Tiansciibeu by Ana Sangauala Septembei 2S, 2u14

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** This is a tiansciipt of the class fiom S:SSPN-4:Su PN. Please see pievious sciipt
foi fiist half of class. No sliues have been posteu foi this lectuie, so I was not able to
cooiuinate the sciipt with sliue numbeis. This lectuie was also not iecoiueu by
poucast.


98% success iate is pietty uamn goou. Is enuo 1uu% successful. Absolutely not. But,
a lot of times, case selection is impoitant. You can maybe help to ueteimine befoie
you stait, the piognosis foi the success.

So, what we'ie looking at heie, you see the iauiolucent aiea theie. The iauiolucent
aiea theie is inuicative of bone loss. We know that's what we'ie seeing. That's what
it means. Theie's iauiolucent aiea at the apical aiea, theie's iauiolucent aiea up
along the siue of the ioot. Now we have, I uon't iemembei the exact time fiame. The
ioot canal is completeu anu theie is complete bone fill. So, can bone iegeneiate aftei
enuouontic theiapy. Absolutely it can. If this now, the ieason I show this also, anu
this is a question I ask a lot of times. When you take a look at this case, you see a
veiy laige iestoiation. You see bone loss along the lateial aspect. Theie's some bone
loss in the fuication. You see calculus ovei heie. Anu also what you see is the
elevation of the tooth in the socket. That's inteiesting that uown the ioau, the tooth
went iight back into the socket. You have the same occlusal level. If the bone loss
heie weie causeu by peiiouontal pioblems, uoing a ioot canal theiapy woulu uo
nothing to iegeneiate the bone.

Bow uo we uiffeientiate if this is an enuouontic pioblem oi a peiiouontal pioblem.
The best way to uiffeientiate is by vitality testing. If this tooth weie vital, then all the
bone loss woulu be of peiiouontal ieason. I'm not going to go into..I uon't know if
peiiouontal tieatment woulu be successful, which I know it woulun't, but I won't go
into that. But, if the tooth was vital, uoing a ioot canal theiapy will have no beaiing
on the iegeneiation of the bone because the bone loss hau nothing to uo with the
enuouontic ieason. If the tooth is nonvital, which this tooth was, by uoing the
enuouontic theiapy anu iemoving all the bugs anu the shmutz in the canal, we then
set up an enviionment to allow the bone, the healthy bone to iegeneiate anu fill in.
That's exactly what happeneu.

Next question is so you guys aie uoing the ioot canal. We've ueteimineu that this
tooth neeus enuouontic theiapy anu you'ie in the clinic anu you have uone all the
access anu you've uone the cleaning anu shaping anu you'ie ieauy to obtuiate. The
patient is asymptomatic anu you take the x-iay. But, this is a week latei, a week oi
two weeks aftei you have initiateu the ioot canal theiapy. Anu you take a look anu
you still see a iauiolucent aiea theie anu you say, "Can I still obtuiate the tooth."
Theie's still a pioblem theie. What uo you think. It still looks the same as it uiu two
weeks ago. Bo I have to wait foi the bone to fill in befoie completing the ioot canal
theiapy. Bow long uoes it typically take foi the bone to fill in. 0i to notice
Tiansciibeu by Ana Sangauala Septembei 2S, 2u14
iauiogiaphically that the bone has filleu in. About 4-6 months! So that uoesn't mean
because the aiea is still theie, it uoesn't mean theie's still a pioblem. You've
iemoveu the pioblem. You've uone the cleaning anu shaping anu you've gotten iiu
of the etiological factois so yes, you can complete the enuouontic theiapy even
though theie is still a iauiolucent aiea theie. What we uo typically, anu again I saiu
enuo is not 1uu% successful, when you see a patient like that, we senu them a
postcaiu to come back to the office in 6 months to take anothei iauiogiaph to see if
the bone has filleu in. I uon't ieally want to see the patient befoie then, even though
it may have filleu in somewhat befoie then. I know that by 6 months, even though
it's not completely filleu in, theie shoulun't be significant change. So that's a veiy
common question. Can we complete the ioot canal if it's still theie. So now, the
othei thing is a lot of you aie being tolu how gieat implants aie. It's not woithwhile
uoing ioot canal theiapy anymoie, uon't bothei being an enuouontist anu ioot
canals will be a thing of the past because implants aie what's going to be uone anu
implants aie 1uu% successful. It's a shame, we shoulu've tuineu the lights out
because you ieally can't tell. Beie's an implant with bone loss all aiounu heie. This
is one of the faculty that teaches heie anu a veiy goou peiiouontist who teaches
heie placeu this implant anu it faileu anu it hau to be iemoveu. Bowevei, this tooth
back heie wheie I uiu the ioot canal on that faculty membei many yeais ago is still
theie. So, case selection is veiy impoitant.

I woulu like to go iight on anu continue with the next lectuie anu not take a bieak
anu get you out of heie in less than anothei houi if that's okay.

Enuouontic uiagnosis. Now, in the pieclinical, I uon't know, maybe you'ie tolu,
maybe they saiu the steps in enuouontics aie access, instiumentation, cleaning anu
shaping, anu obtuiation. A lot of people think theie aie S basic steps in uoing
enuouontic theiapy. I completely uisagiee because the fiist anu most impoitant step
is uiagnosing the case. If you can't uiagnose it, it uoesn't mean anything.

So, I put this sliue up all the time because I iemembei the uate because it was a
week befoie 911. Ny wife anu I aie home about 11:Su at night. We get a phone call
fiom my fathei-in-law's physician in Floiiua. We knew my fathei in law hau been
having some pioblems. The physician calls anu tells us that he has lung cancei anu
he has S months to live. Baseu upon the pioblems that my fathei in law was having,
I wasn't completely suipiiseu. Ceitainly was uevastateu, the man has S months to
live. The next uay, so now the uoctoi uiu a biopsy, aftei he tolu us he hau lung cancei
anu has S months to live. I call the uoc anu saiu afteiwaius, what happeneu with the
biopsy. Be saiu well, it's a little bit confusing because it came back as a possible
saicoma. I saiu, but if it's lung cancei, it's caicinoma not saicoma. Be saiu, yeah,
we'ie not completely suie anu it tuins out, my fathei in law uieu a couple of yeais
ago fiom something completely unielateu. So, if you can't uiagnose it piopeily, you
can't tieat it piopeily. Anu if you'ie stupiu enough to make a uefinitive uiagnosis
anu tell people exactly what it is without having gone thiough the piopei uiagnostic
test to come up with a piopei uiagnosis, then you'ie making a big mistake. So, that
he uiu that was unconscionable. I embaiiasseu him in the hospital in fiont of nuises
Tiansciibeu by Ana Sangauala Septembei 2S, 2u14
anu eveiything anu he was veiy upset with me, but I coulun't have caieu less. I got a
call saying he hau S months to live without uoing the piopei tests. If you have any
ielatives in Floiiua, uon't go to Bi. Stephen Noiiis.

So, when you'ie uoing it, you have to have a sequential step by step sequence to
make youi piopei uiagnosis, aliight. Anu you want to make youi uiagnosis baseu
upon what you know anu not what you think. As I saiu, when I was tolu my fathei in
law hau lung cancei, fiom things that hau been going on, what hau showeu up on the
x-iays I saw anu his symptoms, it wasn't a complete shock. It was wiong, but it
wasn't a complete shock. So the uiagnosis hau been maue on what he thought as
opposeu to what he knew. So what I'm going to uo with you now is to tiy to go
thiough some steps to tiy to make uefinitive uiagnosis baseu upon what you know.

So, now, impoitant: speak to youi patient. Ask peitinent questions. Stuuents come
to me all the time anu say that I have an emeigency patient heie. 0ne of the
pioblems we have in the clinic is that any patient who comes in with an
unscheuuleu appointment is ueemeu an emeigency patient. It's a ieal misnomei.
Patient came in, unscheuuleu because pait of his tempoiaiy filling fell out. Anu then
you'll heie an announcement in the clinic "I neeu a stuuent foi an emeigency
patient." Anu the stuuent comes to me anu says I have an emeigency patient. I say
fiist, what's the emeigency." To me, I think a lot of pain is a valiu emeigency. If I
have the ability to alleviate somebouy's pain anu I can uo it, yeah, it's up to me to uo
it. 0f couise theie aie uiffeient levels of pain. You'ie also going to see with uiffeient
patients. I've often saiu, how uo you uiffeientiate between soieness, achiness, anu
pain. A lot of times, it's just the peiception of the inuiviuual peison, whethei it's
soieness, achiness, oi pain. But, if somebouy has a lot of pain, I feel that it's an
emeigency anu we shoulu be able to get the patient out of pain. Swelling. Swelling
can be an emeigency. Not eveiy swelling can be an emeigency. If the swelling is
going to block the patient's aiiway, then theie's no question that's an emeigency.
You can have patient swelling wheie maybe the eye will close, it coulu be painful. I
woulu go along with that as a valiu emeigency. Bleeuing, bleeuing coulu be an
emeigency. So those aie some of the things that I classify as emeigencies. Some
people say pain is not, but I talk about builuing a piactice. Although I was nevei
ciazy about it, sometimes if I got a call fiom a patient at 2 o'clock in the moining,
with a tiemenuous amount of pain anu I felt that if the patient hau alieauy taken
some kinu of analgesic oi painkillei anu coulun't get iiu of the pain, I woulu go into
the office. I uiun't like it, but you know what happeneu. When I woulu uo that, the
patient woulu tell people what a gieat guy I was foi uoing that. It's anothei thing,
but what woulu get me nuts is the patient calls at 2 o'clock in the moining with pain.
Well, have you taken anything. No, I uon't like taking pills. Well, take the uamn pill,
you know. Naybe we uon't have to go into the office anu I'll see you at 8 o'clock in
the moining.

So, peitinent questions. Patients comes in having pain. Anu stuuents come up to me
all the time saying the patient is sensitive. Patient has sensitivity. What's a peitinent
question. What aie you sensitive to. I saiu, when you guys come up to me anu tell
Tiansciibeu by Ana Sangauala Septembei 2S, 2u14
me the patient has sensitivity, the fiist thing I say is you guys have tolu me nothing.
Tell me what the patient is sensitive to. I gave you the scenaiio of the patient who
comes in aftei I've completeu the ioot canal anu complaining of pain. If he tells me
it's hotcolu, I know it's a uiffeient tooth. If it's sensitive to chewingpalpation, it
coulu be that tooth. So what the patient is sensitive to can be peitinent anu mean
something, so you ask that. You ask peitinent questions anu you think about the
answeis. Anu you want to ielate the answeis to the pioblem. You have to ueteimine
when a patient tells you what is botheiing him oi hei. You then tiy to ueciue which
of the uiagnostic tests, which we'ie going to go ovei. Which of the uiagnositic tests
that you have at youi ability aie you going to peifoim. Anu then, this is the
impoitant pait. Aftei you have peifoimeu the uiagnostic tests anu you've gotten the
iesults of youi uiagnostic tests, know how to ielate the iesults you've gotten to
making a piopei uiagnosis. That's what is veiy impoitant anu too many people uon't
uo that.

When you get into thiiu yeai as stuuents, you uon't have a hell of a lot of enuouontic
iequiiements. In the thiiu yeai, you have two enuouontic iequiiements. You must
by the time you finish thiiu yeai, you must have completeu at least one ioot canal on
a patient. Anu now, we've hau thiiu yeai stuuents who have uone ten anu moie, so
to uo one is not a uifficult iequiiement. Anu then you neeu to fill out a uiagnostic
case iepoit. This uiagnostic case iepoit, it's basically what we'ie going to be going
ovei touay. The patient comes in with a pioblem. Boc, this huits me, oi whatevei. I
want to see if you can figuie out what to uo to tiy to ueteimine what the patient's
pioblem is. Figuie out what uiagnostic tests aie appiopiiate. Bo the uiagnostic tests
anu come up with the iesults. I uon't even caie if aftei you've uone eveiything, that
you ueciue it's not an enuouontic pioblem. Not eveiy patient that comes heie is
enuouontic. But I wanna see, you have to wiite up this iepoit on a sheet of papei.
It's ieally pietty simple. Anu that is what's going to be youi giaue foi the yeai, so as
I say, uon't uo it as a half ass. Bo it ieal anu iight. But it uoesn't have to be..people
come up to me anu say, I uon't have an enuouontic patient. It uoesn't have to be an
enuouontic patient. You uon't even have to uo the ioot canal. You have to ueteimine
anu know what to uo to ueteimine what the pioblem is. You just saveu me senuing
out an email.

0k, so some of the uiagnostic tests, iauiogiaphs. I know a lot of people heie with the
ALARA anu the lack of iauiogiaphs that they want you to take. Theie aie many cases
wheie they just uon't take enough anu you can't make a uefinitive uiagnosis oi
tieatment plan without a full set of x-iays. 0k, so patient comes in. You have to
ueteimine what iauiogiaphs to take, wheie to take them. We'ie going to go thiough
each one of these. vitality testing, I'll go thiough that. Peicussion, tasting, fistula,
palpation, heat, anesthesia, anu test cavity. I'll go thiough eveiy one of these.

0k, so patient comes in with a pioblem in the posteiioi iegion. I uon't what you to
just take a PA. I want you to take the peiiapical anu a bitewing iauiogiaph. This was
uiummeu into me by the fiist enuouontist I woikeu foi, anu he was completely
iight. PA anu a bite wing, ok. Why. This one uoesn't show that much. I'm going to
Tiansciibeu by Ana Sangauala Septembei 2S, 2u14
skip a little time anu I'm going to go ovei to heie. So this patient, I hope you can see,
this patient came in complaining about pain on the iight siue. You take youi PA, anu
you see wow look at all that uecay theie, no biainei. This tooth is the pioblem. As it
tuins out, this tooth is so bombeu out, that although I coulu uo enuouontic theiapy
on this tooth which woulu be iequiieu to ietain the tooth, it woulu be pointless to
uo it because theie's no way the tooth coulu be iestoieu. A lot of times I get, coulu
you uo the ioot canal heie. Suie I coulu uo the ioot canal. The question is shoulu I
uo the ioot canal. If the tooth cannot be iestoieu piopeily aftei the enuouontic
theiapy, it's pointless to uo it. So you have to ueteimine that piioi to completing
ioot canal theiapy if the tooth can be iestoieu. 0k, no pioblem, that's the tooth. Anu
then I take the bite wing anu I'm not suie if you can see fiom theie. Can you see all
the extensive uecay on this tooth unueineath heie. If I know which switch contiols
which lights, I uon't want to put you all to sleep, but well, theie's a tiemenuous
amount of uecay unuei the maigin of this ciown. It's veiy eviuent on the bitewing
iauiogiaph. You cannot see it on the PA. They aie uiffeient. When you take a PA,
when you take a bitewing, they aie at uiffeient angulations. Biffeient angles will
show you stuff. I have a lot of uentists who uon't agiee with me. Anu then I show
them this anu they say wow what a uiffeience. This uoes not mean that eveiy time
you take a PA anu a bitewing, you'ie going to see something uiffeient. Theie can be
many times that they aie not going to, but you uon't know. Since you uon't know
what it is going to be, you shoulu always uo it.

So, like I saiu, I'm ielatively ceitain that this peison has a heau. Fiom that angle, you
can't tell. If you took a pictuie fiom a uiffeient angle, you woulu piobably see a heau
theie. So tiust me, taking iauiogiaphs oi pictuies fiom uiffeient angles will show up
uiffeient things.

We'll talk about vitality testing. vitality testing, we want to know if the pulp is ueau
oi alive. The neive is ueau oi alive. If you'ie uoing vitality testing, the ieason foi
vitality testing is pulp ueau oi alive. Not how ueau oi alive, but ueau oi alive. The
ieason that the case I showeu you back theie wheie you hau to ueteimine if it was
peiio oi enuo. Remembei I saiu that if it was peiio, the bone woulu not have filleu
in. What you want to uo theie is vitality testing to see if it was ueau oi alive. If the
pulp was vital, you know that it was a peiio pioblem. If the pulp was non vital, it's an
enuouontic pioblem. So that's pulp testing. Theie aie a couple of ways we pulp test.
What I'm showing you heie is a pellet of cotton that has been satuiateu with enuo
ice. We put it on the suiface of the tooth anu we say to the patient, I just put
something colu on the tooth. }ust tell me that I'm awaie theie's something colu, oi
you uon't know theie's something colu. Not how painful oi how much, just
awaieness of the colu oi not. If the patient is awaie of the colu, the pulp is vital. If
not awaie, it's non vital. This is what we call an EPT electiic pulp testei. It's anothei
way, piobably even moie uefinitive than the enuo ice to ueteimine vitality. You put
a little toothpaste on theie. Theie's a iounu wiie which you place on the patient anu
you ieally can't see it heie, but theie's a uial which incieases the electiic cuiient.
With the toothpaste, you put it on the suiface of the tooth anu you tuin the uial up to
inciease the cuiient going thiough theie. If the patient feels it, the tooth is vital. If
Tiansciibeu by Ana Sangauala Septembei 2S, 2u14
the patient uoes not feel it, it's non vital. You uo not always have to use both. I tenu
to use the colu test fiist anu it's the easiest. If I get a vital iesponse to the colu, it's
not necessaiy foi me to uo the pulp test because I alieauy know the pulp is vital. If I
get a non vital iesponse with the colu anu I think the tooth may be vital, then what
I'm going to uo is I'm going to go get the pulp test anu uo that also. Anu if both of
them tell me that the tooth is non vital, then I believe it. But if the pulp test tells me
it's vital, I'll go along with that. So theie aie times you have to know whethei the
tooth is vital oi nonvital.

0k, again, I'm not suie just how much, I know you've hau the pie clinical. I'm not
suie what you've seen with iauiogiaphs. Right heie, you see, you see the white line
of the tooth. You know somebouy has uone enuouontic theiapy. You aie taught that
you want to get within a millimetei of the apex. This ioot canal fill is shoit. It's shoit
of the apex anu it's too shoit. It uoesn't look veiy goou. Theie's a iauiolucent aiea
heie. 0k. This ioot canal was uone by a geneial uentist. Now theie is a iauiolucent
aiea at the apices of this molai. Two veiy laige, veiy laige iestoiations. These x-
iays, I hate to use the expiession, but people my geneiation, typically, this is what
theii iauiogiaphs looks like. Tiemenuous iestoiations all along. Befoie fluoiiues
anu all that. We all hau a lot of uecay, a lot of fillings. Ny kius anu piobably most of
you, you piobably won't see it as much. But any time theie is a laige iestoiation on a
tooth oi a ciown on a tooth, theie's a potential foi that tooth to ultimately neeu ioot
canal theiapy. So we take a look at this, see the iauiolucent aieas theie, laige
iestoiations, kinua a no biainei. The tooth must be ueau because you have
peiiapical pathology heie anu theie's iationale, a ieason, foi the ioot canal. So the
uentist who uiu this, the geneial uentist who uiu this ioot canal anu saw this aiea
foiming saiu Ah, I bettei senu this to the enuouontist. Because the one I uiu is failing
anu this one is much moie uifficult, so let me senu to the enuouontist. The
enuouontist goes in anu I'm not suie if he uiu vitality testing befoiehanu. If he uiu,
he knew theie was something wiong. If he uiun't uo the vitality testing, when he
went in anu openeu up anu founu that theie was vital tissue in this tooth, that the
pulp was vital. Then he says nuh uh, theie's something wiong going on with this
because we know that these iauiolucent aieas, if they aie peiiapical pathologies, the
peiiapical pathologies only come fiom a nonvital tooth. Although these exactly
mimic peiiapical pathologies, iight at the apices, iight wheie you woulu finu it,
because the pulp is vital, theie's something wiong. So he uiu a veiy nice job. Be
completeu the ioot canal theiapy anu uiu a veiy nice job, but since he knew that
theie was something not koshei going on iight heie, he sent the patient to an oial
suigeon to uo an apical biopsy of the tissue. Be came back anu has metastatic bieast
cancei. I uefy anyone looking at that x-iay with those iauiolucent aieas theie anu
that iestoiation that size to make the uiffeiential uiagnosis anu think that that is
going to be bieast cancei iathei than peiiapical pathology. It fits eveiything of being
peiiapical pathology except foi the fact that the tooth Is vital. So if you hau uone the
vitality testing befoie initiating the ioot canal theiapy, you woulu know that this is
not. That this is wiong anu you hau to go fuithei. Theie is one thing I uiun't tell you,
which I shoulu have anu no one askeu be about it. But, you know the most common
canceis to the jaw. Netastatic canceis. Nost of them aie not piimaiy. Wheie aie the
Tiansciibeu by Ana Sangauala Septembei 2S, 2u14
most common aieas foi metastases to the jaw. Bieast anu piostate. 0k. Tuins out
this woman hau a histoiy of bieast cancei befoie, so knowing the histoiy of the
bieast cancei anu knowing that the tooth was vital shoulu have put the woiiy in the
piactitionei's heau that it might be metastatic. You can hope that it's not, but the
iight thing was uone anu they maue the uiagnosis. Typically, if it's that bau anu has
metastasizeu to that point, it's not going to be goou.

0k, peicussion testing. It is anothei mouality. So now, again, you'ie asking peitinent
questions. When the patient comes in, I get this fiom stuuents all the time. The
patient came in anu complains about hot anu colu all the time so I peicusseu the
teeth. So I saw, well, was the patient's complain chewing oi biting. No, but I
peicusseu the teeth anyhow. I have no pioblem with you peicussing the teeth, but
iealize that's not the patient's complaint. The patient's complaint is theimal
sensitivity so test it with that stimulus. If the patient comes in anu says that eveiy
time I bite uown anu chew, it huits, then the peicussion is a significant test. Bo you
think peicussion, sensitivity, is a test foi vitality. No it is not. Theie aie many
ieasons why a tooth can be sensitive to peicussion. Peicussion sensitivity means
that the PBL is iiiitateu oi inflameu fiom any one of a numbei of ieasons. It may be
an enuouontic ieason. It coulu also be fiom a piece of foou stuck in between the
teeth causing an iiiitation theie. So peicussion sensitivity is a veiy helpful anu
fiequent way of ueteimining if they have an offenuing tooth. But it is not a test of
vitality, aliight. The way I test peicussion, now I also say that you'll see when you
stait to tieat patients. You'll have some patients who will come in, they'll sit in the
chaii "*yawn*, I uoc, uo whatevei you have to uo". Anu then theie's the patient who
comes in anu sits like this anu is neivous about any uental pioceuuie anu if you uo
this to the patient, he oi she will piobably jump. So now, you want valiu ieauings of
youi uiagnostic tests, so that veiy neivous patient, if any of you have hau anybouy
peicuss youi teeth with a miiioi hanule, it's not a pleasant sensation. 0n a noimal
tooth, it's not. So if you'ie looking to see what tooth is the offenuing tooth to
peicussion, you shoulu have an iuea. The patient will tell you what aiea is botheiing
him oi hei. So you stait the peicussion in an aiea away fiom the aiea of wheie the
pioblem is going to be. You want the patient to have the noimal sensation of what it
feels like. The patient may say, that's not wheie it is. I know, I know. We'll get theie,
we'll get theie. So that's what you uo. You stait a few teeth away anu you uon't
peicuss haiu because if the tooth is, some teeth aie exquisitely painful to any kinu of
peicussion anu just the slightest tap can be ieally painful. You uon't have to bang the
teeth to elicit the pioblem. But that's what you uo, you peicuss with the miiioi
hanule anu you stait a few teeth away, anu you peicuss the teeth to see which is the
offenuing tooth. Again, that uoes not tell you, uoes not give you a uiagnosis. It gives
you an iuea which is the offenuing tooth. You then have to figuie out why it's
offenuing to peicussion.

Palpation. Palpation is you take a fingei anu you move it along up along the gingiva
to see wheie it's tenuei. Again, same thing with the peicussion. You uon't stait
exactly wheie you think the pioblem is. Especially if theie's some swelling.
Typically, if theie's swelling anu you palpate, it's veiy common that the swelling will
Tiansciibeu by Ana Sangauala Septembei 2S, 2u14
extenu ovei moie than one tooth. It can be tenuei to one oi two teeth away fiom the
tooth that's actually causing the pioblem. So as you'ie moving youi fingei along anu
the patient staits to feel it, he might say 0h that's it! So you move youi fingei along.
Also palpation, typically, if it is an enuouontic pioblem, enuouontic pioblems aie
manifesteu in the apical aiea. If the pioblem in the tenueiness of palpation is of
enuouontic oiigin, it is usually going to be in the apical aiea. Figuie out, estimate,
how fai up the ioot woulu go. If it's at the apical aiea of the ioot, it's an enuouontic
pioblem. If it's moie along the maigin of the gingiva wheie the tenueiness is, it's
piobably a peiiouontal pioblem.

Beat. Sometimes, eveiy once in a while, we talkeu the iiieveisible pulpitis. Nost
often, the pioblem is sensitivity to colu. Eveiy time I have something colu, uiink
something colu, it huits me. Anu again, not eveiy sensitivity to colu is an iiieveisible
pulpitis oi a ioot canal. It may just mean that theie's uecay theie. But you have to
figuie out anu see wheie it is. Anu then I come into the office, anu not eveiy patient
that came into my office foi consultation neeueu a ioot canal. Some of them, the two
types of patients who weie the happiest weie the ones who weie in exquisite pain
anu typically I woulu anesthitize the patient oi whatevei, anu that's the best he felt
in uays. They get ieal happy. Anu the othei one, who comes in, who's not in a lot of
pain anu you uo youi uiagnostic test anu you say you uon't neeu a ioot canal. That
thiills them. Those aie the happiest ones. So now, I'm not suie whethei the patient
is going to neeu tieatment, but I come in the opeiatoiy. The patient is sitting theie
holuing a jai oi bottle of ice watei. I know that this patient is going to neeu
enuouontic theiapy. The ieason the patient has that ice watei is he oi she is going to
get spontaneous pain anu if they put something colu on it, the pain will go away
immeuiately. The pain coulu be spontaneous oi any kinu of heat will piouuce the
pain. If they have any hot foou, exquisite pain, they put something colu on it, the
pain goes away. It is anothei foim of an iiieveisible pulpitis. Again, the most
common one is the pain with colu. But with this one, unusually, the colu will actually
ielieve the pain. It's still a pulpitis because the pulp is still vital. It still neeus ioot
canal theiapy. So I come in anu I see this guy's got ice watei. I know he's going to
neeu a ioot canal but I uon't know which tooth it is. I know that any kinu of heat will
cause the pain. So what I uo, I test it with something hot. What you have heie is a
stick of gutta peicha, which I hau put a flame on. The gutta peicha cuils up veiy
quickly anu it has a little bit of ball theie. You heat that up anu it actually caiies the
heat a lot anu you put it on the vaiious teeth. When you get to the tooth which is the
one causing the pioblem, the patient has pain tiemenuously. You have youi thiee
way syiinge hanuy because once you get the pain, you squiit watei on it anu the
pain goes away immeuiately. But you know that is the tooth causing the pioblem.
Anothei way of testing with heat is just take one of the instiuments that is amenable
to being heateu anu you heat that up anu touch it to the vaiious teeth. Tooth, teeth.

I talkeu about a stoma. A stoma is significant with the woiu fistula, ok. Fistula is the
olu teim. The new teim, stoma, means mouth. You'll heai people use the teims
synonymously. Is a uiaining tiact leauing fiom the site of infection buiiowing
thiough the bone, buiiowing thiough the gum, anu uiainage has gotten thiough
Tiansciibeu by Ana Sangauala Septembei 2S, 2u14
theie anu theie is no pain. So you'll eithei call it a fistula with a stoma oi it is, the
piopei teim is a sinus tiact with a uiaining stoma. So I just explaineu to you, what it
is. It's a tiact going fiom the site of infection. You uon't always know wheie it's
coming fiom. Whenevei you see a sinus tiact, what you shoulu uo is tiace it. We
tiace it by putting gutta peicha in theie. You take a stick of gutta peicha anu you put
it into the opening anu you put it in as fai as it will go. It will stop, theie will be
iesistance. If theie's no iesistance, then see if you get theie. 0nce you have the gutta
peicha in place, you then take a iauiogiaph to see exactly wheie it goes to, anu that
will tell you wheie the souice of infection is coming fiom anu what you have to uo.
This is a little bit unusual because you actually have two openings, two stomata. So I
tiaceu them both. I uiun't know wheie it was going to go to. It tuins out, typically,
you will get when you see wheie it's going to, that can tell you what the cause is.
Typically if it is an enuouontic pioblem, the gutta peicha will go iight to the apex of
the ioot. If it goes iight to the apex, it's an enuouontic pioblem. If it goes some place
else, it coulu be a peiiouontal pioblem. I uon't think you'ie awaie yet what's going
on heie, but both of those gutta peichas, you know what you'ie looking at heie on
the iauiogiaph. These aie ciowns, iight. You know what an x-iay is. An x-iay is a
measuie of uensities anu thicknesses. The thickei something is, the whitei it will
show up on the iauiogiaph. The thinnei it is, the uaikei it shows up on the
iauiogiaph. When we see an aiea, a iauiolucent aiea, we think it's an infection. The
ieason the patient says I saw a black uot at the tip of my ioot on the x-iay, what uoes
that mean. You explain to the patient what iauiogiaphs aie anu if it's thinnei, it
shows up uaikei. If theie's a uaik aiea theie, it's because bone has been uestioyeu
anu that's why it's showing up uaik. So, these aie ciowns. This white aiea in the ioot
of the tooth is not gutta peicha because it's too opaque. This is metallic. It is a post.
When you see the gutta peicha going iight to the site of the post, you know that it's a
ioot fiactuie, ok. When you have a veitical ioot fiactuie, the tooth is hopeless anu
must be extiacteu. So piioi to tiacing the sinus tiact with the gutta peicha, I coulu
have assumeu that it was going iight to the apex heie. Especially since theie is no
gutta peicha in this. So whoevei uiu this ioot canal theiapy uiu a pooi job. So if I hau
not tiaceu it with the gutta peicha, I woulun't have known that the pioblem was at
the post. I woulu've thought that the pioblem was at the apex. Now, I know that the
tooth is hopeless. Bau it gone up heie, theie aie othei tieatments we coulu have
uone.

0kay, exteinal fistulas. Sinus tiacts. You can get that also. Beie, this was on the
outsiue of a woman's cheek. Bon't know wheie it's coming fiom. Put the piece of
gutta peicha iight into the sinus tiact, the stoma, on the woman's cheek. It went
iight to the lateial aspect of this molai. Testeu the molai, vitality testeu the molai.
The molai was non vital. We knew that the souice of this out on the cheek was the
ueau tissue insiue this tooth. Bau an aigument with an oial suigeon. Be saiu when
you have that, the only way to get iiu of it, is by extiacting the tooth. I saiu what aie
you talking about. If the tooth weie vital, it's a uiffeient stoiy, but the tooth is non
vital. You know that the whole cause of the sinus tiact is the neciotic tissue in the
tooth by uoing the ioot canal theiapy, you will cleai up the pioblem. Be saiu no no
no, you have to extiact the tooth. Well, ioot canal theiapy was uone. Anu it closeu
Tiansciibeu by Ana Sangauala Septembei 2S, 2u14
up. 0k. Again, a lot of what we uo, a lot of uiagnosis. A lot of what we uo is common
sense. You have to have the basics. You have to have the basic knowleuge. I say this
to stuuents all the time who come up to me anu ask me questions. I ask them
questions. The questions I ask them, a lot is coming stiaight fiom this lectuie anu
the next lectuie I'll give you. Anu they look at me anu we talk, anu they talk, anu they
think it out. Anu I think I saiu that the pioblem is that you have moie knowleuge
than you choose to use. If you stop anu think about all the things you know anu you
put it togethei piopeily, you'ie going to come up with the piopei uiagnosis, but you
uo have to stop anu think.

Swelling. So stoma heie. This is a peiio abcess. Again, I've saiu to you befoie, if the
palpation is the apical aiea, it's usually enuouontic. If it's up highei at the maiginal
iegion wheie this swelling was, this was a peiio abcess. Coupleu with it having a
ciown on the tooth, it is uifficult to uo a pulp test to uiffeientiate. No ciown on the
tooth, I uo a vitality test. Now I know it's a peiio abcess anu not an enuouontic
abcess. Beie by the piobing anu if I hau put gutta peicha in heie, it woulu not have
gone into the apex. It woulu have gone to the fuication aiea, so I woulu know it was
peiio.

So I think this is just a iehash of eveiything we've talkeu about. 0k. This guy came in.
I saw him when I useu to teach at Netiopolitan hospital anu he saiu he was having
an alleigic ieaction. Be was having pain, he hau a toothache. Anu he put ambisol on
the aiea last night anu it then blew up like this, so it's an alleigic ieaction. It's
actually not an alleigic ieaction. Boes anybouy know what it is. Again, not eveiy
patient that comes in is going to have a uental pioblem. You have to know again, I
saiu with the uiagnostic case iepoit, I uon't caie if it's not an enuouontic pioblem
you come up with. As long as you go thiough the piopei uiagnostic tests. This guy
was funny too. Be saiu take pictuies, I uon't caie. But it was heipes zostei. The
funny thing is..I uon't think it was the same one, no it was a uiffeient one. Theie was
an oial suigeiy iesiuent who saw it anu knew iight away that it was heipes zostei,
unlike the iesiuent the yeai befoie who aigueu with me that the othei tooth. That's
it! Biu it in less than 2 houis.