Transcribed by Charles Buchanan Date of the Lecture: 10/02/14

[Diagnosis and Treatment of Oral Diseases] [Lecture #44] [Endodontic Emergency

Treatment] by Dr. Leigh R. Busch, D.D.S.
Hey guys. There are a few slides that were not included in the slides that were uploaded for us so
I put up a screen shot of them. They arent that serious content wise but I didnt want there to be
any confusion for people. He tends to jump from thought to thought within the same breath so I
tried to punctuate it in a way that was easy to follow (I guess). Nothing was omitted aside from a
few umms and oks. I put the important things he said in BOLD if you are pressed for time or
dont feel like reading too much extra. There are a bunch of details that he didn't talk about
though so check out that Powerpoint. Enjoy.
[Slide 1] [Endodontic Emergency Treatment]
[Dr. Busch] SKIP
[Slide 1A] [When a dog catches a car, whats he going to do with it?]
This slide was not originally part of our slide deck
(just a cartoon- an ACTUAL cartoon)
[Dr. Busch] Ok. So last week. Last week we
spoke about diagnosis. How to diagnose a problem.
The steps to go through to come up with a
diagnosis. And as I relate this, you see, if a dog is
chasing a car, you kind of question, well if when a
dog catches a car, what is he going to do with it?
So now, you have all the information about making
a diagnosis. Now youve made the diagnosis, what
are you going to do with the diagnosis. Alright. So
what were going to speak about today basically is,
uh, treating endodontic emergencies. Um, I said
last week, that my denition of emergency is
pain, swelling and bleeding. Were going to
concentrate mostly on pain. Some of it on swelling.
Were not going to talk about bleeding. Again. so if
the most common emergency you get with a patient
coming in, as we talk about new patients, building practice - new patient comes in, why does he
come? Because he or she is in pain. So now the patient has come in, complaining of pain.
What is your objective for this day? For treating the patient? Relieve the pain. I told you I will
ask you questions in clinic. A lot of times when Ill help out a student and Ill ask well, what was
our objective today? And theyll say well, we want to do a pulpotomy, or you wanted to do this
or that. No, no. The objective was to get the patient out of pain. Now what we had to do to get
the patient out of pain - thats what were going to speak about now - what you have to do. But
your objective, again, is to get the patient - the patient comes in in pain, when that patient leaves,
when that patient goes home at night, he or she doesnt want to be in pain. Another practice
builder, I think Im not sure if I mentioned that, is the patient came in in pain, new patient/
emergency patient with pain or swelling or whatever. That patient goes home that night, you give
that patient a call. Howre you doing? They love it,they eat it up. I cant believe how
concerned this doctor was. He called to see how Im doing. And if youre smart, youll call
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Transcribed by Charles Buchanan Date of the Lecture: 10/02/14
while they're still numb. ~chortles~ But that a real - either call that
same night or the next day and ask the patient how theyre doing.
[Slide 1b] [Why Do Patients Seek a Dentist] -not in our slide
deck, nothing important
[Dr. Busch] So, Alright this is what we just talked about.
[Slide 2] [Odontogenic Dental Emergencies]
[Dr. Busch] So, Ok. So I get ahead of my self. I know what I
want to talk about so I forget that theyre on the slide. Pain,
swelling and bleeding.
[Slide 3] [Pulpitis (titled Reversible Pulpitis in lecture ]
[Dr. Busch] Ok. So now, patient comes in. We talked about this
last week. Reversible pulpits. A patient with reversible pulpits
means that the patient has pain. Pain typically is diagnosed as pain to thermal sensitivity. Ok. As I
talked about- that the tooth is vital. Pulpits means a vital inamed pulp - not necrotic. Ok. You
have to remember that it is usually caused by a recent treatment. Thats important. The patient
comes in to you with thermal sensitivity and nothing has been done to the tooth in 5 or 10 years.
Why would that be a reversible pulpitis. What has been done recently to cause that pulp to be
inamed? Nothing. So really the reversible pulpits is after a recent treatment. Because of the
treatment, the pulp is irritated and inamed. The treatment for reversible pulpits is, as I said,
tincture of time. You wait and it goes away. You reassure the patient. You tell the patient its very
normal to go away within a few days. So if when that patient comes in with pain, you think
transient pain, its reversible pain, that is the treatment. There is no treatment.
[Slide 4] [(Symptomatic) Irreversible Pulpitis]
[Dr. Busch] Ok. We talked about it last week also. Symptomatic Irreversible pulpitis. The tooth
is vital. Cold causes again, lasting or lingering pain. Those are the classic words which you will
see all the time - lasting or lingering pain. Um, its because of the vasodilation of the vessels.
Now whats important also in making a diagnosis that the tooth may or not be tender to
percussion. An irreversible pulpitis may or may not be sensitive to percussion. Percussion
sensitivity - I think we spoke about that last week. The tooth is tender to percussion? What does
that tell you? It tells you that there is an inammation of the PDL. Thats what percussion
sensitivity is caused by. There are many different reasons why a tooth can be sensitive to
percussion. A vital tooth can be sensitive to percussion and a non-vital tooth may be sensitive
to percussion. So percussion sensitivity does not tell you vitality. It tells you that the PDL is
irritated or inamed for some reason. Ok. Irreversible pulpitis, the treatment: initiate root
canal therapy. Now, I discussed it last week. So the patient comes in in pain. You want to get that
patient out of pain because hes in so much pain. The initiation of root canal therapy. The
initiation is pulpotomy. All you have to do with a vital tooth with an irreversible pulpitis is a
pulpotomy. You may go further, you may do a pulpectomy but its not necessary. Now when I
get all the time in the clinic that the patient has seen with an irreversible pulpitis, the emergency
treatment was a pulpotomy and then the patient comes back to a subsequent appointment and the
student says Ok. We did the pulpotomy last time. Now were going to do root canal. And I
always correct the student no, you did start the endodontic or root canal treatment by doing the
pulpotomy. That is the rst step of the endodontic treatment but it is only palliative treatment. It is
to relieve the pain. So what we are going to do now at this appointment is continue with
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Transcribed by Charles Buchanan Date of the Lecture: 10/02/14
endodontic treatment. Were not starting it. You started it last time. Were going to continue it this
time.
[Slide 4a] [Asymptomatic Irreversible Pulpitis]
[Dr. Busch] Asymptomatic irreversible pulpitis. Ok. Again. Patient is not painful. These terms
asymptomatic and chronic are synonymous. Acute and painful are synonymous. So why do
we do RCT on an asymptomatic tooth? Because what happens is the pulp- this is typically the
patient came in not in a lot of pain but with extensive decay and when you were excavating the
decay, the decay went into the pulp. Once the decay has gone into the pulp, the pulp was
contaminated from the caries and we have to do RCT. The pulp was still alive. Remember,
pulpitis,whether it be symptomatic or asymptomatic - the pulp is still alive or vital, vital and
alive. But root canal therapy should be initiated then.
[Slide 5] [Treatment for Irreversible Pulpitis]
[Dr. Busch] OK. Alright, so the patient who comes in with a severe, and youll see differences
in degrees of pain with someone with irreversible pulpits. Sometimes we use the term hot tooth.
A hot tooth means the patient is really very painful to the stimuli. In particular to the cold.
Alright. So its a hot tooth, you know its vital and what do you think the biggest problem you can
have when treating this patient? Remember, you want to be a good guy, this patient is coming to
you in a lot of pain and this is a hot tooth. The biggest problem youre going to have is
anesthesia. Making sure the patient is completely anesthetized. As I said, I hear, I paraphrased a
part of a Robert Frost poem. The Robert Frost poem says Good fences makes good neighbors. I
say good anesthesia makes good patients. I talked about, last week, the inordinate fear people
have of RCT. When you get right down to it, they tell me Im afraid of root canal, blah, blah,
blah. And I say What is he worried about? If they're honest, mostly theyre worried its going
to hurt - its going to be painful. And you know what, if it is painful, its not a pleasure. So you
want to make sure that the patient is completely anesthetized to do the treatment. So this patient
has come in. I said good anesthesia makes a good patient. Its a hot tooth. We know the main
symptom. The main symptom that is causing pain to this patient was sensitivity to cold. How are
you going to - and I ask students this all the time- and Im telling you that is the biggest problem
all the time, getting the patient adequately anesthetized. What you don't want to do is place the
rubber dam on, start to drill into the tooth and have the patient say oh it still hurts. So now you
have to take the rubber dam off, youve hurt the patient already, take the rubber dam off,
reanesthetize the patient and hope the patient is now numb enough for you to go in and start. Ok?
You think there is a way that you can avoid that? Ok. Patients main complaint was sensitivity to
cold. How am I going to know if the patient is now adequately anesthetized? Its common sense.
A lot of what we do is common sense. I want to know if the patient is completely anesthetized.
He or she was complaining about sensitivity to cold, Im going to put something cold on the
tooth. Ok? If the patient still feels the sensitivity to cold, he is not adequately anesthetized. If
there is no longer sensitivity to the cold, the patient is anesthetized. Because whenever I ask this -
how are you going to know if the patient is adequately anesthetized if it was a mandibular block?
- theyll say oh, well the lip is numb. So I say Are we treating the lip? No, no, no, the tongue
is numb also Are we treating the tongue? No. Were treating the tooth. The tooth was what
was so painful. If you want to know if the patient is adequately anesthetized, if the patient
was very sensitive to cold, you put cold on the tooth. Basically, you want to check to see if
whatever was bothering the patient is now no longer bothering the patient. If its not, the patient is
adequately anesthetized and you can initiate the treatment.
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Transcribed by Charles Buchanan Date of the Lecture: 10/02/14
Now there is a little bit of a controversy if a patient is completely anesthetized or not. You will
see that different dental procedures youre doing require different depths of anesthesia. Very
frequently, when I think the patient is numb, because Ive checked and I can start the access and I
can drill not the tooth and I can get down into the pulp chamber and the patient has not felt
anything. However, once I get into the pulp chamber, the patient still feels it. So do you know
what we do then? Have you ever heard of an intrapulpal injection? Ok. My feeling has been, if I
can get to the pulp without the patient feeling anything, but I do still have to give an intrapulpal
injection, Im content that that anesthesia was ok. Because before I started, I put the cold on the
tooth, the patient didn't feel it and now I get to the pulp, I can give an intrapulpal injection -
which is a very, it is the most effective injection you can give because it is right in the pulp. Ok.
So I feel if you can get to that point, its adequate anesthesia. Now if you were going to be doing
a lling or a crown, the patient wouldnt have felt anything because you wouldnt have gotten to
the pulp. So we are going to give an intrapulpal injection. I dont know if anyone has spoken to
you about that. Dr. Rosenberg usually gives a lecture but I dont think hes lectured to you. An
intrapulpal injection, Im asked usually what anesthesia do you use - do you want carbocaine, or
do you want lidocaine? And my answer to that is I dont care. The reason for that, when youre
giving an intrapulpal injection, what relieves the pain is the pressure of the injection. The
study that was don't by Dr. Rosenberg and other showed that even if you give the intrapulpal
injection with saline, it is still effective. The pain is gone and you can continue your work.
Intrapulpal injection, It is the pressure of the injection which gives you the adequate anesthesia.
The technique - typically when youre doing that, theres a small opening from the roof of the
chamber into the pulp chamber, so what I always do and again, by denition, intrapulpal
injection you must get the needle into the pulp to give the to deposit the solution, to give
the injection. Intrapulpal by denition. So its a small opening. So very frequently, I almost
always make sure Im using the thinnest needle that we have. A short, 30 gauge needle. Short
needle is much easier to manipulate. And because its a 30 gauge, its very narrow. I can get it into
the opening, into the pulp and inject immediately. Its not a pleasant sensation, the intrapulpal
injection. As I told you, Ive had many root canals done myself, and Ive gotten intrapulpal
injection. My partner and I was completely numb, I thought until he got to the pulp and I felt it.
And he gave me an intrapulpal injection. And its not pleasant. But its not that bad. Whenever I
give the injection, and you don't want to lie to the patient. If you tell the patient the truth, theyll
trust you. So I tell the patient you're going to feel a stick for a second. Alright? But as opposed
to when you feel it, the pain lingering and getting worse, its going to be gone immediately. The
intrapulpal injection works immediately. So I tell them- and when youre giving it, I said I use
a short needle which I usually bend so I can get better access in there. And as I go in, Im
injecting as I am putting the needle into the pulp tissue so its immediate instantaneous
anesthesia. It is a wonderful, very good injection and youll probably be using it a lot. Ok, alright
so now, we talked about pulpotomy, pulpectomy. Also, you want the patient to be comfortable. I
talked about with the irreversible pulpitis that it may or may not be sensitive to percussion. If the
tooth was sensitive to percussion, in order to alleviate the patients pain when you go- you
always want to reduce occlusion. Thats a very important step before sending the patient home.
Make sure you reduce the occlusion. What I do is with the rubber dam still on, I reduce the
occlusion to where I think is adequate. Then after the rubber dam comes off, I take articulating
paper, have the patient bite down to make sure that I have reduced the occlusion adequately
where it has to be. Ok. Mandibular molars, where would you reduce the occlusion? Buccal
cusps. Maxillary molars? Lingual.
[Student] Do you only reduce the occlusion if you plan on putting a crown on it afterward?
[Dr. Busch] No. No. If the patient were sensitive to percussion, then Im going to reduce the
occlusion. Ok. Now you asked- you brought up a question, again I diverge a little bit - I believe
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Transcribed by Charles Buchanan Date of the Lecture: 10/02/14
that every posterior tooth after root canal therapy should have cuspal coverage with either an
onlay or a crown. You know the reason for that? Because after root canal therapy, think about it
also, typically when youre doing endodontic therapy, youre not treating a virgin tooth. Youre
treating a tooth that has had extensive decay or large restorations, whatever. The tooth is
compromised to begin. Its very unusual where you would treat a virgin tooth. The teeth which
were traumatized. You know you get your anterior teeth that will look like a virgin tooth but it
needs root canal therapy from the trauma which is next weeks lecture. What can happen after the
endodontic therapy, if you dont have cuspal coverage, the patient will bite down on the tooth
and split the tooth in half. And if the tooth is- if there is a vertical fracture, the tooth is split in
half, you have to- the tooth will have to be extracted. Ok. One of the problems as a specialist,
my income, my patients were 99% referred by other dentists. I know that these teeth should be
restored with cuspal coverage. The problem is once the patient leaves my ofce, I dont have that
much control over how the tooth is restored. So now the patient comes back, an amalgam or
composite was put in there, the patient bit down, now think about the incline of the cusps. The
inclines of the cusps, youre getting food wedged in there, theres a greater chance that the tooth
will fracture. If you reduce it, theres less of a chance, but now the patient comes back to me, the
tooth is fractured in half and has to be extracted. The patient says to me I knew I shouldnt have
had the root canal done. It doesn't work anyhow. Now I spent all this time and money and I have
to have the tooth extracted anyhow. This root canal stuff doesn't work. What I want to say to the
patient is no, the root canal or the endodontic therapy worked ne. You have no infection, you
had no pain. Had your dentist restored the tooth properly with cuspal coverage, you would still
have this tooth. Now if I said that tot his patient, and the patient went back to his dentist and said
thats what Dr. Busch said, how many more patients do you think I would get referred from
that dentist? None. You dont always say what you want to. But that is the truth. Ok. So thats
why you reduce the occlusion.
Now in bold, with an irreversible pulpits, no antibiotics are ever indicated. What are
antibiotics for? Theyre for infection. Ok. Irreversible pulpitis- the tooth is vital. It is not infected.
There is no reason or rationale for giving antibiotics when the patient comes in with irreversible
pulpitis. Its a mistake I see commonly made by a lot of practicing dentists, and it is absolutely
incorrect. Dentists and physicians overuse and abuse antibiotics. Thats why the bacteria are
building up resistance. Thats something that I try to drum into you guys. Now, what drive me
crazy sometimes, a patient will be seen hear, lets say a late on a Friday afternoon and whoever
sees the patient doesnt have time or want to treat the patient although its determined to be an
irreversible pulpitis, and they send the patient with antibiotic- with a prescription for antibiotics.
Absolutely incorrect. If you want to give a patient an analgesic- a pain killer, I have no problem
with that. If you do the proper treatment, these analgesics are probably not necessary but at least
theres rationale for what youre doing. What we do advocate, after the endodontic therapy,
although we have alleviated the pain from inside the tooth, the pulp, you can still have some pain.
Ok, so now, doc, you know what? You told me you took all the nerve out of the tooth. You did a
great job and you told me you took all the nerve out of the tooth. How come Im in so much
pain? Good questions isnt it? Makes a lot- makes sense. Theres no nerves, how can you have
pain? Patients will ask you that. If you tell a patient that you have taken all of the nerve out of the
tooth- Go home, weve gotten all of the nerve out of the tooth. That great. Next time, were
going to obturate the case and were going to ll it. And next morning, 8:00 in the morning, the
patient is on the phone. I am in tremendous pain, every time I touch that tooth, it hurts. But doc,
I dont understand, theres no nerve. So what are you going to say to the patient. Thats a good
question. Right? No nerve, how can you have pain? Whats the answer? Hm? The PDL. Ok. So,
again, I don't know if I discussed this last week. I said if youre smart, when the patient leaves,
you warn the patient. You give the patient a little bit of course on endodontics. You can explain to
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Transcribed by Charles Buchanan Date of the Lecture: 10/02/14
the patient whats going on. You can have a model, you can draw a picture. You can explain the
patient that what we are doing is removing the pulp tissue or the nerve from inside the tooth. But
there is a PDL or membrane which goes around the tooth that attaches the tooth to the bone. This
periodontal ligament, or PDL, does contain nerve bers. You will still know that the tooth is
there. It can become irritated and inamed from the work that weve done. Even though
weve taken the nerve or the pulp out from inside the tooth. You can still have some pain. So
what do you tell the patient. You tell the patient, because we know this, you advocate that they
take analgesics right away. Its actually advocated to take analgesics prior to the treatment.
We typically advocate that the patient takes 600mg of Ibuprofen and a Tylenol. That is the
regimen that is really being advocated at this point. Because the pain that the patient would feel
after that is inammatory pain because the PDL was irritated and/or inamed. So thats why you
want to give the patient an anti-inammatory. Some controversy as to whether or not to give a
patient a stronger prescription of an opiate. I am not averse to that when necessary.
However, it is usually not necessary. Usually if the patient takes that ibuprofen right away, I tell
em take it right away even though youre numb now. Take it right away. And I explain to them
now because the inammation. After that, if you need it again, take it. If you dont need it, dont
take it. But that is what you want to recommend to the patient but no antibiotics for a vital tooth.
[Slide 6] [Non Vital Teeth]
[Dr. Busch] Ok. Non vital tooth. So we have different categories of the non-vital tooth. You
have the asymptomatic apical periodontitis or chronic periodontitis. That is a tooth that is
asymptomatic- is not painful. So what happens. Patient comes in for checkup. You take
radiographs. You take radiographs, you see on the X-ray at the tip of the root, there is a
radiolucent area there. You dont know what that radiolucent area is, so what do you do? We went
over this last week. You do your various pulp tests. If it turns out that that radiolucent - that the
tooth is vital, that radiolucent area is not a periodical pathology from the tooth. Ok. If you
remember last week, I showed you the case with radiolucent areas right at the apices and the tooth
was vital and it turned out to be metastatic cancer. So if there is a radiolucency, and the tooth is
vital, It is not a pathology. More often than not, its just normal trabeculation on the lm. It can
be an anatomical structure. As I said, it could be something as severe as cancer. Luckily it usually
isnt. But you have to- but its not a periapical pathology. So now you tested the tooth, and the
tooth is non-vital. So now you know that radiolucent area is periapical pathology. Whats the
treatment for periapical pathology? Endodontic therapy. So youre going to initiate RCT. This is
not an emergency. You do not have to initiate RCT at that day. Ok? So now, you tell the patient
you need a root canal on that tooth. Why doc? I have no pain. You just want to go on
vacation? Is that it? You just want to charge me a lot of money for something I dont need? Why
do I need a root canal on this tooth? Again, good question from the patient. A lot- Sometimes
there is that fear that youre going to perform unnecessary treatment. So what are you going to do
to? I was going to say convince, but to explain to the patient why you feel that he/she needs root
canal therapy because of that dark area you see on the X-ray at the tip of the root. You know
what it is? Did I go over it, when you see- what x-rays are? X-rays are measures of density. This
is what I tell patients, ok? An X-ray is a measure of density or thicknesses. The thicker something
is, the whiter it shows up on the X-ray. The thinner something is, the darker it shows up on the x-
ray. I then point on the lm, I will show the patient normal bone where there is no dark area. Then
I point to the dark area. I said as I told you, the thinner something is, the darker it shows up on a
lm. The reason theres this dark area here is because the bone is thin. The chronic infection you
have has actually destroyed the bone there. Which is why it shows up on a radiograph. Does
every non-vital tooth have a periapical pathology radiographically? No. A certain amount of bone
must be destroyed before it shows up on the radiograph. You have to have destruction of the
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Transcribed by Charles Buchanan Date of the Lecture: 10/02/14
cortical bone prior to getting a radiolucent area on the X-ray. Do you know what an apicoectomy
is? Apicoectomy is a surgical procedure where we go in through the tip of the root to clean out
the area of infection, clean out the area of infection and shave off the tip of the root. Thats what
you call an apicoectomy by denition. Apico-ectomy. Apex- cutting it off. We usually, then, put a
retrograde lling at the tip of the root. The retrograde llings used to be amalgam all the time.
Now amalgam is not used. Either MTA or Super EBA is being used. But what Im getting at-
sometimes we do the apico, see the area on the X-ray and we know its there. Sometimes, we, just
by symptoms, we know that the patient needs the apicoectomy. And if you go and you ap back
the tissue, you get to the bone- now sometimes there is a fenestration - a hole in the bone. You
ap back the tissue and you get to the area and you see the whole in the bone where you have to
go and you clean it out. Not always. Sometimes when you ap it back, you don't see the
fenestration- the hole in the bone - you have to gure out where it is and then youll fall into it.
But because it wasn't enough bone destroyed- not enough cortical bone destroyed that you don't
see it but the destruction is there and you will fall into it. Ok. So thats an apicoectomy. Alright.
So thats how I explain to a patient. I went off a little bit further but I explain to the patient that
the reason you need the RCT there is because you have a chronic infection and as obvious as it is
on the radiograph, there is bone destroyed there. And basically you have a hole in the bone.
Another way of thinking about it, and a lot of times students and dentist will say well, you know,
the area is there but the patient doesnt feel anything. Its asymptomatic. Do I have to do
anything? And what I say is have you ever seen a patient who comes in swollen and in pain?
Ok the patient comes in swollen and in pain and you take a radiograph and you see the
radiolucent area on the X-ray. Patient was ne yesterday. Swelling started today. Thats where I
came in. So now you took the X-ray and you see the patient swollen. You see the area there. No
brainer. You know the patient needs root canal. So I say, I always say, the patient had no swelling
yesterday. Do you think if you had taken the radiograph yesterday, you would have seen that
radiolucent area there? Yes, of course. Why it picked today to are up? I dont know. But thats the
rationale for treating an asymptomatic non-vital tooth with an area there because the problem is
there. The problem exists. Is it going to are up later and give him an acute problem? I don't
know. It certainly may, it has the potential. When will it happen? I dont know. Typically on a
Sunday afternoon. But that is the rationale for treating an asymptomatic non-vital tooth. And
thats why you have to have the knowledge to explain to the patient why you are doing this- why
you are suggesting this. Alright the acute apical abscess. Thats an emergency. Thats the patient
who comes in with swelling and pain. You want to get that patient out of pain. Ok. So that's when
you know what to do to get the patient out of pain, youre a hero.
[Slide 7] [Is It Necessary to Control an Infection With Antibiotics Prior to RCT?]
[Dr. Busch] I showed you this case yesterday- last week. I showed you the guy. He had the
swelling. Last week, I also showed you the radiograph. The day before the swelling, he didn't
have it. But the radiograph showed that it was in areas there. And I asked the question, do you
have to put the patient on antibiotic treatment prior to treating- to calm down the infection
prior to treating it? And the answer is denitely no. You initiate the RCT.
[Slide 8] [No!! Attempt to Establish Drainage & Remove the Cause of Infection]
[Dr. Busch] And as I showed there, you get the pus coming out of the tooth. A lot of times, the
students - I give basically the same lecture to you guys all the time time. Next year, second year
class give the same lecture. And I showed you, last week, the matador with the bulls horn in his
crotch. And said Id rather have a root canal. I also showed this kind of thing and I say I love
pus, I love seeing pus. Ok. And Ill get students coming, who graduate fourth year, who say you
know, Dr. Busch, I still remember that picture you showed with the matador and I also remember
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Transcribed by Charles Buchanan Date of the Lecture: 10/02/14
how you said you love seeing pus. I say thats great. Do you remember anything else I said to
you but ~chuckles~ So, I said I love seeing pus!
[Slide 8a] [Scalpel Image]
[Dr. Busch] So now you have a patient, um, I
dont know if you can tell, there is signicant
swelling there. Fluctuant swelling there. This is
a scalpel. Ok?
[Slide 8b] [I&D video]
[Dr. Busch] So I talked about opening the
tooth. Im not sure If I spoke about doing I&D.
An I&D is a procedure- its called incision and
drainage. You may wanna watch this one
because this is what people remember also. So you take the scalpel. ~very disappointedly~ Oh
shit. How do I get that up there then? Thats a bummer. Thats bad. Thats the highlight of the
whole lecture ~chuckles~ and I dont know how to get that. Wheres that. Come on up here.
~Jason M. comes to save the day~ Ok, so I&D. And then you do the I&D, you get the copious
pus and what you do is you milk it a little bit to get more pus coming out of there. ~pus
comes oozing out of this guys mouth and the whole class groans (See podcast at about 44:29 ;) ~
Wrong attitude! This is what you want to see! If I had made that incision and there was no pus
coming out of there, I dont know that the patient is going to feel better. So thats why I said I
love seeing the pus! Because I know the patient is going to feel good. If I did that and nothing
came out, now Im worried that I didnt do anything good for the patient. And that is the exact
reaction I get all the time ~laughs~ I showed it to my wife last night and she goes Eeeew! I go
yeah, thats what they all say. Ok. So an I and D is a great way to alleviate a patients pain.
When you get the uctuant swelling, you saw that I didnt have to do much. I just made a little
opening and the pus came pouring out. The previous one where I showed the tooth, it was
basically the same thing where I opened into the tooth and I got drainage. When you have a
patient with an acute abscess, you want to get drainage. Because if you get drainage, you know
the patient is going to feel better. You can get the drainage either from through the tooth or the
swollen site where you have the I&D. So, it is a great procedure, it is a very dramatic procedure.
Um, patients feel better right away. So why did I lose this now.
[Slide 10] [Non Vital Teeth Treatment]
[Dr. Busch] Ok, alright. Alright. So. But thats- ok so now. How do you treat the non-vital tooth?
[Student] So for I&D, you make the infection to come out. Do you always cut at the same
position?
[Dr. Busch] You want the most dependent position. You can tell- you want to use gravity also-
so that dependent place. [?] And if you notice, after the initial drainage, I put my nger up there
and I press a little. Im milking it to get all the pus out of there. Its also a little controversial, so,
another patient is going to have relief because we have the drainage through the I&D. You want
to make sure the patient is going to go home and be comfortable. Its amazing how quickly, if the
tissue from where you opened it will come together and stay together. Um, what I advocate, when
I see that, when I do that, Im also going to open up the tooth. Because we know that the cause of
the problem was the tooth, was the necrotic tissue. I want to remove the cause of the problem. So
I did the I&D to alleviate the patents pain, but I want to get rid of the problem. So what I do, I
always like to do the I&D rst before opening the tooth. Some people tell you no I do that
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Transcribed by Charles Buchanan Date of the Lecture: 10/02/14
last because its too messy after doing the I&D. It really isnt. After that initial burst of the pus
and a little bit of bleeding it really calms down. So what I do, I do the I&D and then I put a little
piece of gauze into the fold because therell probably be a little bit of oozing but not much. And
then Ill put the rubber dam on and open up the tooth. Typically, if Ive gotten drainage
from the I&D site, I probably wont get drainage from the tooth. Had I not done the I&D,
would I have gotten drainage from the tooth? I don't know. Maybe. But since I know I want
to get drainage, thats why I know I like to do the I&D rst. I know the patient is going to feel
better. And again, thats the objective of emergency treatment: to get the patient feeling
better. The other thing is, you dont really need much anesthesia to do that. The patient doesnt
feel much. If you palpate around there, its going to be very tender. Theyll say well, in a swollen
area like that, the local the local anesthesia doesn't work well. You can give block injections to
get, you know, like the mandibular block that gets the whole area. You can give block and then
Ill do circle inltrations around there. And the, the scalpel - its very fast and its not painful. So
now, were treating a non- I told you with the irreversible pulpitis, the biggest problem youre
going to have is getting the patient adequately anesthetized to do what you have to do. So now
the patient comes in and the tooth is non vital. As we discussed- ok, so that guy- that patient with
the acute abscess is very painful. So there you have the non-vital tooth which is causing a
tremendous amount of pain because of the acute abscess. I also told you about the non-vital tooth,
which is completely asymptomatic and not causing any pain at all. So you know that a non-vital
tooth may or may not be causing pain. So now, if you need adequate anesthesia to treat the
irreversible pulpitis, if the patient, if the tooth youre treating is non-vital, do you need
anesthesia? Ok? What you want to know is that the treatment or the work that youre doing
within that tooth, anesthesia is not necessary. Its non-vital, its dead. Ok? So do I give
anesthesia to a patient where I know that the tooth is non-vital? Sometimes, it depends on the
patient. As I discussed last week, youll get patients who come in and theyll sit down and do
whatever you have to do doc. That with a non-vital tooth, with an asymptomatic non-vital
tooth, Im going to tell the patient you dont need- we say Novocaine, we dont mean
Novocaine. You don't need anesthesia, you dont need injections. Is that ok with you? Oh,
thats great doc. Other people, Ill say- and then theres the patient like this and I know you dont
need anesthesia for it. I probably wont even suggest that they dont need it, but if I do- you
really dont need anesthesia are you crazy, you cant come near me unless Im numb. I know
thats not necessary. I know it, you should know it. However, theres also a psychological
component to treating patients. If that patient is going to feel more comfortable psychologically
knowing that he or she is numb, its going to be a better patient. If you dont anesthetize that
patient, even though its not necessary, if theyre worried that it is, theyre going to be uptight and
any little movement, theyre going to jump. So I will give, even though I know its not necessary
for the anesthesia, that nervous patient, I will give anesthesia. It doesnt have to be profound
because I know that its not necessary. Ill do it just to make the patient happy. Ok. Now theres
the other scenario. That was the asymptomatic non-vital tooth. Now you have the patient with a
non-vital tooth which is painful. I dont need to give the patient anesthesia to actually treat
the patient but I do give the patient anesthesia just to get them comfortable before I initiate
treatment. So theres a difference. Yeah.
[Student] Can a tooth be somewhat vital and not vital at the same tooth?
[Dr. Busch] Yeah, when you have a multi-rooted tooth you can nd that sometimes, yes. You
have molars that have typically at least three canals. You can nd that. Its not the norm, but it
can be that. Yeah. So in that case, thats another reason for giving anesthesia. Just to make sure-
hey, I thought the whole tooth was non-vital, they dont need anesthesia - whoops - I was wrong,
that canal is alive and its painful. So theres- I know some endodontists tell me they anesthetize
every patient for every procedure because they dont want the patient to feel anything. And even
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Transcribed by Charles Buchanan Date of the Lecture: 10/02/14
that calm patient who I dont have to give anesthesia to, and I say to them Im not gonna tell you
youre not going to feel anything. You may feel something but its not going be bad. And some
people are thrilled. If you have ever had mandibular block/mandibular injection and youre going
to be numb for 4-5 hours, thats not pleasant either. So some people, its just a thrill not to go
away numb. So, with a non-vital tooth, remember: the vital tooth, all you have to do is
pulpotomy. The non-vital tooth causing the pain or problem is because all the necrotic
material, the bacteria and the schmutz thats in the canals. So what you want to do with the
non-vital tooth is clean out or debride the canals. Ok? If there, you also want to establish
drainage. I talked about doing a possible I&D. I&D is a great procedure. You know the patient is
going to feel good after that. Theres a controversy about leaving the tooth open or closed. What
Im talking about with that is, after youve made your access opening, do you put a lling in
your access opening of the tooth or do you leave the tooth open for drainage or pus or gas?
It used to be advocated, a lot of times, that we would leave the teeth open. Right now, the
philosophy is you do not want to leave the tooth open. Youre just creating more problems by
leaving the tooth open. Youre getting more contamination from saliva, from food youre
eating. So you always want to put a lling in the non-vital tooth. There is an exception. The
exception is the patient who has come in in a tremendous amount of pain. Doc, I didnt sleep last
night. I was in so much pain. Again, I keep going back to it. What do you want to do to have this
patient like you? You want to get the patient out of pain. You want to treat the patient painlessly
and when the patient leaves and goes home, you want the patient to be out of pain, even after the
anesthesia wears off. So, if that patient is in tremendous pain, and I open up the tooth and there
was no uctuant swelling- in order to an I&D, you must have what we call uctuant swelling.
Ok? So you can have very painful, non-vital teeth without the swelling. You open up the tooth
and the pus comes pouring out and you feel good. You know that the patient is going to feel better
because youve established the drainage. And the patient is there for half an hour and the pus
is still coming out. You cant dry it- when I say dry the tooth, after the initial drainage, frequently
thats it and you can, before temporizing the tooth, you make sure that the canal is dry and clean
and that there is no more drainage. But now, you cant do that. It is still continuing to come out
and you cant dry it. That is the only time that I will leave a tooth open overnight. And I
always put the patient on antibiotics and I always want to see the patient the next day or the
day after that. At that point, nothing is 100% but almost always, there will no longer be any
drainage. You can irrigate the canal, debride it, put your medicament in there and close the
tooth with a temporary lling. Ok. What is the medicament? CaOH is the medicament that
we use. We put it in the canals. The calcium hydroxide uses- its antibacterial because of the
pH. Thats the way that the CaOH works. Antibiotics. Ok. The patient with the copious
swelling. The acute abscess where Im getting the drainage either through the tooth or through
the I&D site. That patient, I will put on antibiotics. It is indicated there. Ok? Remember,
antibiotics are for infection. There was obviously an infection there. Antibiotics are indicated
there but not on a vital tooth.
[Slide 11] [Video] - SKIP
[Slide 12] [Antibiotics of Choice]
[Dr. Busch] Antibiotic of choice. It is still penicillin VK or amoxicillin. That is what we-
those are the antibiotics we choose. And its not that we choose it. Its because that is whats
indicated from all the [Coach and Sensitivity studies?] If the patient is allergic to penicillin, we
use clindamycin. We used to think that Erythromycin was the drug of choice if the patient is
allergic, but thats proven not to be in dental infections. Clindamycin is the drug of choice.
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Transcribed by Charles Buchanan Date of the Lecture: 10/02/14
Metronidazole. Sometimes you can use that in conjunction. Some oral surgeons advocate that
a lot. Its not always necessary.
[Slide 13] [Erythromycin no longer]
[Dr. Busch] Umm. Ok. Erythromycin, I talked about the erythromycin. We dont use it. The
Clindamycin is the second choice.
[Slide 14] [Intracanal Medications]
[Dr. Busch] Intracanal medications.
[Slide 15] [Calcium Hydroxide]
[Dr. Busch] I said CaOH is the drug of choice. Im running over. Ok.
[Slide 16] [Formocresol]
[Dr. Busch] We talked about- someone said formocresol. And the reason I said formocresol has
fallen out of favor is because the antimicrobial effectiveness is lower than toxicity. And were
considering the outright toxic and tissue destructive effects and mutagenic/cariogenic
potential, there is no reason for using formocresol. Even though I used it for a lot of times. We
dont do it anymore. Ok. Not too bad Lisa. Thats it. Thank you.
11