any tips for these clinical procedures?

[razor1911]

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Would appreciate some tips and hints for the following clinical procedures:

1) inferior alveolar nerve blocks. Often, my patients tell me that they don't feel any numbness or they feel numbness only on the anteriors and soft tissues ( but not the posteriors ) of the injected quad.

2) root canals on multi-rooted teeth. My problem often comes during the pulpotomies. Are molar access preps supposed to have distinctively visible canals? My previous molar pulpotomies appeared to be a huge dark spot in the center where you can feel the canals with a probe but can't see them. In cases like these, are you supposed to clean up the "dark hole" with a bur so that you can see the canals clearly? If so, wouldn't you perforate?

3) what do transitional partials look like? do they have metal frameworks with metal clasps and rest seats?

 

[Zzzdentist]

1) inferior alveolar nerve blocks. Often, my patients tell me that they don't feel any numbness or they feel numbness only on the anteriors and soft tissues ( but not the posteriors ) of the injected quad.

How long are you waiting for the patient to numb up? Usually it take a few minutes or longer for some people before there is profound anesthesia. You might want to review your landmarks and positioning. Do you have Stanley Malamed's anesthesia handbook? I can't remember exactly, but I believe one of the more common errors is to block too low.

2) root canals on multi-rooted teeth. My problem often comes during the pulpotomies. Are molar access preps supposed to have distinctively visible canals? My previous molar pulpotomies appeared to be a huge dark spot in the center where you can feel the canals with a probe but can't see them. In cases like these, are you supposed to clean up the "dark hole" with a bur so that you can see the canals clearly? If so, wouldn't you perforate?

In situations where there's still a fair bit of pulp tissue in the chamber obscuring visibility (eg. direct pulp exposures during excavation), it's best to remove as much as possible so you can see where the canals are to finalize the shape of your access opening.

You can clear out the tissue with endo spoons, files, barbed broaches, round burs, gates gliddens or peezo reamers, etc. For someone new at it I'd probably stick to files and spoons since that will minimize any iatrogenic damage. Once you get the hang of it, you can progress to gates, peezo, or round burs. I'd be very careful with the round burs since you don't want to damage the pulpal floor or walls.

Don't use a high speed bur to clean out the "dark hole" unless you know what you're doing. High speed = high chance of oh oh. 😱 Once you've cleaned out the chamber, you can refine the shape of your access opening for straight line access.

Have you done any kids pulpotomies? What do you use for those?

3) what do transitional partials look like? do they have metal frameworks with metal clasps and rest seats?

Typically most transitional partials are all acrylic. You can ask the lab to add in wrought wire clasps or ball clasps. Sometimes you can put in a reinforcing bar or wire to strengthen any fragile areas (eg. lower lingual area). They also can put in metal rests to help reduce the forces on the gums if you want. The fancier you get, the more pricier the lab will charge you.

You may as well charge for a full acrylic partial if it has a lot of extra components and you are preparing the teeth for rests and such. I believe the fee for a transitional reflects the minimal amount of work which is pretty much a couple of alginates, a bite, tooth selection and a shade which goes to the lab.

There's a few different varieties of flippers. Valplast is a flexible kind. I don't know if Virginia partials are considered transitional partials, but they pretty much are. They have a rubber like gasket that replaces a portion of the labial flange. It fills in missing gum and offers retention.

http://www.aurumgroup.com/english/aurumceramicclassic/denturecastpartial/virginiapartial.stm

Zzzdentist
http://www.dentalminds.com​

 

[razor1911]

In situations where there's still a fair bit of pulp tissue in the chamber obscuring visibility (eg. direct pulp exposures during excavation), it's best to remove as much as possible so you can see where the canals are to finalize the shape of your access opening.

You can clear out the tissue with endo spoons, files, barbed broaches, round burs, gates gliddens or peezo reamers, etc. For someone new at it I'd probably stick to files and spoons since that will minimize any iatrogenic damage. Once you get the hang of it, you can progress to gates, peezo, or round burs. I'd be very careful with the round burs since you don't want to damage the pulpal floor or walls.

Don't use a high speed bur to clean out the "dark hole" unless you know what you're doing. High speed = high chance of oh oh. 😱 Once you've cleaned out the chamber, you can refine the shape of your access opening for straight line access.

But what if the dark areas ( where you can feel the canals but not see them )are hard? There's no way I can use a spoon excavator then, can I? And the region I'm talking about, are those pulpal tissues?

And are molar access preps supposed to look exactly like clear dots in the center?

And is it possible to perforate but not see any bleeding or patient symptoms?

 

[Elipar]

1. IA blocks. Use the following guidelines. Have the patient open a moderate amount and look for the pterygomandibular raphe. Imagine a line going from that entry point to the tragus of the ear. That's where the needle goes. One other reference point that's usually pretty close is to use the corner of the mouth on the contralateral side. So...

Enter the mouth from the contralateral corner of the mouth and aim for the pterygomandibular raphe, which if pointed properly, points towards the tragus of the ear. If using a short needle, take it to the hub. If a long needle, take it about 2/3s length. You will probably NOT hit bone. Aspirate well and inject 1 full carpule.

The AVERAGE number of carpules needed for a successful IA is actually 2 carpules, so it's not uncommon not to feel complete anesthesia with just the 1. With that said, I probably do most of my work with just 1 carpule of 3% mepivicaine, but that's anecdotal.

2. RCTs. If you don't know what a molar access looks like, DON'T DO IT ON A REAL PERSON!!! You can always ask an oral surgeon to provide teeth to practice on first. The best place to see what an access looks like is in a textbook, like Pathways of the Pulp. Other sources include www.dentaltown.com and www.rxroots.com.

An access should be just large enough for you to adequately clean and shape the canals. Thus, the first requirement is that you remove all overhangs. If you can't see the canals, it's likely that either A) you still have overhangs, or B) you need magnification. One way to "test" for adequate access is to place a file in the canal. If it's leaning against one of the walls, then that wall must be opened up. Ideally, when your access is complete, you should be able to see all canals without moving the mirror.

The floor of the access chamber will have a characteristic color, which is fairly dark compared to the walls. It's a bit hard to explain what it looks like... much easier to look at a picture and point to it.

As far as distinctively visible canals, some are and some aren't. Sometimes calcifications block the canals, sometimes the canals are small. Sometimes the canals have a steep curve such that tertiary dentin covers the orifice. And sometimes there's a huge whopping canal pointed at you. What I do is use a 10 or 15 file to guestimate where the canal would be and gently probe. If I find a "stick" I gently work it to resistance and note where it is. Then I use bleach to kill the nerve so that it stops bleeding. Dry it out, and look for the canal in the same place. Then take Gates Gliddens to really open that orifice up. Then it's hard to miss.

As far as perforation, if you're careful with "easy" cases, it's hard to perforate. If you're blindly thrashing about the access it's easy to perforate. Know what it is you intend to do and do it diligently. If you just see a hole and put a bur to it, then you'll likely perforate. But if you know there's an overhang, then take careful steps to remove it. Some use round burs ONLY against the wall (never the floor), some use diamond burs. Safe ended diamond burs are kind of nice for this too.

3. Transitional partials were covered well by the last person.

 

[crazy_sherm]

1) inferior alveolar nerve blocks. Often, my patients tell me that they don't feel any numbness or they feel numbness only on the anteriors and soft tissues ( but not the posteriors ) of the injected quad.

Are they not getting any soft tissue numbness or is it also no hard tissue numbness in the posterior? The IA alone will not give soft tissue numbness to the posteriors, you have to also make sure to give enough of a lingual injection and also a long buccal. Make sure to give the long buccal distal to the tooth you plan to clamp or work on. It would be very unusual to have only anterior hard tissue numbness without posterior hard tissue numbness unless you gave a mental block.

Give the IA/lingual first, wait for profound numbness. I've found the most reliable way for the patient to verify is when they say their lip feels fat to the midline. Don't give the long buccal before the IA is set in, sometimes the anesthetic can drift forward and get into the mental foramen, giving you a false positive on the lip. If you're having trouble getting your IA, you can try a Gow-Gates or Vazirani-Akinosi injections. They're essentially hitting the same areas, and some people argue they aren't really a different injection, but it's worth a shot. Maybe the change in technique will fit your needs better.

Some patients may also have accessory innervation to some of their molars. A mylohyoid or a lingual injection near the distal root apex usually does the trick.

 

[Zzzdentist]

But what if the dark areas ( where you can feel the canals but not see them )are hard? There's no way I can use a spoon excavator then, can I? And the region I'm talking about, are those pulpal tissues?

And are molar access preps supposed to look exactly like clear dots in the center?

And is it possible to perforate but not see any bleeding or patient symptoms?

You might be referring to some cases where there is a pulp stone or secondary dentin covering the canal entrances? In those cases you have to be very careful not to perforate or create a blockage. Sometimes I'll try using a pathfinder or very small spoon to chip away pieces of the dentin if there is a lip available to get around. I've had very large chunks of secondary dentin (or calcified nerve tissue) chip out with a little prying pressure from a spoon. I haven't tried ultrasonics, but I hear they are good to for this exact application.

Usually it's possible to slip a very fine file past the covering to open it up a little. After that you can try using a gates glidden and glide it around the area. It helps if you can open a small hole into it with files first. Last resort would be to try using a small endo round bur or tapered, round ended finishing bur to try to remove the covering. I wouldn't recommend it unless you are very careful and experienced or else you might end up creating perforations, ledging, etc.

If it's that calcified internally and you can't get past large chunks of blocking dentin, an endo referral is always an option. Never make it an ego thing where once you go in that you feel that you have to "finish" a case. The specialists are there at your disposal to take over.

Molar access preps are supposed to look similar in shape to the pulp chamber, but slightly larger. They may not be exactly in the centre of the tooth since you're following the shape of the chamber walls. It might be best to consult an endo text to get a better idea.

Upper molar:

Borrowed from : http://www.dentalindia.com/ucmb2.html

You can perforate a tooth in so many ways with bleeding or no bleeding. If the patient is numb, there won't be symptoms. Later on, the patient may complain of pain, aches, etc. depending on where the perforation occured.

Regarding anesthetic delivery, I personally would never use a short needle to do a mandibular block. I don't think it's a good idea to ever bury a needle down to the hub since it's at the hub where breakages can and will occur however unlikely. If a patient flinches suddenly or turns their head and the needle breaks off in the deep tissues, it's going to be a very bad day. I've seen cases where the oral maxillofacial guys have had to retrieve a broken needle, and it wasn't pretty.

 

[razor1911]

Are they not getting any soft tissue numbness or is it also no hard tissue numbness in the posterior? .

it's sometimes one or the other.

Just as often, I even get patients who tell me they don't have ANY tingling or numb sensation, even after two carpules of lido injection.

 

[razor1911]

And for the molar endos, generally speaking, do you keep drilling deeper until you can locate the holes?

I know you're supposed to follow the root morphology with the drills but how exactly do you go about doing it if the gingiva/bone are covering up the roots?

By the way, it's not my first time doing endo. I'm really quick in doing anterior endo. I've done several molar pulpotomies ( no obturations ) but I've never quite gotten the hang of it. Previously, I have perforated one mand first molar and one max first premolar.

 

[crazy_sherm]

Just as often, I even get patients who tell me they don't have ANY tingling or numb sensation, even after two carpules of lido injection.

If that's the case, then you're missing your block completely. Every patient is different and has slight variations in anatomy. Perhaps you're shooting too low, not angling the needle far enough laterally, or you could be penetrating too deep and overshooting the mandibular foramen. Do you try to sound bone first when you do your IA? This tends to work better as you can then tell where the tip of the needle is and you can walk it back to the lingula so you aren't just shooting into space and guessing.

 

[drhobie7]

Would appreciate some tips and hints for the following clinical procedures:

1) inferior alveolar nerve blocks. Often, my patients tell me that they don't feel any numbness or they feel numbness only on the anteriors and soft tissues ( but not the posteriors ) of the injected quad.

I recommend talking with an instructor about this and having him/her watch you do them on patients. This is the kind of thing that you learn much better in person. Don't be hesitant to ask your teachers for advice about this. There's some crazy statistic on failed IAN blocks by general dentists and it's something like 10%!

2) root canals on multi-rooted teeth. My problem often comes during the pulpotomies. Are molar access preps supposed to have distinctively visible canals? My previous molar pulpotomies appeared to be a huge dark spot in the center where you can feel the canals with a probe but can't see them. In cases like these, are you supposed to clean up the "dark hole" with a bur so that you can see the canals clearly? If so, wouldn't you perforate?

I certainly didn't do a lot of endo but I would do pulpotomies with a curette. I agree that trying to remove every shred of coronal pulp with a bur would increase the chance of perforation. Again I'd ask a pedo or endo instructor.

3) what do transitional partials look like? do they have metal frameworks with metal clasps and rest seats?

A treatment partial is made of acrylic and wrought metal wire but there is no framework. It's more like a retainer than a partial.

 

[clickytop]

Would appreciate some tips and hints for the following clinical procedures:

1) inferior alveolar nerve blocks. Often, my patients tell me that they don't feel any numbness or they feel numbness only on the anteriors and soft tissues ( but not the posteriors ) of the injected quad.

2) root canals on multi-rooted teeth. My problem often comes during the pulpotomies. Are molar access preps supposed to have distinctively visible canals? My previous molar pulpotomies appeared to be a huge dark spot in the center where you can feel the canals with a probe but can't see them. In cases like these, are you supposed to clean up the "dark hole" with a bur so that you can see the canals clearly? If so, wouldn't you perforate?

3) what do transitional partials look like? do they have metal frameworks with metal clasps and rest seats?

Gow-Gates. And use septocaine. It works better.

 

[Zzzdentist]

And for the molar endos, generally speaking, do you keep drilling deeper until you can locate the holes?

I know you're supposed to follow the root morphology with the drills but how exactly do you go about doing it if the gingiva/bone are covering up the roots?

By the way, it's not my first time doing endo. I'm really quick in doing anterior endo. I've done several molar pulpotomies ( no obturations ) but I've never quite gotten the hang of it. Previously, I have perforated one mand first molar and one max first premolar.

Generally I will access lower molars near the central area slightly mesially. With upper molars I start in the mesial pit. Parallel your approach to the angle of the tooth (take careful note of the slope of the mesial wall of the crown), and aim to the centre of the chamber. Make sure you that check the xray to see how the tooth is angled and how the anatomy looks like. Take your drill with bur and compare lengths directly next to the xray. You can see how deep you are and avoid going too deep.

With really calcified pulp chambers it gets a bit trickier since you might not get that satisfying "drop" into the chamber. You really have to examine the area carefully. Whenever in doubt, stop, take an xray or two from different angles. As a patient, I think I'd rather have the dentist zap me a few times and know where they're going rather than perf through the tooth.

In deeper areas you have to basically translate what you see on the xray and in the chamber and progress carefully. Once you've cleared the floor of the chamber, there will usually be noticeable darkened "channels" that seem to join the canal orificies.

I think this is a lower molar with an extra canal on the mesial. Notice the H or T shaped darkening of the floor.

Don't worry - it will come in time. Once you've done a few basic cases (start with the non-calcified ones), you'll get a feel for the anatomy. Sometimes the anatomy varies a bit too so expect that it might not be exactly like the textbook.

Everyone has their first time, and if you do enough dentistry you'll end up perforating, ledging, zipping, blocking, etc.. It happens. The important thing is to learn from your mistakes.

EDIT: BTW get some extracted molars and start making access openings into them. I'm surprised they haven't gotten you to do that in endo lab. They had us do practice access openings into extracted teeth. Take a molar, embed it into plaster in a Dixie cup or wax block, and start doing endo. Open enough teeth on the bench, and you should get a feel for angulations and depths.

 

[aphistis]

Gow-Gates. And use septocaine. It works better.

Great advice. It doesn't matter what anesthetic you use once you've refined your technique properly (our supply staff love buying mepivicaine for some reason), but septocaine is more forgiving during your initial learning curve. A properly delivered GG injection, though, will have a very high success rate with any anesthetic. I usually give one carpule as a GG and another lower as a traditional IANB, and I've had very good results so far.

 

[razor1911]

For the inferior alveolar block, I'm having some other problems.

After a block injection, suppose the patient says she feels "some" numbness from the posterior to the anterior midline. She feels "numb" also on the posterior, but not the anterior, portion of her tongue on the side of the injection. She was given about two carpules of lidocaine.

But during a pulpotomy, the patient would sometimes jerk violently because she claims to feel the burr.

I've had many similiar instances. What should I do?

 

[Elipar]

Tongue numbness doesn't correlate with hard tissue numbness, so ignore that. I was looking up Gow-Gates. To do it properly, apparently you need a long needle. Have the patient open wide, then insert the needle distal to the 2nd molar and aim for the tragus. Stop when you hit bone, back up a bit, and inject. If you don't hit bone, reposition a bit laterally or medially and try again. Have the patient stay open for about a minute. If done correctly, it's a V3 block, so EVERYTHING should get numb in the V3 area. If your patient "jumps"... trust her! She's feeling it! Try either an intraligamental, or intrapulpal injection.

Now onto endo. If you've perforated twice before, maybe you shouldn't be doing molar endo for now. I know it's not what you want to hear, because I never wanted to hear it myself. But if you're perforating, it's a terrible disservice to patients. You need to practice on extracted teeth until you're relatively comfortable making access preps. To visualize the roots, look at the pre-op PA first. Then use a probe to sense where and how the roots extend into bone. Before you make an access, assess the pulp chamber. If you've got a large chamber, you'll drop right in. If it's small, then you could conceivably pass right through the pulp chamber and not know it. The average depth from crown to pulp chamber is 7mm. Make an access roughly 7-8mm. If you still have not found the chamber by then, STOP. Put a bur in your access and take a PA to see how deep and in what relation you're at compared to the pulp chamber.

There are a bunch of other clues that you can use to make the proper access. But you need two things. Knowledge and magnification. Knowledge is something you can gain by studying texts and practicing on extracted teeth. Magnification... you probably can't get until you graduate. Loupes are nice, but not a substitute for a microscope. Good luck to you.

 

[Zzzdentist]

Learn from one of the endo masters, Dr. Stephen Buchanan:

http://www.endobuchanan.com/Education.aspx?currentSection=courses

http://www.endobuchanan.com/education/ce/access.aspx

Review of Anesthesia Technique:

http://www.dentallearning.org/course/fde0010/c12/p02.htm

http://www.novocol.com/Septodont/english/other/cea_di01.html

http://www.utmb.edu/otoref/Grnds/Anesth-mouth-0410/Anesth-mouth.pdf

Get Stanley Malamed's Handbook of Anesthesia if you don't already have it. It's a great book and straightforward to read. I consider it the Bible of Local Anesthesia.

http://www.elsevier.com/wps/find/bookdescription.cws_home/697862/description#description

Who needs to go to dental school when you have Google?