Group Function – Protrusive Dental Podcast

Jaz’s Introduction:
What is your current protocol for EXTIRPATION? So let’s say you made a diagnosis of irreversible pulpitis. Your patient is in raging pain. And you have to squeeze in this pain relieving treatment, a extirpation probably of a lower molar or something in five minutes. What are you going to do? Well, some of you will listen to this and it will 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 extirpation anymore after today, because I’ve got Dr. Sanj Bhanderi, specialist endodontist to talk us through what is the right way, the proper way to do an extirpation of your patient who is in pain. And there are just so many gems from pain relief, diagnosis, isolation, and what I love about Sanj in this episode, is that he’s not dogmatic. Yes, he’s a specialist endodontist and so easy for him or anyone say you must always use rubberdam. But yes, he does discuss a scenario that okay, if for whatever reason, you had to do it without rubberdam, how can you optimize the isolation? How can you reduce the saliva getting inside the tooth, so I really appreciated that about this episode. I’m sure it 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 extirpation without wasting time and without actually making things worse for future treatment.

Main Episode:
So hope you enjoy this episode. And I’ll catch you in the outro. Dr. Sanj Bhanderi. Welcome to the Protrusive Dental Podcast. How are you my friend?

[Sanj]
Very well. Thank you, Jaz. Thanks for the invitation. Excited. I’ve done one of these before.

[Jaz]
Well, I’m amazed it’s your first time and it’s your real hero of mine, Sanj because I remember 10 years ago, I met you at the British Endodontic Society. Can you believe it was that long ago?

[Sanj]
God. 10 years? You know what? Everything’s a blur nowadays at my age. Yesterday, still seeing the same but no, thank you. It’s lovely to have, to be here. Thank you.

[Jaz]
Thank you so much. And I remember your lecture even then I remember some of your lectures the BDA and probably because our paths haven’t collide. I haven’t seen you. I know you’re very active with your teaching, but our paths haven’t collided since then that much, but it’s great to have you on to talk about a very important topic, which is how to get a patient out of pain in terms of your diagnosis, irreversible pulpitis. We’re going to talk about what is the optimum and best Sanj approved way of dealing with 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 it’s an international audience in terms of where is it that you work? What got you into endo a bit of your background?

[Sanj]
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 which is a bit frightening, so now I’m qualified in London, actually in London but I now live in Manchester enough sort of wormed my way up north to the northwest, maybe by accident, really, and just just hospital jobs initially came up, then I did my postgraduate training up here. I mean, back in those days 1995, there was no, there were only three postgraduate endodontic programs outside the hospital training pathway and that was either London or Manchester and I happen to be the right place, the right time in Manchester. I go on to the Masters quite young, actually quite early. I think it was the first one in our batch in our year and guys and I wasn’t I flying student at all. I managed to, there’s one to get an MSc and then I stayed in Manchester that time the mid 90’s I don’t know if you’re too young to remember Jaz but it was quite a good university. And it was a hot thing. I had a better student life as a post grad than I did in London. But, now, it was things were changing in Manchester the Dental School’s good I was teaching. There were not many endodontist one of the reasons I stayed up north actually because I needed a job prospects. This is before endo became really popular and I could see it in fact is by accident fell into endo it was gonna be either implants at that time there was an implant MSc and there was an endo MSC because that was one of the only endo at implant Msc in the country. I was too young I would never go on the people that got onto that were experienced practitioners and I’ve 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’s sort of taken off from there and I just got into Endo, the state of Manchester got job offers and I pretty much been full time endo day one from finishing the Master’s since 1997.

[Jaz]
So how many days are you clinical at the moment in terms of doing your endodontics referral practice?

[Sanj]
Yeah, so I’m pretty much now full, full time as in I was four days and at three days now. And I’ve got an associate Rob, Rob Jacobs, who covers me so. So I’m down to three and a half days, teaching now just in private courses up and down between London and Manchester with a couple of friends. So that keeps me out of the practice. But pretty much I’ve always been a hands-on clinician.

[Jaz]
So you’re very wet fingered, very clinical, you, you’ve got a great name in the UK as the person for endo. So again, it’s a privilege to have you on. The reason I have you on is because extirpations, 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 extirpation cases anymore, because usually by time they’ve come see me there’s a sinus tract. There’s a perio endo lesion, and they’re really complicated.’ So firstly, I’m just being nosy. How much emergency extirpation do you get? How many of those phone calls you get? How many of you actually treat in that regard?

[Sanj]
In terms of the practice, you’re absolutely right there being an endodontist. We, by the time they get to us, they are non vital previously root-filled, 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 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 dental casualty where they call it nowadays. So you have to deal with that you have to learn pretty quickly. One of the reasons I went into endo is just okay, it’s not just about the white lines at the end of the endodontic 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 in that way, I’m kind of shielded being in specialist practice, because it’s my general dental colleagues. They’re at the coalface and they’ve got to deal with that stuff on a Friday afternoon, just before they close patient will knocks in you know, they haven’t slept for a week and they’re anxious and nervous that never been to dentists, sometimes you got a lot to deal with, and you got to get them out of pain. And we can’t shove them off with antibiotics. It’s just not appropriate nowadays, medically legally, now you could get into well, or if something happens, so you’ve got to be able to get in there and deal with it efficiently, as painlessly as possible. And that’s a challenge because the tooth is extremely inflamed, 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 with whatever the protocols are. For that is important. Yeah.

[Jaz]
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 further for the younger audience listening, those students who are listening right now, just coming up with a diagnosis of when it is appropriate to give antibiotics? Because perhaps necrotic infected and really, it might already root-filled or whatever. And then what kind of history and clinical findings are leading you to towards a diagnosis of irreversible pulpitis that needs that intervention that wouldn’t settle with antibiotics? Can you just give a distinction between the two different types of patients?

[Sanj]
Okay, so you’ve got two different situations, you’ve got the root filled or non root filled teeth, or we’re talking about the root filled tooth yet because that’s a different slightly different scenario, but on a tooth that’s either potentially vital or semi vital or partially necrotic or completely necrotic. Okay, so it starts from the disease process obviously starts at the top of the pulp typically caries, tooth fractures, bugs are going to get into that pulp. Now, sometimes patients will have very low grade symptoms and a niggle, a dull ache, maybe a bit of thermal sensitivity, and they kind of put up with it. And sometimes this pulp will die, but it’s the ones that don’t die or die painfully and they go through an acute phase what we describe as irreversible pulpitis. They’re the ones that the challenge because because the the top of the pulp, the pulp, is the most inflammed closest to the insult, could be caries or a fracture, that bit of the pulp will be difficult to anesthetise. So the whole, when you give a block typically for a lower teeth, you’ll get a block anesthesia, you’re given filtration, the anesthesia will not penetrate up the ID nerve, you won’t get into the pulp, it will get into the pulp, atypically, maybe reticular area, but it won’t get to that point which is the closest to the insult most inflamed. That’s the challenge getting from the, way I describe it to the patients, I show them the X ray, this is your tooth, that’s the top, you’ve got all refilling there we need to go from the top the occlusal surface down to that pulp chamber bit. We’re going to go down to there now a lot of its patient management is preparation. Okay, because we’ll go through the anesthetic protocol, which hopefully will work but sometimes it is not going to work. But you need to know that and you know that from the patient’s symptomology where they can walk in. You just know that as a hot pulp, there’s a chance that they’re not, you’re not gonna melt anesthetise and doesn’t matter what hit them with. There are a few things we’ll talk about how to prep that if they walked in off the street If you know there’s a pulpitis just coming in, you can, there’s a few things you can ask them to do before they come in, just to help the anesthesia process. And then when they get them in the chair, it is management’s a lot of good anesthesia, multiple techniques, 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 too much you sometimes have to do in stages, sometimes you got to gotta go for it. And as it’s sometimes you got to be cool to be kind but in the appropriate patient. You can’t just dive in and you know, you lose a patient and it’s not nice to so you’ve got to imagine yourself in that position. But equally, you want to get them out of pain. It’s a balance. It’s a real fine balance.

[Jaz]
Yeah, so just the other day I saw an acute, patient in acute pain and after getting somewhat good anesthesia, you know objective, you know, I tried with endo frost beforehand, managed to elicit a necrotic response compared to others actually. But he had recent symptoms of irreversible pulpitis. So it was probably mostly necrotic. But there’s still some element of vitality to it based on his symptoms he was presenting with. And so when I did manage to reach the pulp chamber of his lower molar. Place to file just into distal, this wasn’t bleeding. So it confirmed my diagnosis of necrotic. But I saw the white pulpal tissue. So as soon as I put my K file into the distal, he pretty much jumped out the chair so I gave the intrapulpal. And that just settled him. So it kind of leads communists 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’ve given on the phone as you alluded to, to help achieve better success rate of anesthesia?

[Sanj]
Yeah, it’s about reducing the inflammatory stages that pulp as best you can and systemically, there’s plenty of evidence to say that loading them up with anti inflammatories, nonsteroidal so four to six of Ibuprofen with or without paracetamol, if they can’t tolerate anti inflammatories, asthma or stomach issues, Tramadol, something like that, or 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 needs to dies. But it will 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 or is notoriously the worst teeth, molar teeth, first second molars, those teeth are really difficult to numb. And it’s because they’ve got accessory nerve supply as well often. And for me, the baseline technique is ID, we do an ID block, I don’t mess about with intraPDLs and this sort of thing. And, you know, there’s usually to knock them, knock that nerve out and not as much as you can supplemented with buccal infiltration is of an age of this absorb as well. And for me, it’s articaine. So if my ID block, I would give lignocaine. As a start, this is an acute emergency, don’t use lignocaine off, and actually, I’ll tend to fall back on mepivacaine. We’ll come to that later on why I use preferred mepivacaine for routine Endo, but for hot teeth need, you need profound anesthesia. You don’t need longevity. But lignocaine works pretty well as an ID. I’m not a fan of giving ID blocks with articaine. But I know the evidence suggests it is very good. And it’s controversial that the risk of paraesthesia. And it may not be anything to do with the agent, it’s probably to do with the fact that’s trauma from the needle. But I’d rather not if there’s an alternative and it which works just as well. So ID lignocaine wait for that to be to work completely work. So we’re talking, the lip is completely numb. The lingual mucosa are completely numb, not even the patient alveolar thing, then articaine buccal infiltrations, it tends to absorb better through the buccal plate is pretty thick, and especially in the sixth and seventh area. And then I might give PDLs as well, or lingual underpressure I’ve got an intra paradata device called the wand, there are few other devices and now available which do the same sort of thing. They basically under high pressure with a short needle, they can deliver the anesthetic through the PDM. The theory behind that is a PDLs is almost as good as an entry onto osseous. Injustice is the other mechanism, you can drill a hole into the bone through these self drilling devices, which has a pretty good effect. I’ve never got are used to those devices, but some people swear buy them. But you need to get that profound anesthesia in there. And you just got to wait. Make sure you just make sure that the anesthetics work, don’t just dive in. And then you want to patient management.

[Jaz]
Well, with the busy lives of a general dental practitioners, but juggling at getting these patients in, making the diagnosis can take in 15,20 minutes. Sometimes you take a radiograph then give them the block let’s say aren’t getting infiltration, get them set outside while you see a few more patients. I’ll see you in my lunch breaks Mrs. Smith or whatever. Then the lunch rate comes your nurse is rolling her eyes, they swap nurses and so it’s all happening in busy practice. Now, let’s say we made a diagnosis of irreversible pulpitis. And we know we need to extirpate we have given sufficient anesthesia and the patient loaded up with ibuprofen and all the stars aligned when we’re dealing with such teeth. They usually have a large MOD amalgams or something like that. Right? So my first question in terms of making a very tangible for general dentist is in ideal world we’d love to remove the entire restoration. Remove any caries, access cracks but when I’ve 20 minutes we need to get in go for the kill. Is that okay? Can you forgive us?

[Sanj]
At the end of that, this is about patient this is about getting a 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 a patient realizing it. That’s my principle in endo. Whether it’s emergency or endo, you want to-

[Jaz]
Stealthy.

[Sanj]
Stealth, stealth okay. And the first priority is getting into the pulp. You’re releasing the ,by going into the pulp you will automatically release pressure, there’s pressure buildup, that’s the number one property of inflammation, isn’t it? Then you need to sit basically, you’re applying a sedative material to relieve the inflammation, most common and popular products steroid.

[Jaz]
Before we talk about medicamento and stuff. Yeah, before we talk about the medicaments I just love to ask some real world questions like let’s say you go in you open up the pulp chamber, do you think it’s desirable for the practitioner who’s going to 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 other day had four canals mesio-buccal, mesial-lingual, and two distals, so four canals. And I did. I opened it all up as much as I could to visualize those four canals and it was mostly restorative material I was moving at this point at now. Is it okay, in that short appointment to just literally go in? See the pulp chamber and then proceed the medicaments? Or would you recommend to open it? Or does it depend on any factors?

[Sanj]
Okay, in short, forget about the root canals. Job is getting there, relieve the pressure, open the pulp space up and apply the dressing. That’s simple. That’s all you have to do on a Friday afternoon.

[Jaz]
Even like three or four millimeters in them in the middle that’s insufficient?

[Sanj]
Because what then tends to happen is, so the inflamed part is the coronal pulp, where in fact just the top bit of the pulp horn, you’ll find once you’ve, in those cases, you’ve got to give an intrapulpal going back to that essentially all you doing is crashing the nerves. It doesn’t matter what agent you can use, there are water, but the pressure crushes a nerve and that inflamed pulp, you’ll often find the rest of the pulpit, okay, it might be hyperemic might be bleeding a lot, but they won’t feel that. Remove the coronal pulp if you can, if 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 going to start shredding pulp tissue. And unless you get the rest of the whole pulp out, that pulp tissue that you leave behind in the apical or mid third, it’s gonna be inflamed, and then the patient just you get equals other problems. So the pain is coming from the coronal pulp, deal with that, dress it and going back to the restoration unless there’s a gaping hole underneath the MOD amalgam, or it’s clearly this care, you know, it’s just the saliva coming in. Don’t worry about the stage, you can temporarily seal that off with Cavit or Kalzinol or whatever you going to use, just close the tooth, sedate it, close it and then get them back in for to dense the teeth apart, if you have to, it’ll be easy to numb up, you can then the resolvability assessment. If it’s not, if it’s too knocked from the outside, then you just refer for an extraction or book in for an extraction. But if you’re not sure, then don’t worry about that you can assess restorability, and then treatment plan for Endo once the patient is out of pain, and they’re easy to anesthetise. So don’t miss about the pulp root canals at this stage. This is about dressing and getting them out of pain, don’t fish around root canals

[Jaz]
This is going to be enlightening Sanj there’s gonna be absolutely enlightning because I know plenty of colleagues who advised me in the past and they swear by this Sanj they said, ‘You won’t get the patient out pain until you file all the way to the apex.’ Now is that a myth?

[Sanj]
Largely yes, it’s a myth because-

[Jaz]
Have you heard this?

[Sanj]
Vital so the pain is coming from that topic. It’s not the rest of the pulp. In fact, we’ll come on to this we get tired things are slightly changing. Now the way we treat vital pulps. Okay, this is an interesting conversation where we are now and it was too early to bring this in. We were in the realms of what’s called Vital Pulp Therapy where maybe we don’t need to extirpate pulps at all or the root canal we can do the coronal pulpotomy as we used to do for kids individual teeth. Remember the Cvek pulpotomy back in the day? That concept is now coming in adult teeth, not just immature adult teeth molars for example evan in mature teeth. And this comes this is the kind of crossover between risk cariology, the caries management and restorative dentists coming in. And they’ve been doing this kind of stepwise technique and all that but I think endodontists we’ve always been, not been happy with that because if you’re not predictable, 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 with the level of prognosis is low. All the pulps completely obliterate and then when you have to do the endo is a nightmare. Things are changing a little bit with the new materials but at this stage in terms of emergency management is enough just as deal with the coronal part of the pulp. The rest of the pulp often it will stay vital whether you then take the dutiful-

[Jaz]
This music to everyone’s ears, Sanj. This is music.

[Sanj]
So whether you then go and do new canal was, so yeah, do the full Endo. Or you don’t and you apply these new vital pulp therapies. That’s the that’s the next interesting question. Because endodontics is changing now, we didn’t prevent-odontic, like it.

[Jaz]
Very good, very good. I think that’d be a whole new episode. But just to continue on the reign of the emergency management, I think what you’ve said is going to be music to the ears of all the GDPs listening who perhaps had this thought that and they’re going to 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 sedative in and we’ll talk about sedative in a moment. Now, and don’t go sticking your K file. So in fact, your nurse now knows not even to give you a K file for this emergency extirpation, which is brilliant. Would you recommend using hypochlorite? Now before we can get to that, let’s take one step back. I personally I would always use rubber dam you know, with your influence on the BES, I can’t go to BES conference and then not use rubberdam for anything like this. So I always use rubber dam but I’ve got some colleagues that were more experienced. And they say, ‘Jaz, it’s okay, because we’re killing the nerve anyway.’ The endodontic, the endo buds will sort the bugs out afterwards. So just get going put some sedative in and come out. We don’t need to irrigate and we don’t need rubber dam. What do you think on that? What is best practice? What do you want from your referring practitioners?

[Sanj]
Okay, but I mean best practice is you’ve got to isolate the teeth properly, both from a safety point of view and also from microbiological point of view. Now, okay, that dentist may not be doing the endo, and it’s not their problem, it will go to the endodontist. The problem is if bugs get in their, saliva 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 PYtest actually exist apart from that inflamed bit, it’s actually a sterile situation, which is where relative vital pulp therapy comes in. So you don’t want to introduce bugs there. Because either you don’t know when that patient is going to get to the endodontist. Or when they’re going to have the endo might be weeks, it might be months. And if they get an infection, and it gets into apical, then you’re into different ballgame in terms of prognosis and treatment. So isolation still is important. Now, whether you rubberdam or you compromise, depending on the clinic. And if you’re working in emergency department, and another factors, it’s easy for me to say in my ivory tower of dental school or endo practice, you have rubberdam there and then but again, good isolation, your nurses there good aspiration, open the pulp, give it an irrigation. Remember, it’s only the coronal part, you know, messing about root canals, you just need to bathe the area-

[Jaz]
Hypochlorite, or Corsodyl or whatever. What do you recommend? Hypochlorite. Now, what do you think about people who, because maybe they’re not using rubberdam, then they’re using chlorhexidine 2%, maybe or-

[Sanj]
It’s better than nothing, and then we’ll be using 2%, we’ll be using mouthwash, which is useless to be honest, it’s the surface.

[Jaz]
It’s true,

[Sanj]
It’s the same for sure, because that’s quite expensive. And most people don’t, even endodontist don’t use that one. Not many of you. Even if it’s as simple as opening the pulp chamber, you’ve got isolations, suction to stop saliva getting in there, dipping a cotton will pledge it in hypochlorite and squashing it in there. So at least is bathed, then dress and close. That’s fine. Just be quick. Everything’s efficient, you know what you’re doing. Hence, keep it simple. You don’t need endo Files. The aim is, all you need is your high speed. Ideally, rubber dam but all good isolation. You need an irrigant enough to dip into whether you’re injecting, that’s another issue, you will send some material and close.

[Jaz]
But are you happy for us to use a hypochlorite and using maybe a whole syringe of hypochlorite to irrigate the superficial pulp?

[Sanj]
Yeah. It’s not a problem, whether you’re going to do vital pulp through endo, it doesn’t matter. For the fuse for a minute or to 30 seconds you’re going to do it. It doesn’t make a difference. It’s not going to do anything, any damage.

[Jaz]
But again, we don’t need to go into the canal. It’s just staying very superficially in the pulp chamber, right?

[Sanj]
Yeah, that’s all you’re trying to do get some hemostasis if you can, if you can’t get hemostasis, the agent you’re going to use will hopefully no, no, it’ll kill the pulp off. So when you go back and there’ll be less messy next time. But it’s good to have some disinfected within there. Remember the dressing material probably also have disinfectant effects. So that’s fine. But ideally, yes, get good isolation as best you can. And for the sake of a 30 seconds or a minute, it’s not the end of the world. You know, we can be careful. Another thing you can be careful of to use hypochlorite, you don’t need much. You don’t need a syringe that’s friendo.

[Jaz]
Just in a cotton pellet, as you said is a real gem right there actually.

[Sanj]
Yeah, just so getting in close.

[Jaz]
I really respect you, Sanj. And what I’m saying, I really respect you. Because what you’ve given is you really respected the plight of the GDP there, and you haven’t been dogmatic and I really repeat, it’s so easy for you as an endodontist saying, you know, you absolutely must be committing a cardinal sin, which we know we are if we don’t, but sometimes you only got five minutes, and you’re really 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, what’s going to help us either way, so really good suction, dip your cotton pellet 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 situation before we talk about post op pain is which is your sedative of choice and which is your temporary restoration of choice?

[Sanj]
Sedative choice, very popular one and I still like it, if you can get hold of it as Ledermix. This is purely for a coronal pulpotomy it’s not for sticking down root canals. Okay? It’s got a steroid in it. So naturally, it’s anti inflammatory. The antibiotic component is broad spectrum that’s neither here nor there, to be honest, but it might have some effect. This is the fact that sedative, you just wanna get the patient out of pain. But you need to go back and you can’t leave other beings for long because it does its thing. It doesn’t do much after that. And if there’s any pulp beyond that, it’ll start getting inflamed, the pulp will become inflamed deeper down. So if you’re using Ledermix, it’ll keep it quiet for two to four weeks, maybe. But you need to get back in there and do the full extirpation do the full endo quickly. The alternative and it’s still the gold standard is calcium hydroxide non setting. It hasn’t got the direct anti inflammatory properties, but it’s a necrotising agent, it’s antibacterial. So kind of indirectly, it’ll disinfect the environment it’ll necrotize a pulp because 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 endo or go down and keep preserve the rest of the pulp. Calcium hydroxide’s fine. Nonsetting Calcium hydroxide if you can’t get hold of Ledermix. Because I know that-

[Jaz]
How much do we need here? Because, you know, sometimes nurses will depending on which dentists they work, when they’ve got previous biases, sometimes give you a huge splodge of it and they give you a file because they expect you to take it all the way to the apex because that’s what they used to with a dentist they work with. Or sometimes they give you like the tiniest bit and, and a cotton pellet. And I personally me Sanj, 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?

[Sanj]
Okay, so what I do is once you’ve got hemostasis, or relative hemo state, if you’ve got hemostasis literally inject the, it’s like cream, Calcium hydroxide cream, into the over the pulp chamber floor, a third of the pulp chamber floor very gently. You can use PTFE. The only problem with PTFE. And I know a lot of endodontists. And everyone goes on about PTFE. The problem is, if you’ve put that into place, you’ve run into a ball you meant to roll into a ball, you squash it in it displaces the calcium hydroxide, it just squirts back out so you haven’t got the volume. So a better material and you’re right cotton wool, there’s plenty of evidence saying you shouldn’t use cotton wool, because you can’t, you often can’t see the fibers and they sometimes protrude through and you’re gonna get an infection, it’ll just penetrate through the temporary material. So better alternative I use is a sponge pellets, these sponge pellets, then either endofrost pellets or VOCO pellets, they’re better. Because it compressible, their porous. So they’ll hold the calcium hydroxide or whatever agent you’re in. And it just holds a bit of bigger volume of dressing material. Unlike probably PTFE as you push it in, you meant to displace it. And it’s good because it’s antibacterial. And when I say antibacterial it 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, what postoperatively before you send back, but for the dressing, you just end up displacing it out and you want the dressing material to soothe the tooth. So-

[Jaz]
Fair point.

[Sanj]
In terms of material on top, it did get it depends on how when the patient’s going to come back. The options are Kalzinol traditional reinforcing zinc-oxide eugenol If you think the patient is not going to go see a dentist for a long time, either GI or IRM. IRM is my favorite, because it’s super reinforced Kalzinol. It’s rock hard, and in fact, it was designed. Do you know the history of IRM? Where it came from?

[Jaz]
No, I don’t.

[Sanj]
It developed this, I’m not sure this. It’s developed by the I think it was the US Navy for at least during the Vietnam War. So what they used to do is they find the material where they do a dress again is emergency dressings, get the soldiers out of pain, and they knew they wouldn’t come back for months on end. And that’s where IRM was developed. They used it there. So it’s a long term. It’s quite hard. It’s not as hard as amalgam or composite. But it’s pretty rare. It’s the other property it’s got that huge knock components it’s slightly antibacterial, which is why a lot of endodontist love it. It’s called a long term antibacterial and it sort of reflects biofilm and bacteria so IRM is great but otherwise GI capsulated bog-standard GI is hard enough or is resistant enough and is easily accessible for the endo and the choice.

[Jaz]
Cavit, quite soft. Is that okay? For a short term?

[Sanj]
Short term is fine. It depends on the cavity. If it’s an enclosed cavity and literally an occlusal access cavity. You need depth and bulk of Cavit. It’s not very, it’s quite it’s poor 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 it’s okay, it’s okay.

[Jaz]
Sure. Okay, but we do a favor Kalzinol or even more IRM and then use a GIC if appropriate as well. So that’s good. If I was just summarize because the reason I’ve done a whistlestop story of this because I also want to about post op pain, perhaps after doing rc while I’ve got this precious time. For those who don’t know, we’ve been months in the waiting to sync our diary. So I’ve got this very valuable specialist, precious time to extract everything out of your brain and distribute it to Protruserati. So just to summarize so far, guys, we need to get a 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 Ledermix or a non setting calcium hydroxide or foam on top, put some Kalzinol or GIC for good measure. IRM maybe if you want something longer lasting, and that should work. Do we have any data? Cause sometimes I’ve done it maybe some years getting patients calls up next day, saying I’m still in pain. But most of the time, I’d say 95% plus patients out of pain the next day because I did throw for a while do an audit the day after especially when I worked at Guy’s in the emergency department. Do we know how successful it is? Or is that not been studied?

[Sanj]
The emergency dressing protocol?

[Jaz]
Yes. Emergency Emergency protocol?

[Sanj]
Yeah, I’m not aware of any specific studies on that. But anecdotally, from when patients can’t had the dressings done, it seems within a couple of days, most patients are out of pain once a denture has been in there. Yeah.

[Jaz]
What advice would you give to your patient in terms of you know, give it a couple of days and analgesics. Let’s just finish off with what advice you’d get before we talk about post op pain.

[Sanj]
Yeah, a woman is going to suddenly get get better. So give her a couple of days I could 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 want the olders just to in terms of just symptomatic relief, I just flattened the occlusion, get all the deflected contacts out to say there’s no, most of the pain is often on lateral percussion. So just flatten the tooth. The tooth is probably going to be indirectly restored probably anyway. So just relieve any, the tooth will be in hyper-occlusion anyway, if there’s any apical involvement as well in evidence in multiple teeth, one pulp could be vital, inflamed, the other part could be dead. So you might have also a combination of apical inflammation, you don’t really know that immediately. So just relieve the tooth out of occlusion. And then yeah, post operative anti inflammatories it should settle within a couple of days should do and tell them to go to the dentist.

[Jaz]
Amazing.

[Sanj]
You must, they must follow this I’ve been warn than what could happen. Because if there is, again, medical legal hat on, if you haven’t worn them this, it kicks off. They’ll say you didn’t warn them and you know it just to prevent a complaint you need to warn them put in the notes, this is the advice given if you’re not going to come back to your clinic. This needs to be done. So you just protect yourself for the future.

Jaz’s Outro:
Yep, and warn them and also make an entry into notes that patient one that needs to this is not the final treatment. You know, some people just assume that, ‘Oh, I’ve got my root canal and I take a radiograph there’s no root for the material. You see, it obviously has been dressed at some point probably five years ago, whatever.’ So yeah, good point, well made. So Sanj, let’s switch gears a little bit. I recently treated a gentleman. Oh, 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 medicament. And we also talked about what kind of materials we can use afterwards, I feel like we covered a fair amount in this group function. Listen, if you are listening on the app, you’re listening or watching on the premium version of the app, just scroll down now. And then you’ll see a form, fill in a few details and answer a few questions. And you’ll get your half an hour’s worth of CPD certificate with all the aims objectives and the reflective log. So it’s like legit and future proof. And if you’re not already on app, look, you can download it for free. It’s on iOS and Android. And the benefit is you can download these episodes, videos and audios and any PDFs and save it to your device in case you have choppy connection. And it’s one of those membership programs that actually let you download all the stuff like if you’re on a membership website for dentistry, then it’s very unlikely they’ll let you download the videos on your hard drive or on your phone or your tablet. You actually download the video and audio to a device to listen in the future. And if you want CPD and exclusive premium content that I’m making all the time, then I’d really appreciate your support if you support the team protrusive and joined the premium package on a monthly subscription. And I’ll promise you, I’ll make it worth your while. Anyway. Thanks so much for listening all the way to the end, your true Protruserati and I’ll catch you same time same place on the next episode.