Endo and Pain

[MsPurtell]

Hi guys,

I need some advice. I'm in the midst of doing a root canal tx on a molar and I'm having a hell of a time keeping my patient out of pain long enough to get through the procedure. I was told be the resident that I'm not "getting the nerve out fast enough". What the heck does that even mean? I got to the point where I was trying to take my working length radiographs. What was I supposed to have done to "get the nerve out"? THe patient was crying and we ended up stopping because she couldn't get through the radiographs because the files being in the canals was killing her! What on earth am I going to do at the next visit.

The only suggestion they gave me was to give intra-canal injections. That only lasts 5 minutes! I just can't work that quickly. I still have to get through taking two radiographs and instrumenting the canals. I don't want to torture this woman and I don't know what to do.

TIA for advice!

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[joel4sale]

Leave CaOH and pellet in canal for couple of week, that should does it.

Intra pupal only lasted 5 min?! What size of needle are you using? Did you go deep into canal?.....Or did you went too deep that you end up shooting past the apex?

Lido for the block, Septo for intrapupal & infiltration & interosseous.......

She is likely to experience pain for few day afterward. Be prepare

If everything fail, REFER.

 

[Shiko]

Leave CaOH and pellet in canal for couple of week, that should does it.

Intra pupal only lasted 5 min?! What size of needle are you using? Did you go deep into canal?.....Or did you went too deep that you end up shooting past the apex?

Lido for the block, Septo for intrapupal & infiltration & interosseous.......

She is likely to experience pain for few day afterward. Be prepare

If everything fail, REFER.

Pain control during and post endodontic treatment isn't an easy job ..
According to a paper I've reviewed in the Journal of Endodontics , CaOH used as intracanal medication produced efficient results in controlling the pain as well as its antibacterial effects especialy in Perio-endo cases .
Somehow after working on so many root canals you'll end up developing a forevision of the case according to the signs and symptoms , If the pulp is acutely inflammed I'd leave a cotton pellet moistened with Formocresol for 10 minutes and have the patient wait oustside .. I've tried this technique on various occasions and it worked like magic (provided that you apply formocresol before you touch the nerve ,if the patient encounters pain after you have already started removing the nerve and taking the working length, you should try CaOH between visits rather than Formocresol to avoid the adverse effects of the caustic and cytotoxic material especially if it seeps beyond the apex .
Be careful with injecting CaOH into the canal , some cases showed permanent numbness right after CaOH application ..
Best of luck

 

[groundhog]

Hi guys,

I need some advice. I'm in the midst of doing a root canal tx on a molar and I'm having a hell of a time keeping my patient out of pain long enough to get through the procedure. I was told be the resident that I'm not "getting the nerve out fast enough". What the heck does that even mean? I got to the point where I was trying to take my working length radiographs. What was I supposed to have done to "get the nerve out"? THe patient was crying and we ended up stopping because she couldn't get through the radiographs because the files being in the canals was killing her! What on earth am I going to do at the next visit.

The only suggestion they gave me was to give intra-canal injections. That only lasts 5 minutes! I just can't work that quickly. I still have to get through taking two radiographs and instrumenting the canals. I don't want to torture this woman and I don't know what to do.

TIA for advice!

I've had six molar root canals (1 GP, 4 Endo, 1 D4). All involved some degree of pain during the procedure ranging from merely annoying to very aggravating. As was explained to me by the Endo, the acid environment of an infected pulp tends to nullify the impact of the local anesthetic. In the two most severe cases I was unable to get much relief from the "numb juice" that was injected into the canals. In those situations I just chose to get a grip on myself and get through the procedure. It was not pleasant but neither was it unbearable. I reminded myself that real pain is having your finger smashed in a car door or, in the case of my wife, having to give birth without the benefit of any anesthetic.

In the D4 case I was the beneficiary of a new (to me) technique of injecting the "numb juice" which produced great results. The syringe needle was placed into the canal and the "juice" dispensed in multiple steps with the needle being pushed further into the canal at each step. It seemed much more effective than the "one shot" method that I had perviously experienced.

Perhaps your patient has a low tolerance for pain. I remember reading a short while back about the development and testing of sugar based local anesthetics which were projected to be more effective under acid environment conditions. Don't know where that is headed though.

 

[lnn2]

Hi guys,

I need some advice. I'm in the midst of doing a root canal tx on a molar and I'm having a hell of a time keeping my patient out of pain long enough to get through the procedure. I was told be the resident that I'm not "getting the nerve out fast enough". What the heck does that even mean? I got to the point where I was trying to take my working length radiographs. What was I supposed to have done to "get the nerve out"? THe patient was crying and we ended up stopping because she couldn't get through the radiographs because the files being in the canals was killing her! What on earth am I going to do at the next visit.

The only suggestion they gave me was to give intra-canal injections. That only lasts 5 minutes! I just can't work that quickly. I still have to get through taking two radiographs and instrumenting the canals. I don't want to torture this woman and I don't know what to do.

TIA for advice!

Upper or lower molar? did u miss IAN block? It sounds like the LA wasn't effective when u started the tx. Intra-canals injection should last more than 5min. if not the whole appointment.
You can try PDL infiltration at the buccal furcation of the molar. It can be a painful injection so I would do it after the initial infiltration/block.

 

[DoctorH]

Greetins all and Happy new year
All of you guys had great and resonable answers which are all valid. I think you are dealing with a hot tooth that even if you had good anasethia that tooth is still painful. I personally have tried a differnt combination of things, but with hot teeth or hypermic pulps the best things that worked for me was combination of intracanal injections, don't put too much just drops and let it stay there for a minute or so, then I would put forocerosol, then interligamintary injection into the PDL. And remeber after yoau are done take the tooth out of occlusion. I think also patient managment plays a great factor, some people are just more sensetive than others.
Good Luck
Khalid Hussein, DDS

 

[DrJeff]

You're probably doing absolutely nothing wrong. From time to time in your career, you'll get a tooth that you just can't get numb on any given day (this goes for regular restorative dentistry too )

Just remain patient, and if after you've tried everything you can think of (and most likely closed in on a toxic dossage of anesthetic ) don't be afraid to tell the patient that the day is done, you've tried everything and you'll try again on another day (believe you me if they've been feeling alot of discomfort while you're trying to work on them they'll appreciate this statement).

As for some tricks for the endo tooth, consider switching your irrigant from NaOCl to lidocaine (I'm talking flood the entire pulp chamber to the occlussal surface and then just walk out of the operatory for ATLEAST 5 minutes). Another thing that mnay times people are guilty of is suctioning off too much NaOCl, as soon as your bur enters the pulp chamber get some NaOCl in there, and let it saty in there and break down as much organic debris as possible. Unfortunately though the sad truth that I'm noticing with the teeth that you just can't get numb is that about two thirds of the time its a psychologic response. You can often see these patients with a "defensive" hand position (think fetal position of their hands) or with the "white knuckle death grip" on the arm rests. If you're a GP and you see these signs, do yourself a favor and refer them to your local endodontist, atleast YOU'LL sleep alot easier that way

 

[myra1972]

recently I have an old endo case, upper right first premolar, with a post in it, I have remove the post, but still there is a Gutta Percha on the apical 3rd, the obturation is not that good. what should I place to soften the GP during biomechanical preparation, some suggest I used CaOH and leave it until next appointment, do you think guys it will work.

 

[DrJeff]

recently I have an old endo case, upper right first premolar, with a post in it, I have remove the post, but still there is a Gutta Percha on the apical 3rd, the obturation is not that good. what should I place to soften the GP during biomechanical preparation, some suggest I used CaOH and leave it until next appointment, do you think guys it will work.

When I'm trying to remove gutta percha from a canal, the following is my sequence.

After isolating and accessing the old fill material and removing as much as I can with a small round bur, I'll soak the canal space with chloroform for about 10 minutes. That will usually soften up the gutta percha so that I can then remove the rest with a combination of my rotary endo files and warm pluggers. My partner likes to use ethyl alcohol as a softening agent for the gutta percha, but then again the rotary files and a warm plugger. Oh yes, the most important thing is be patient and take your time/

 

[Shiko]

recently I have an old endo case, upper right first premolar, with a post in it, I have remove the post, but still there is a Gutta Percha on the apical 3rd, the obturation is not that good. what should I place to soften the GP during biomechanical preparation, some suggest I used CaOH and leave it until next appointment, do you think guys it will work.

You said the obturation was not that good .. try using a regular k file , rotate it into the G.P like a cork screw and PULL .. it should all come out in one piece if the G.P is not well condensed .. I don't try Chloroform in cases where the X-ray shows a single cone or poorly packed Gutta percha ..
Good luck

 

[MsPurtell]

Update!

Thanks for all the advice guys. Not a peep out of my patient today! I was THRILLED! Here's what I did:
mandibular and mental blocks, both with lidocaine. Mylohyoid block and injections into the papilla (just enough to blanch) and around the PDL, all with septicaine. Before even applying the rubber dam, I checked for sensitivity w/endo ice. NONE! And she stayed that way throughout the procedure! Didn't even need any intra-pulpal anesthesia.

Incidentally, the resident told me that what gets you anesthesia with an intra-pulpal is the pressure applied, not necessarily the use of anesthetic. She also told me never to give PDL injections in a patient not getting the pulp extirpated, because there is evidence that it can damage pulp! Didn't know that.

Margaret

 

[lnn2]

You seized the day! I guess that you're enjoying clinical experience more nowadays!

 

[MsPurtell]

Yep! Things are definitely looking up!

You seized the day! I guess that you're enjoying clinical experience more nowadays!