:15:41,350 --> 00:15:42,640 Then you need to set, 307 00:15:42,640 --> 00:15:46,280 basically you are applying a set to material to relieve the inflammation. 308 00:15:46,820 --> 00:15:49,800 The most common, uh, and popular products that steroid. 309 00:15:49,800 --> 00:15:52,600 Based. No, but before we talk about ments and stuff, Yeah. 310 00:15:52,600 --> 00:15:53,960 Before we talk about the predicaments, I, 311 00:15:53,960 --> 00:15:56,720 I'd just love to ask some real world questions. Like let's say you go in, 312 00:15:56,720 --> 00:15:57,680 you open up the pop chamber, 313 00:15:58,290 --> 00:16:01,800 do you think is desirable for the practitioner who's gonna refer to you in the 314 00:16:01,800 --> 00:16:02,040 future? 315 00:16:02,040 --> 00:16:06,320 Should we be also removing the roof of the pulp chamber as much as possible? 316 00:16:06,320 --> 00:16:09,200 So let's say that lower molar saw the, the other day had four canals, 317 00:16:09,200 --> 00:16:12,600 mis buckle melenal, two distals. So four canals. And I did, 318 00:16:12,600 --> 00:16:16,360 I opened it all up as much as I could to to, to visualize those four canals. 319 00:16:16,360 --> 00:16:19,160 And it was mostly restorative material I was removing at this point at now, 320 00:16:19,330 --> 00:16:22,960 is it okay in that short appointment to just literally go in, 321 00:16:22,960 --> 00:16:25,280 see the pop chamber and then proceed to predicaments? 322 00:16:25,280 --> 00:16:28,840 Or would you recommend to open it? Or does it depend on any factors? 323 00:16:29,270 --> 00:16:33,840 Okay, in short, forget about the root canals job is get in there, 324 00:16:33,840 --> 00:16:37,040 relieve the pressure, open the pulp space up and apply the dressing. 325 00:16:37,110 --> 00:16:39,760 That's simple. Like that's all you have to do on a Friday afternoon. 326 00:16:39,760 --> 00:16:42,800 Even even like three or four millimeters in, in the middle, that's sufficient. 327 00:16:42,800 --> 00:16:44,960 That's tissue. Because what then tends to happen is, 328 00:16:45,050 --> 00:16:46,560 so the inflamed part is the, 329 00:16:46,560 --> 00:16:49,440 the al pulp or in fact just the top bit of the pulp horn. 330 00:16:49,510 --> 00:16:52,880 You'll find once you've though, in those cases, you've gotta game in chipo and, 331 00:16:53,060 --> 00:16:54,760 and intra pulp. Going back to that, 332 00:16:54,760 --> 00:16:57,280 essentially all you're doing is crushing the nerves. 333 00:16:57,330 --> 00:16:59,360 It doesn't matter what agent. You could use sterile water, 334 00:16:59,580 --> 00:17:01,960 but the pressure crushes the nerve in that inflamed part, 335 00:17:01,960 --> 00:17:04,720 you'll often find the rest of the pulp. Okay? It might be hyper emmic, 336 00:17:04,720 --> 00:17:06,400 it might be bleeding a lot, but they won't feel that. 337 00:17:06,870 --> 00:17:10,080 Remove the cor pulp if you can, if you know if the, it's not painful. 338 00:17:10,540 --> 00:17:13,640 And then just dress it. Don't worry about the root canals at this stage, 339 00:17:13,640 --> 00:17:15,720 that's not the priority. In fact, 340 00:17:15,720 --> 00:17:17,760 if you then start fishing around the root canals, 341 00:17:17,760 --> 00:17:19,720 you're gonna start shredding pulp tissue. 342 00:17:20,180 --> 00:17:22,520 And unless you get the rest whole pulp out, 343 00:17:22,950 --> 00:17:27,760 that pulp tissue you lead behind in the ale or mid third it's gonna be inflamed. 344 00:17:27,760 --> 00:17:30,760 And then the patient just, you get equals other problems. Mm-hmm. . 345 00:17:30,760 --> 00:17:35,680 So the pain's coming from the al pulp deal with that dress it and, 346 00:17:35,680 --> 00:17:39,120 and going back to the restoration, unless there's a gaping hole underneath the, 347 00:17:39,120 --> 00:17:42,800 the, the, the ODM album or it's clearly this care, you know, 348 00:17:42,800 --> 00:17:45,640 it's just this saliva coming in. Don't worry about this stage. 349 00:17:45,640 --> 00:17:49,000 You can temporarily seal that off with cavitt or cows on or whatever you're 350 00:17:49,120 --> 00:17:52,080 gonna use. Just close the tooth, sedate it, close it, 351 00:17:52,080 --> 00:17:54,960 and then get them back in for, to then strip the tooth apart if you have to. 352 00:17:54,960 --> 00:17:59,120 And it'll be easy to numb up. You can then doability assessment. If it's not, 353 00:17:59,120 --> 00:18:01,960 if it's too knackered from the outset, then you just refer for an extraction or, 354 00:18:01,960 --> 00:18:04,280 or booking for an extraction. But if you, if you're not sure, 355 00:18:04,280 --> 00:18:05,080 then don't worry about that. 356 00:18:05,080 --> 00:18:08,600 You can assessability and then treat and plant endo, uh, 357 00:18:08,600 --> 00:18:11,200 once the patient's out of pain. And they're easy toti. 358 00:18:11,200 --> 00:18:13,360 So don't miss about the po root canales at this stage. 359 00:18:13,360 --> 00:18:15,200 This is about dressing and getting out of pain. 360 00:18:15,200 --> 00:18:16,640 Don't fish around the root canales. 361 00:18:16,640 --> 00:18:19,600 Endo. There's gonna be enlightening san there's gonna be absolutely enlightening 362 00:18:19,600 --> 00:18:22,760 because I know plenty of colleagues who have advised me in the past and they 363 00:18:22,760 --> 00:18:23,920 swear by this san, they said, 364 00:18:23,920 --> 00:18:27,880 You won't get the patient out of pain until you file all the way through the 365 00:18:28,000 --> 00:18:29,800 apex. Now is that a myth? Largely. 366 00:18:29,800 --> 00:18:31,040 Yes. It's a myth because. 367 00:18:31,110 --> 00:18:31,943 Have you had this. 368 00:18:32,120 --> 00:18:36,200 Vital, So the pain is coming from that top bit. It's not the rest of the pulp. 369 00:18:36,250 --> 00:18:38,280 In fact, we'll come onto this. We get time. We, 370 00:18:38,280 --> 00:18:42,840 things are slightly changing now the way we treat vital pulps. Okay, 371 00:18:42,840 --> 00:18:45,320 this is an interesting conversation where we are now, 372 00:18:45,590 --> 00:18:47,040 I think this is too early to bring this in. 373 00:18:47,170 --> 00:18:50,440 So we're in the realms of what's called vital pulp therapy, 374 00:18:50,600 --> 00:18:55,600 where maybe we don't need to extricate pulps at all or the 375 00:18:55,600 --> 00:18:56,040 root canal. 376 00:18:56,040 --> 00:18:59,720 We can do the cro pulpotomy as we used to do for kids in immature teeth. 377 00:19:00,400 --> 00:19:03,960 Remember the Shrek pulpotomy back in the day. That concept is now coming in, 378 00:19:04,530 --> 00:19:09,040 in adult teeth, not just immature adult teeth molars, for example, 379 00:19:09,040 --> 00:19:11,840 even in mature teeth. And this comes, this is the, 380 00:19:11,840 --> 00:19:14,360 the kind of crossover between cardiology, 381 00:19:14,360 --> 00:19:16,880 the caries management and restorative dentist coming in. 382 00:19:16,880 --> 00:19:19,760 And they've been doing this kind of stepwise technique and all that. 383 00:19:19,860 --> 00:19:22,600 But at the end of, we've always been aware, 384 00:19:22,820 --> 00:19:25,480 not been happy with that because it's been unpredictable. 385 00:19:25,800 --> 00:19:26,800 Materials haven't been appropriate. 386 00:19:27,220 --> 00:19:31,160 And the risk is the patient could come back in acute pain, 387 00:19:31,170 --> 00:19:33,920 they'll come back with advanced disease, endo disease, 388 00:19:33,920 --> 00:19:36,240 which then therefore the prognosis lowers. Um, 389 00:19:36,240 --> 00:19:37,960 all the pulps completely obliterate. 390 00:19:37,960 --> 00:19:39,840 And then when you have to do the endos a nightmare, 391 00:19:40,070 --> 00:19:43,360 things are changing a little bit with the new materials. But, but at this stage, 392 00:19:43,360 --> 00:19:46,080 in terms of emergency management, it's enough just to deal with the, 393 00:19:46,080 --> 00:19:48,480 the criminal part of the pulp, the rest of the pop. 394 00:19:48,480 --> 00:19:52,360 Often you'll stay vital whether you then take the do the full root. This. 395 00:19:52,360 --> 00:19:54,480 Is music to everyone's a this is music. 396 00:19:54,690 --> 00:19:58,240 So whether you then go and do root canal. Yeah. So yeah, 397 00:19:58,240 --> 00:20:01,160 whether you go do the full endo or you don't, 398 00:20:01,980 --> 00:20:04,920 you apply these new vital pulse therapies. That's the, 399 00:20:04,920 --> 00:20:07,960 that's the next interesting question. Cause endodontics is changing. 400 00:20:07,960 --> 00:20:10,440 Now we didn't prevent Adon, if you like it. 401 00:20:10,910 --> 00:20:13,600 Very good, very good. I think, I think that'll be a whole new episode. 402 00:20:13,600 --> 00:20:16,480 But just to, to continue on the reign of the emergency management, 403 00:20:16,480 --> 00:20:20,080 I think what you said is gonna be music to the ears of all the GDPs listening 404 00:20:20,080 --> 00:20:21,440 who perhaps had this thought that, 405 00:20:21,440 --> 00:20:25,960 and they're gonna spend this extra time and extra risk in opening up all 406 00:20:26,220 --> 00:20:29,960 the individual canals, filing all the way to the apex. 407 00:20:30,050 --> 00:20:33,840 So really what I'm hearing is to get sufficient anesthesia, get in there, 408 00:20:33,840 --> 00:20:37,160 open up the pulp chamber just enough to get your SIV in and we'll talk about 409 00:20:37,160 --> 00:20:40,400 assertive in a moment. Now my, and don't go sticking your K file, 410 00:20:40,400 --> 00:20:44,440 so in fact your nurse now knows not even to give you a Kal for this emergency 411 00:20:44,440 --> 00:20:48,280 expectation, which, which is brilliant. Would you recommend using HypoChlor? 412 00:20:48,300 --> 00:20:51,160 Now, before we get to that, let's take one step back. I personally, 413 00:20:51,160 --> 00:20:54,600 I I would always use rubber damm, you know, with your influence on, under B Bs. 414 00:20:54,600 --> 00:20:57,680 I can't go to a BS conference and then not use rubber dam for anything like 415 00:20:57,680 --> 00:21:00,040 this. So I always use raam, but I've got some colleagues, uh, 416 00:21:00,040 --> 00:21:01,360 little bit more experience and they say jazz, 417 00:21:01,360 --> 00:21:03,160 it's okay cuz we're killing the nerve anyway. 418 00:21:03,160 --> 00:21:07,320 The endo don Endos will sort the bugs out afterwards. So just get, go in, 419 00:21:07,320 --> 00:21:08,760 put some ve in and come out. 420 00:21:08,770 --> 00:21:10,920 We don't need to irrigate and we don't eat rubber dam. 421 00:21:11,110 --> 00:21:13,280 What do you think on that? What is best practice? 422 00:21:13,280 --> 00:21:14,960 What do you want from your referring practitioners? 423 00:21:14,960 --> 00:21:18,080 Okay, but I mean, best practice is you've gotta isolate the two properly, 424 00:21:18,080 --> 00:21:21,320 both from a safety point of view and know also from micro biological point of 425 00:21:21,320 --> 00:21:25,320 view. Now, okay, the end, that person dentist may not be doing the endone, 426 00:21:25,320 --> 00:21:27,440 it's not their problem. It'll go to the endo Dons. 427 00:21:27,440 --> 00:21:30,120 The problem is if bugs get in there, Sali gets in there, 428 00:21:30,440 --> 00:21:33,440 it'll kill the rest of the pulp. Okay, fine. The plan is to do endo. 429 00:21:33,440 --> 00:21:37,040 But the problem is, if in reverse pulpit actually is a, 430 00:21:37,120 --> 00:21:39,800 apart from that inflamed bit, it's actually a sterile situation, 431 00:21:40,000 --> 00:21:43,520 which is where pop therapy comes in. So you, 432 00:21:43,520 --> 00:21:46,160 you don't want to introduce bugs there because you don't, 433 00:21:46,160 --> 00:21:49,160 you don't know when that prevent patient's gonna get to the endodontist or when 434 00:21:49,160 --> 00:21:51,640 they're gonna have the endo might be weeks, it might be months. 435 00:21:51,780 --> 00:21:54,120 And if they get an infection and it gets into the aprille, 436 00:21:54,120 --> 00:21:56,880 then you're into a different ballgame in terms of prognosis and treatment. 437 00:21:56,880 --> 00:22:00,680 So isolation still is important. Now whether you rubber down or you compromise, 438 00:22:01,040 --> 00:22:04,520 depending on the clinic and if you're working in the emergency department, 439 00:22:05,110 --> 00:22:09,880 I know other factors is easy for me to say in my every tower of 440 00:22:09,880 --> 00:22:12,800 dental school or or endo practice, you have rubber dam there and then, 441 00:22:13,020 --> 00:22:17,960 but get good isolation. Your nurse is there, good aspiration, open the PU pub, 442 00:22:17,960 --> 00:22:20,080 give it an irrigation. Remember it's only the AL bar. 443 00:22:20,080 --> 00:22:21,680 You're not messing about the root canals. You don't, 444 00:22:21,780 --> 00:22:24,040 you just need to bathe the area. HypoChlor. 445 00:22:24,250 --> 00:22:28,000 Or coril or whatever. What do you, what do you recommend HypoChlor? 446 00:22:28,000 --> 00:22:29,600 Now what do you think about people who, 447 00:22:29,600 --> 00:22:32,560 because maybe they're not using rubber dam, they're then using, um, 448 00:22:32,560 --> 00:22:34,640 chlorhexine 2% maybe, or, or, or, or. 449 00:22:34,640 --> 00:22:37,760 It's kinda than nothing. They won't be using 2%. They're using mouthwash, 450 00:22:37,760 --> 00:22:40,920 which is useless to be honest. It's the surface. It's. 451 00:22:40,920 --> 00:22:41,200 True, it's. 452 00:22:41,200 --> 00:22:41,610 True. 453 00:22:41,610 --> 00:22:44,720 It won't be using 2% for sure cause that's quite expensive and most people don't 454 00:22:44,720 --> 00:22:46,800 even then doners don't use that. Why not many do. 455 00:22:46,830 --> 00:22:51,680 Even if it's as simple as open the Polk Chamber, you've got isolation, suction, 456 00:22:51,680 --> 00:22:52,920 stop and I getting in there, 457 00:22:52,930 --> 00:22:57,440 dipping a cotton pledge it in hyperly and squashing in there. So at least it's, 458 00:22:57,550 --> 00:23:01,560 it's bathed, then dress and close. That's fine. Just be quick. 459 00:23:01,560 --> 00:23:04,320 If everything's efficient, you know what you're doing. Hence, keep it simple. 460 00:23:04,500 --> 00:23:08,880 You don't need endo files. The, the aim is all you need is your high speed, 461 00:23:09,090 --> 00:23:13,080 ideally rubber down, but all good isolation. Um, you need your, 462 00:23:13,080 --> 00:23:16,640 you in arrogant even to dip into whether you injecting to see if there's another 463 00:23:16,640 --> 00:23:19,560 issue. You'll send the material and close. 464 00:23:19,940 --> 00:23:22,520 But are you happy for us to use a hyper and, 465 00:23:22,520 --> 00:23:26,640 and use a maybe whole syringe of HypoChlor to irrigate the superficial pulp? 466 00:23:27,030 --> 00:23:27,800 It's, yeah, 467 00:23:27,800 --> 00:23:30,680 it's not a problem whether you're gonna do vital pop theory or do endo, 468 00:23:30,850 --> 00:23:34,800 it doesn't matter for the fus for a minute or two or 30 seconds, 469 00:23:34,800 --> 00:23:38,240 you're gonna do it. It doesn't make a difference. It's not gonna do anything, 470 00:23:38,240 --> 00:23:38,980 any damage. 471 00:23:38,980 --> 00:23:41,120 But again, we don't need to go into the canal. 472 00:23:41,120 --> 00:23:43,760 It's just staying very superficially in the, in the, in the pulp chamber, right? 473 00:23:43,760 --> 00:23:44,200 Yeah. 474 00:23:44,200 --> 00:23:46,680 That's all you're trying, trying to do. Get some hemostasis if you can. 475 00:23:46,730 --> 00:23:50,280 If you can't get hemostasis, the agent you're gonna use will hopefully, no, 476 00:23:50,520 --> 00:23:54,280 it'll kill the pulp off. So when you go back and it'll be less messy next time. 477 00:23:54,280 --> 00:23:57,000 Mm-hmm . But it's good to have some disinfectant within there. 478 00:23:57,640 --> 00:24:00,480 Remember the dressing material will probably also have disinfectant effect, 479 00:24:00,480 --> 00:24:04,840 so that's fine. But ideally, yes, get good isolation especi, you can. 480 00:24:05,220 --> 00:24:08,680 And for the sake of a 30 seconds or a minute, it's not the end of the world. 481 00:24:09,300 --> 00:24:11,280 You know, you can, you can be careful enough, 482 00:24:11,280 --> 00:24:14,200 I think you can be careful enough to use hypocrite. You don't need much, 483 00:24:14,220 --> 00:24:16,120 you don't need a syringe. That's foro. 484 00:24:16,950 --> 00:24:20,400 Just in a co p as you said is, is a real gem right there actually, yeah. 485 00:24:20,430 --> 00:24:22,520 Just so can then close in. 486 00:24:22,520 --> 00:24:24,120 There. I I really respect you sound Jen. 487 00:24:24,280 --> 00:24:27,280 I'm not saying I really respect you because what you've given is you really 488 00:24:27,280 --> 00:24:31,360 respected the, the plight of the GDP there and you haven't been dogmatic. 489 00:24:31,360 --> 00:24:35,000 And I really, it's so easy for you as an say no, you absolutely must. 490 00:24:35,000 --> 00:24:37,200 You're committing a cardinal in which we know we are if we don't. 491 00:24:37,200 --> 00:24:39,720 But sometimes you only got five minutes and you are already 45 minutes into it, 492 00:24:39,920 --> 00:24:40,160 whatever, right? 493 00:24:40,160 --> 00:24:43,160 So therefore I really respect that you've given us guidelines in terms of best 494 00:24:43,360 --> 00:24:45,800 practice. But you've said that, okay, if we have to compromise, 495 00:24:45,800 --> 00:24:48,520 let's do it in this fashion, which is gonna help us either way. 496 00:24:48,520 --> 00:24:51,920 So really good suction dip your cotton palette in hypochlorite and those 497 00:24:51,920 --> 00:24:52,520 guidelines you gave. 498 00:24:52,520 --> 00:24:55,480 So I really respect you for considering our position sometimes. 499 00:24:55,480 --> 00:24:56,220 So thank you for that. 500 00:24:56,220 --> 00:25:00,560 Now the last question in this segment for emergency acute situations before we 501 00:25:00,560 --> 00:25:02,440 talk about post-op pain is, 502 00:25:02,440 --> 00:25:06,640 which is your sedative of choice and which is your temporary restoration of 503 00:25:06,640 --> 00:25:07,040 choice. 504 00:25:07,040 --> 00:25:09,320 Sensitive choice. Very popular one. 505 00:25:09,320 --> 00:25:11,680 And I still like it if you can get a hold of it is leix, 506 00:25:11,950 --> 00:25:16,400 this is purely for a corona poly otomy. It's not for sticking down root canals. 507 00:25:16,470 --> 00:25:20,720 Okay? It's got a steroid in it. So naturally it is anti-inflammatory. 508 00:25:20,860 --> 00:25:23,040 The antibiotic component is broad spectrum. 509 00:25:23,040 --> 00:25:25,760 That's neither he inal there to be honest. But it might have some effect. 510 00:25:25,950 --> 00:25:28,960 This is the fact it's sve. You just wanna get the patient outta pain, 511 00:25:29,420 --> 00:25:32,800 but you need to go back in. You can't leave emix for long because it it, 512 00:25:32,800 --> 00:25:36,120 it does its thing and it, it doesn't do much after that. And the, 513 00:25:36,120 --> 00:25:39,160 if there's any pulp beyond that, it'll start getting inflamed. 514 00:25:39,160 --> 00:25:42,160 The PU will become inflamed deeper down. So if you're using leix, 515 00:25:42,360 --> 00:25:44,840 it'll keep it quiet for two to four weeks maybe. 516 00:25:45,060 --> 00:25:47,280 But you need to go back in there and do the full expectation, 517 00:25:47,280 --> 00:25:49,520 do the full endo quickly. The alternative, 518 00:25:49,520 --> 00:25:52,720 and it's still the gold standard is calcium hydroxide, onsetting, um, 519 00:25:52,810 --> 00:25:55,640 it hasn't got any direct anti-inflammatory properties, 520 00:25:55,640 --> 00:25:58,920 but it's a necrotizing agent. It's antibacterial. 521 00:25:59,170 --> 00:26:02,480 So kind of indirectly it'll disinfect the environment. 522 00:26:02,480 --> 00:26:04,760 It'll necrotizing the pot cause it's pretty caustic. 523 00:26:04,760 --> 00:26:07,840 Calcium hydroxide is pretty caustic stuff. It'll fry the pulpit, 524 00:26:07,840 --> 00:26:11,440 comes in contact with very alkaline and it'll do the job. 525 00:26:11,690 --> 00:26:14,760 So when you go back in, you've then got the choice, whether you do end, 526 00:26:14,760 --> 00:26:16,760 it will go down and keep preserve the rest of the pub. 527 00:26:16,760 --> 00:26:18,120 But council drop side's fine. 528 00:26:18,300 --> 00:26:21,160 Non setting councilman drop side if you can't get a hold of . Mm-hmm. 529 00:26:21,160 --> 00:26:21,620 Cause I know. 530 00:26:21,620 --> 00:26:24,720 How, how much do we need here because you know, sometimes nurses, 531 00:26:24,840 --> 00:26:28,280 depending on which dentist they work with, they've got previous biases. 532 00:26:28,280 --> 00:26:31,480 Sometimes give you a huge splodge of it and they give you a file cuz they expect 533 00:26:31,480 --> 00:26:33,960 you to take it all the way to the apex cuz that's what they're used to with the 534 00:26:33,960 --> 00:26:34,793 dentist they work with. 535 00:26:35,010 --> 00:26:38,280 Or sometimes they give you like the tiniest bit and a and a cotton pellet. 536 00:26:38,280 --> 00:26:41,840 Now personally mes i, I like to use PTFE instead of cotton nowadays. 537 00:26:41,840 --> 00:26:45,000 We can hear your thoughts about that. But then how do you best apply that? 538 00:26:45,000 --> 00:26:47,440 And then how much do you put and how do you seal over that? 539 00:26:47,670 --> 00:26:51,200 Okay, so what I do is once you've got hemostasis or relative hemostat, 540 00:26:51,200 --> 00:26:54,720 if you have, if you've got hemostasis, I literally inject the cre. It's cre, 541 00:26:54,720 --> 00:26:59,320 it's like cream, I've got it. Calcium oxide cream into say this over the pole, 542 00:26:59,320 --> 00:27:04,240 chamber floor, a third of the PO chamber floor. Very gently. I you can use ptfe. 543 00:27:04,240 --> 00:27:05,560 The only problem with ptfe, 544 00:27:05,560 --> 00:27:09,000 and I know a lot of Adonis and everyone goes on about ptfe, 545 00:27:09,000 --> 00:27:12,640 the problem is if you put that into place, you roll it into a bull, 546 00:27:12,640 --> 00:27:14,440 you have to roll into a bull and you squash it in, 547 00:27:14,690 --> 00:27:17,960 it displaces the councilman oxide, it just squirts back out. 548 00:27:17,960 --> 00:27:21,680 So you haven't got the volume. So a better material. And you write Carlton woo, 549 00:27:21,680 --> 00:27:24,680 there's plenty of evidence saying you shouldn't use cotton woo because um, 550 00:27:24,680 --> 00:27:25,340 you can't, 551 00:27:25,340 --> 00:27:28,200 you often can't see the fibers and they sometimes petree three and you're gonna 552 00:27:28,200 --> 00:27:31,160 get an infected. It'll just penetrate through the temporary material on the top. 553 00:27:31,510 --> 00:27:35,800 A better alternative I use as sponge Ps. These, the sponge pelles, um, 554 00:27:35,800 --> 00:27:39,120 either endo pellets or um, voco pellets, 555 00:27:39,170 --> 00:27:42,480 they're better because they're compressible the poorest. 556 00:27:42,480 --> 00:27:46,520 So they'll hold the calcium drug side or whatever agent you're in and it just 557 00:27:46,560 --> 00:27:49,400 holds a bit bigger volume of dressing material and like, 558 00:27:49,400 --> 00:27:51,520 well the problem with PTFE is you push it in, 559 00:27:51,700 --> 00:27:54,960 you meant to display it and it's good because it's antibacterial. 560 00:27:54,960 --> 00:27:57,520 And when I say antibacteria, because it's ptfe, 561 00:27:57,690 --> 00:27:59,720 nothing bugs don't stick to the material, 562 00:27:59,880 --> 00:28:04,840 which is great as an inter appointment between root canal treatment is great 563 00:28:04,840 --> 00:28:08,800 for that or postoperatively, uh, we need before you send back. But uh, 564 00:28:08,800 --> 00:28:11,600 for the dressing you just end up displacing it out and you want the dressing 565 00:28:11,720 --> 00:28:14,920 material to soothe the tooth. Mm-hmm. . So, um, sponge, okay, 566 00:28:14,920 --> 00:28:17,320 fair point. In terms of material on harp, it it, again, 567 00:28:17,320 --> 00:28:21,000 it depends on how when the patient's gonna come back. It, the options are, um, 568 00:28:21,030 --> 00:28:24,200 cows and all traditional reinforcing car or cows and all. 569 00:28:24,410 --> 00:28:27,640 If you think the patient's not gonna go see a dentist for a long time, 570 00:28:27,640 --> 00:28:29,560 either GI or irm. 571 00:28:29,660 --> 00:28:34,320 IRM is my favorite because it's super reinforced cows and it's rock hard. 572 00:28:34,320 --> 00:28:38,160 And in fact it was designed. Do you know the history of IRM where it came from? 573 00:28:38,330 --> 00:28:39,640 Uh, no I don't, I don't. 574 00:28:39,640 --> 00:28:44,280 It was developed this, I'm not sure this quite, but it was developed by the, 575 00:28:44,350 --> 00:28:47,360 I think it was the US Navy. So they used doing the Vietnam war. 576 00:28:47,450 --> 00:28:48,680 So what they used to do is they, 577 00:28:48,680 --> 00:28:52,520 they found a material where that they'd do address again, emergency dressings, 578 00:28:52,700 --> 00:28:56,240 get the the soldiers out of pain and they knew they wouldn't come back for 579 00:28:56,240 --> 00:29:00,360 months on end. And that's where our aim was developed. They used it there. 580 00:29:00,360 --> 00:29:02,920 So it's a long term. It's really, it's quite hard. 581 00:29:02,920 --> 00:29:06,240 It's not as hard as a will composite, but it's pretty rare. 582 00:29:06,340 --> 00:29:09,760 The other property's got that original component. It's slightly antibacterial, 583 00:29:09,760 --> 00:29:12,160 which is why a lot of endodontics love it. Um, 584 00:29:12,160 --> 00:29:16,720 it's got that long term antibacterial and it sort of deflects biofilm and 585 00:29:16,920 --> 00:29:17,920 bacteria. So iron's great, 586 00:29:17,920 --> 00:29:21,240 but otherwise GI encapsulated bo standard GI is hard enough, 587 00:29:21,240 --> 00:29:25,080 is resistant enough and is easy, easily accessible for the of the fine endo. 588 00:29:25,160 --> 00:29:26,000 They're the choice ca. 589 00:29:26,000 --> 00:29:28,360 Quite soft. Is that okay for, for a short term? 590 00:29:28,680 --> 00:29:31,880 Short term is fine. It depends on the cavity. If it's an enclosed cavity, 591 00:29:31,880 --> 00:29:33,720 you'd literally, and the clues or access cavity, 592 00:29:33,940 --> 00:29:37,840 you need depth and bulk of Cabot. It is not very, it is quite, 593 00:29:37,840 --> 00:29:39,120 it's pool wear resistance, 594 00:29:39,120 --> 00:29:43,520 but it's okay for no more than two to three weeks and it depends on the 595 00:29:43,520 --> 00:29:46,720 patient's occlusion as well. So mm-hmm it's okay. It's okay. 596 00:29:46,830 --> 00:29:51,080 Sure. Okay. But we do favor counsels on even more IRM and then user GIC if, 597 00:29:51,080 --> 00:29:52,960 if if appropriate as well. So, but that's good. 598 00:29:52,960 --> 00:29:56,160 If I was just summarized because the reason I've done a whistle stop straw this 599 00:29:56,160 --> 00:29:59,800 because I also wanna talk about postop pain perhaps after doing RT and while 600 00:29:59,800 --> 00:30:01,880 I've got this precious time, for those who don't know, 601 00:30:01,880 --> 00:30:04,880 we've been months in the waiting to, to sync our diaries. 602 00:30:04,880 --> 00:30:06,760 So I've got this very valuable specialist, 603 00:30:07,160 --> 00:30:11,480 precious time to extract everything out of your brain and distribute it to a 604 00:30:11,640 --> 00:30:15,000 producer rti. So just to summarize so far guys, we need to uh, 605 00:30:15,000 --> 00:30:16,160 get profound anesthesia. 606 00:30:16,290 --> 00:30:19,840 We don't need to explore in that emergency appointment to get to every single 607 00:30:20,000 --> 00:30:22,600 canal. We certainly don't need to file into every single canal. 608 00:30:22,600 --> 00:30:23,720 If you open up the pulp chamber, 609 00:30:23,760 --> 00:30:27,720 place a sedative like letter mix or a onsetting, calcium hydroxide, 610 00:30:27,870 --> 00:30:31,520 a foam on top, put some cows or GI for good measure irm, 611 00:30:31,520 --> 00:30:34,240 maybe if you want something longer lasting and, and that should work. 612 00:30:34,240 --> 00:30:38,040 Do we have any data on how, Cause sometimes I've done it maybe some years ago, 613 00:30:38,040 --> 00:30:41,240 just patients call calls up next day and say I'm still in pain. But, 614 00:30:41,240 --> 00:30:44,640 but most of the time I'd say 95% plus patients are out of pain the next day. 615 00:30:44,640 --> 00:30:47,240 Cuz I, I did for, for a while do an audit the day after, 616 00:30:47,240 --> 00:30:50,080 especially when I worked at guys in the emergency department. Uh, 617 00:30:50,080 --> 00:30:52,680 do we know how successful it is or has that not been studied? The. 618 00:30:52,680 --> 00:30:54,840 You mean the emergency dressing protocol? 619 00:30:54,860 --> 00:30:56,800 Yes, the emergency dressing protocol. Yeah. 620 00:30:56,800 --> 00:30:58,640 I'm not aware of any specific studies on that, 621 00:30:58,640 --> 00:31:03,280 but it anecdotally from when patients car had the dressings done, 622 00:31:03,370 --> 00:31:05,880 it seems to, within a couple of days, 623 00:31:05,910 --> 00:31:09,040 most patients are outta pain once the dentist's been in there. Yeah. 624 00:31:09,040 --> 00:31:11,320 Yeah. What advice would you give to a patient in terms of, you know, 625 00:31:11,320 --> 00:31:13,160 give it a couple of days and analgesics, 626 00:31:13,160 --> 00:31:15,840 Let's just finish off with what advice you'd give before we talk about post-op 627 00:31:15,840 --> 00:31:16,520 pain. Yeah. 628 00:31:16,520 --> 00:31:19,600 I'd warn them if almost suddenly get, get better. So give it a couple of days. 629 00:31:19,670 --> 00:31:24,200 I ask them to continue the ibuprofen. If they can take ibuprofen or paracetamol, 630 00:31:24,250 --> 00:31:27,880 it was acute pain, then tramadol or something like that. And I, 631 00:31:27,880 --> 00:31:31,880 one thing I also do is just to, in terms of just symptomatic relief, I just, 632 00:31:31,880 --> 00:31:33,400 I'll flatten the occlusion, 633 00:31:33,500 --> 00:31:36,160 get all the deflected contacts out just so there's no, 634 00:31:36,160 --> 00:31:39,320 most of the pain is often non lateral percussion. Uh, so just, 635 00:31:39,320 --> 00:31:40,000 just flatten the tooth, 636 00:31:40,000 --> 00:31:43,600 the teeth probably gonna be indirectly restored probably anyway. So just, 637 00:31:43,600 --> 00:31:47,080 just relieve an ear. Uh, the tooth will be high hyper occlusion anyway. 638 00:31:47,250 --> 00:31:50,920 If there's any acal involvement as well. You never in multiple teeth, 639 00:31:50,930 --> 00:31:54,720 in multitude teeth, one pop could be vital inflamed, 640 00:31:54,720 --> 00:31:55,640 the other part could be dead. 641 00:31:55,640 --> 00:31:58,440 So you might have also a combination of ale inflammation. 642 00:31:58,440 --> 00:32:00,160 You don't really know that immediately. 643 00:32:00,210 --> 00:32:03,760 So just relieve the tooth out of occlusion, all that exclusion and, 644 00:32:03,760 --> 00:32:07,440 and then yeah, postoperative antis, it should settle within a couple of days. 645 00:32:07,440 --> 00:32:11,160 Should do. And sell 'em to go to the dentist, not your patient. You must, 646 00:32:11,160 --> 00:32:15,000 they must follow this up and warn them what could happen. Because if they, 647 00:32:15,200 --> 00:32:19,000 again, medical legal hat on, if you haven't warn them this, it kicks off, 648 00:32:19,490 --> 00:32:23,360 they'll say you didn't warn them. And you know, just to prevent a complaint, 649 00:32:23,360 --> 00:32:26,080 he needs to warn them, put in the notes, this is the advice given. 650 00:32:26,130 --> 00:32:29,080 If you're not gonna come back to your clinic, uh, this needs to be done. 651 00:32:29,080 --> 00:32:30,840 So you just protect yourself for the future. 652 00:32:31,030 --> 00:32:32,320 Yeah, warn them. 653 00:32:32,320 --> 00:32:35,520 And also make an entry into the notes that patient warn that needs to, 654 00:32:35,520 --> 00:32:38,200 this is not the final treatment. You know, some people just assume that, oh, 655 00:32:38,200 --> 00:32:40,840 I've done my root now and I take a radiograph. There's no root filling material. 656 00:32:40,840 --> 00:32:43,640 You've seen, obviously he's been dressed at some point probably five years ago, 657 00:32:43,800 --> 00:32:46,480 whatever. So yeah, good point. Well made. So thanks. Let's, 658 00:32:46,480 --> 00:32:49,720 let's switch gears a little bit. I recently treated a, a gentleman, 659 00:32:49,720 --> 00:32:50,560 Well there we have it guys, 660 00:32:50,560 --> 00:32:54,040 you don't need to find and open up every single canal. Just get in there, 661 00:32:54,040 --> 00:32:56,200 relieve the pressure, place your predicament. 662 00:32:56,200 --> 00:32:59,720 And we also talked about what kind of materials we can use afterwards. 663 00:32:59,720 --> 00:33:03,360 So I feel like we covered a fair amount in this group function. Listen, 664 00:33:03,450 --> 00:33:05,000 if you are listening on the app, 665 00:33:05,000 --> 00:33:07,880 you are listening or watching on the premium version of the app, 666 00:33:07,880 --> 00:33:10,480 just scroll down now and then you'll see a form, 667 00:33:10,480 --> 00:33:13,680 fill in a few details and answer a few questions and you'll get your half an 668 00:33:13,680 --> 00:33:16,120 hour's worth of CPD certificate with all the aims, 669 00:33:16,120 --> 00:33:19,280 objectives and the reflective log. So it's like legit and future proof. 670 00:33:19,280 --> 00:33:21,800 And if you're not already on the app, look, you can download it for free. 671 00:33:21,800 --> 00:33:25,160 It's on iOS and Android. And the benefit is you can download these episodes, 672 00:33:25,160 --> 00:33:29,000 videos, and audios and any PDFs and save it to your device if you, 673 00:33:29,000 --> 00:33:30,160 in case you have Choppy connection. 674 00:33:30,160 --> 00:33:34,320 And it's one of those membership programs that actually let you download all the 675 00:33:34,320 --> 00:33:36,720 stuff. Like if you're on a membership website for dentistry, 676 00:33:36,720 --> 00:33:40,080 then it's very unlikely they'll let you download the videos on your hard drive, 677 00:33:40,080 --> 00:33:41,200 on your phone or your tablet. 678 00:33:41,200 --> 00:33:44,760 You actually download the video and audio to your device to listen in the 679 00:33:44,760 --> 00:33:45,040 future. 680 00:33:45,040 --> 00:33:49,240 And if you want CPD and exclusive premium content that I'm making all the time, 681 00:33:49,240 --> 00:33:50,880 then I really appreciate your sport. 682 00:33:50,890 --> 00:33:54,840 If you support a team Protrusive and joined the premium package on a monthly 683 00:33:54,840 --> 00:33:57,680 subscription, and I'll promise you, I'll make it worth your while. Anyway, 684 00:33:57,680 --> 00:34:00,600 thanks so much for listening all the way to the end. You true prorate. 685 00:34:00,660 --> 00:34:03,600 And I'll catch you same time, same place on the next episode.