Tiansciibeu by Kyuun Lee '17

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!"# %&'( ) If I use any teims oi expiessions that you uon't know what I'm talking
about please stop me anu ask me because sometimes I assume too much aliight. I'm
Bi. Bush in case you uon't know hopefully I'll be able to woik with most oi all of you
while I'm in clinic anu we'll have a goou time. 0k

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!"# %&'( ) Aliight so back to basics what is enuouontics. Enuo is usually iefeiieu to
as RCT. Root canal theiapy. The piopei teim of couise is enuouontic theiapy. What
is it we aie uoing. We aie uiagnosing anu tieating pulpal anu peiiapical uiseases.
That in a nutshell is ieally what weie uoing iight. I hau a fiienu who um also an
enuouontist, he tiieu to sum up what we uo as enuouontists anu what we uo is,
since you hau the pieclinical couise you have an iuea of what we uo, he summeu it
up by saying we open up teeth we make them biggei anu put pink ciap in them.
That's in a nutshell what we'ie uoing but we uo moie than that. We'ie going to
teach you the how anu when anu why, anu the iationale behinu uoing enuouontic
theiapy. 0k. Why uo we uo ioot canals oi enuo. Any iueas. Theie aie a few ieasons
why.

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!"# %&'( ) Peiicapical infection Infection iight. We uo enuouontic theiapy to ielieve
infections that aie causeu by the tooth, not by peiiouontal infections. But by
enuouontic, pulpal infections. What else. (No vitality to the tooth.) What is the most
common ieason a patient will come to youi office neeuing RCT. Tiauma. Pain!
Right. I uunno if I shoulu say most but a goou % of patients that you will see in
piactice neeuing enuouontic theiapy aie because they came in in pain. When you
aie builuing a piactice you have to get new patients all the time. If you uon't get new
patients youi piactice will uie. Bopefully on youi existing patients you'ie going to uo
such goou tieatments on them that when you uo a iecall you'ie not gonna have
anything else to uo. Youi hygienist will uo a piophy anu you'ie not gonna make a
living like that ok. You have to get new patients, anu piobably the most common
ieason foi a new patient to come to youi office is uue to pain, pain anu swelling. Anu
it usually enus up being an enuouontic situation oi an extiaction. So if it's
enuouontic, if you know how to tieat the patient anu alleviate the patient's pain oi
pioblem, you'ie a heio anu the patient will say goou things about you anu come
back to you anu iefei othei people to you. So you wanna know how to hanule
enuouontics. So again piobably the most common ieason you uo RCT is to alleviate
pain. The othei one we talkeu about alieauy is infection; sometimes you have
patients come in, anu some will not have any pain, but they will come in because
they aie swollen. When a patient comes in who is swollen you have to ueteimine the
etiology of the pioblem anu if enuouontic tieatment is the piopei couise oi
something e else. But we uo eliminate infections. Anu someone else saiu something
that was veiy tiue also - lets say a patient comes in with a tooth that is bioken
uown, any type of tiaumatic acciuent, bikecai acciuent, I was uancing with
somebouy else's wife anu got puncheu in the face so now my tooth is bioken, so
theie's no infection oi pain but the tooth is bioken anu ieally cannot be iestoieu
Tiansciibeu by Kyuun Lee '17

until you uo enuouontic theiapy fiist. So theie is a multituue of ieasons you uo
enuouontic theiapy, these aie some of the most common ones.
0k so, bottom line why aie we uoing it. So the patient comes into pain. Bas a laige
caiious exposuie, wants to get out of pain. 0i the patient comes w an infection oi
the tooth is bioken uown. The choice is to uo enuouontic theiapy oi what. Extiact
the tooth. Because when it comes to uoing enuo the alteinative to uoing enuo is to
take the tooth out. So the bottom line is ieally why we'ie uoing enuouontic theiapy
is to save oi ietain the tooth in the mouth. That's the bottom line. So I'm in clinic anu
it uiives me nuts all the time when I walk by anu I heai stuuents speaking to the
patient anu the patient has a laige caiies. Anu it's questionable whethei the uecay is
going into the pulp. So it if goes into the pulp the patient will neeu enuouontic
theiapy. If the patient is asymptomatic anu even though he oi she has laige uecay
anu it uoesn't go into the pulp, theie's goou likelihoou that you can excavate the
uecay anu put some type of iestoiation in theie. So I heai this stuuent say to the
patient, I'm going to go slowly hoping that I can save the tooth. Neaning that the
stuuent is hopeful that theie wont be a caiious exposuie iequiiing the patient to get
a ioot canal. So now none of you aie going to say that because you know that we uo
ioot canals to save the tooth. Anu if theie's ueep uecay theie anu you'ie excavating
it, theie's ieally no ieason to feel guilty about iemoving the uecay anu if the pulp is
exposeu. 0nless you aie the people that put the uecay theie. But if you uiun't put the
uecay theie anu the patient came in with it, you aie uoing the piopei tieatment by
iemoving all the uecay that is theie anu whatevei the patient neeus you supply oi
pioviue the piopei tieatment. 0k. So you'ie going to see in this couise of lectuies
weie giving you theie's going to be a lot of ieuunuancies. You can say its boiing,
ieuunuant, ieally the ieason foi it is iepetition foi emphasis. The things that we'ie
iepeating aie things that we think aie impoitant anu we wanna get the point acioss
to you. So you will heai a lot of the same issues biought up. So, one of the biggest
pioblems we have as piactitioneis in telling a patient that he oi she neeus a ioot
canal. "Root canal.. I cant think of anything woise than having a ioot canal uone!!"
People make jokes about it, I just happeneu to see an exceipt fiom a guy that was
talking about a golf vacation, saicastically saying it's not gieat, he'u iathei be uoing
a ioot canal. A couple yeais ago even Piesiuent 0bama in I think one of his State of
the 0nion speeches *CANT BEAR* Foi some ieason we have gotten a bau ieputation
as fai as having ioot canals uone. A lot of times in my office I've heaiu patients say "I
cant think of anything woise than having a ioot canal uone." *pictuie of bull
speaiing matauoi's ciotch* As I always say, peisonally I'u iathei have a ioot canal.
Anu I've hau 1u ioot canals uone anu I'm still heie stanuing. So having a ioot canal
uone is ieally not the woist thing in the woilu as you can see, theie aie woise things
ok. But that is one of the pioblems we iun into. Ny biothei is a uentist also anu he
was tieating a patient anu at the enu of the tieatment the patient saiu well what aie
we gonna uo next time. Well you neeu a ioot canal such anu such a tooth. "N0 N0
N0 I uon't want a ioot canal, anything but I just uon't want a ioot canal uone next
time." So the patient came in the next appointment anu saiu so what aie we gonna
uo touay. Anu he saiu we'ie gonna uo enuouontic tieatment. She saiu fine! So he uiu
the enuouontic tieatment anu the patient was fine afteiwaius, she saiu "That was a
ioot canal wasn't it." So maybe, maybe we shoulun't call it ioot canals. People aie so
Tiansciibeu by Kyuun Lee '17

afiaiu of having ioot canals uone that we shoulu always tell them we'ie gonna uo
enuouontic theiapy foi them ok. Well what is enuouontic theiapy. Then you explain
to them what it entails, aliight. Any questions so fai.

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!"# %&'( ) So what aie we uoing in a ioot canal. See past yeais I woulu have to
explain what all this is, but now since you've all hau the pieclinical couise you
shoulu know what we'ie uoing ok. So heie's youi pulp, we'ie making an access,
we'ie going thiough the enamel anu the uentin we get to the ioof of the chambei
anu we iemove the entiie ioof of the chambei uown anu get all the pulp tissue out
of the chambei anu to the flooi of the chambei. Anu then once we'ie at the flooi of
the chambei we stait to look foi the oiifices to the vaiious canals. 0k. 0ne of the
biggest mistakes I see in beginneis, anu its bettei than the othei mistake, but the
biggest one I see is stuuents uon't wanna go too fai anu peifoiate the tooth, which I
think is commenuable, anu they get neivous, so because now heie's the chambei
anu if you go thigouht he chambei anu the fuication anu peifoiate thiough the
fuication then the piognosis foi the tooth is almost hopeless anu it will piobably
have to be extiacteu. (N0RE) So you'ie going to be tentative, when you'ie going
uown so as not to peifoiate, like I saiu which is commenuable. Bowevei you shoulu
know the anatomy of the tooth. The biggest mistake I see the most common is that
when stuuents get to the ioof of the chambei, anu in a vital tooth you will see a bit of
bleeuing, they see the bleeuing anu they get neivous because they uon't wanna go
too fai so a lot of times they will stop, thinking they've uone a completeu access,
taking the entiie ioof off anu gotten to the flooi of the chambei, wheieas what
they'ie ieally uoing is woiking thiough the pulp hoins. That's the most common
mistake. Theie's a couple of ways when you'ie going in to know whethei you'ie still
at the ioof of the chambei oi you'ie at the flooi of the chambei. Fiist of all the
amount of uepth you go in. You wanna stuuy the iauiogiaph befoie you tiy to uo
youi access. uet an iuea of the anatomy anu how fai you have to go uown to get to
the ioof of the chambei. uet an iuea of the size of the chambei. It's not all the same.
As people age oi as theie's moie tiauma to the tooth, the canal, the chambei tenus
to get smallei anu the canals can become naiiowei. So they'ie not all the same. A
young patient you'ie going to have a veiy laige pulp chambei anu youi access is
going to be easiei. Then you get an oluei patient who's hau a lot of woik uone to the
tooth, anu the size of the chambei is veiy naiiow. So you'ie going to have to go
uown fuithei to ieach the ioof of the chambei anu the chambei is naiiowei. So you
wanna have an iuea befoie you'ie going in as to what you'ie going to be uoing
aliight.

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!"# %&'( ) So this is what I was talking about ok. So heie you take a look anu see the
iauiogiaph befoie hanu. You see that heie this is a veiy laige chambei. You get an
iuea of how fai you have to get the bui uown just to get to the ioof of the chambei.
Anu then even aftei you've got to the ioof of the chambei you woulu have a little
moie space in the chambei to get to the flooi. Anu even fiom the flooi of the
chambei to the fuication theie is a bit of a uistance. So these aie some of the things
Tiansciibeu by Kyuun Lee '17

you wanna take a look at. Now if you take a look at this othei molai, heie's the
chambei anu look how much smallei this chambei is than heie. You stait to have
these calcifications heie. This tooth has hau moie extensive iestoiations. Anytime
you uo something to the tooth it is an insult to the tooth. When the tooth anu the
pulp is haimeu oi insulteu, what uoes it uo. It tiies to piotect itself. Bow uoes the
pulp piotect itself. By laying uown seconuaiy uentin. So it lays uown seconuaiy
uentin at the expense of the chambei anu the canals. So that's why the chambei gets
smallei anu the canals will get smallei because of the seconuaiy uentin that is laiu
uown. What uo you have to have to lay uown uentin. You have to have a vital pulp.
0nce the tooth is not vital, uevitalizeu, foi any numbei of ieasons, uentin will no
longei be laiu uown. 0k. So this is just to illustiate what I was talking about. 0k so
now, what I think is the biggest news flash foi you guys foi this set of lectuies - you
may wanna pay attention to this this is veiy impoitant. The ieason anu the iationale
foi this seiies of lectuies is not foi you to pass the exam at the enu of the seiies of
lectuies. 0k. Because what happens all the time is that you guys aie going to
*laughs* we give veiy faii exams at the enu of this couise. We uon't tiy to tiick you.
We have a ieputation of giving faii exams. So you all uo well anu get into the clinic,
anu if you'ie in the clnic in S
iu
yeai I ceitainly assume you've passeu this class oi
you woulun't have gotten to S
iu
yeai. Then I ask you basic questions about what you
have been taught in this seiies of lectuies. Anu I get blank staies. Anu I get "well you
know Bi. Bush we have uata uump. Because we have so much infoimation in so
many uiffeient couises that aftei we pass the exam we kinu of foiget stuff that we
weie taught. 0k. So the newsflash heie is that the ieason foi these lectuies is not to
pass the exam, its foi you guys to get infoimation to use in the piofession you'ie
going to be uoing foi the iest of youi life. 0k. So we'ie tiying to get acioss to you the
infoimation you'ie going to neeu anu use when you'ie tieating patients. I piomise
you if any of you woik with me in the clinic, I piomise you that I will ask you
questions. Come up to me anu say I neeu a stait signatuie to uo RCT oi enuouontic
theiapy on the tooth, I am going to say why uoes this patient neeu that. 0k. Youi
answei shoulu not be "Because I have iequiiements." 0k. I know you uo, I went to
uental school, I unueistanu, ok. The piopei answei shoulu be the ieason anu
iationale why this paiticulai tooth on this paiticulai patient iequiies enuouontic
theiapy. Theie may be a few ieasons why. S0 that's the kinu of things we want you
to get out of this couise. Now I know anu I unueistanu all the stuff that all the othei
couises give, I know you guys have ciazy amounts of woik you tiuly uo. But what I
expect of you when you come into clinic, when you'ie going to be tieating patients,
is come up to me anu say "Bi Bush this is the fiist ioot canal I'm uoing." Anu please,
it's veiy goou foi you to tell me that - as long as its not in fiont of the patient. You
have no iuea how many stuuents have tolu me that in fiont of the patient. Bi. Bush
this is the fiist ioot canal I've evei uone anu I'm not suie what I'm uoing. So this is
what we want. I tolu you befoie theie's gonna be a lot of iepetition of things, we
want you to iemembei it, go ovei it piioi to it, when you come into clinic anu you'ie
going to say to me this is the fiist ioot canal I've uone, so what uo you think I expect
of you. To be able to uo a ioot canal as well as I can. Think I expect you to be an
expeit in uoing eveiything. No. I expect you to know why you'ie uoing it anu expect
you to know what you'ie supposeu to uo. I have no pioblems with you having
Tiansciibeu by Kyuun Lee '17

tiouble uoing it. Come the enu of the fouith yeai with a simple case if you still have
pioblems, then we'ie gonna have some issues. But when you stait what I expect is
that you know the basics you know why you'ie supposeu to uo anu what you'ie
supposeu to uo. 0k. Cause you'll all pass this exam, some bettei than otheis but
you'll pass.

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!"# %&'( ) Aliight. I uon't know if it was uiscusseu in the pieclinical, the philosophies
about uoing the ioot canal theiapy. When I was in the enuo piogiam heie many
yeais ago, it was heiesy to attempt to uo a complete ioot canal in one visit. It was
just not uone. Theie have been tiemenuous changes maue in enuo, not in the basics
of what we uo, theie have been tiemenuous changes in the technology, ok, anu the
philosophies of how anu what to uo. It hasn't been a ievolution, it hasn't been
changeu iight away, the changes have evolveu foi ieasons ok. It was taught to me
that you just uon't uo a ioot canal in one visit. The fiist time I evei uiu a complete
enuouontic theiapy in my office in one visit because the patient was going on
vacation oi leaving out of town oi moving away oi whatevei the case, it was smaitei
to complete it. Anu I uiu it in one visit anu saiu ok gou, stiike me uown, anu nothing
happeneu you know. So now uoing enuouontic theiapy in one visit has now become
accepteu anu acceptable in many cases but not in all cases aliight. We still, if the
tooth is non vital, neciotic, we aie still not comfoitable in uoing the case in one visit
we wanna uo it in multiple visits 2 visits can be fine. Sometimes yes a neciotic tooth
can be uone in one visit but the ieason foi it is because when you'ie uoing a vital
tooth theie is no infection of the pulp tissue, theie is no infection of the canal aliight.
So you'ie not woiiieu about a flaieup fiom infection. When you have a non vital
neciotic tooth, the canal is filleu with bacteiia. Theie is much gieatei chance you can
get a flaieup. Flaieup means pain oi swelling afteiwaius. So we uon't like to uo it in
one visit, we like to clean out the canals thoioughly anu meuicate them, you know
what the stanuaiu ioot canal meuication is that we use now. Piobably shoulu've
hau that. Bave you heaiu of calcium hyuioxiue. 0k. Calcium hyuioxiue is the
inuicateu meuication that we put in the canals between visits, ok always in a non-
vital tooth, anu if you'ie uoing a vital tooth not in one visit, put the calcium
hyuioxiue in theie then also. So in the clinic when you get theie we'll ueteimine
whethei the case can be completeu in a single visit oi multiple visits. The uegiee of
uifficulty can uictate that also. So if its uh, fiequently a single canal vital tooth,
asymptomatic, the patient wasn't in a lot of pain, can be uone in one visit; but a
symptomatic multi-iooteu tooth we piobably cant uo that in one visit - its gonna be
multiple visits.

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!"# %&'( ) This is what I was talking about so many technological changes. This is a
piouuct of one of oui post giauuate stuuents. We have an apex locatoi heie we have
a micioscope foi the system B, uh iotaiy systems, all these things aie ielatively new
in the scheme of how long enuouontics has been uone these things aie ielatively
new. They have maue the ability the actual mechanical pait of uoing enuouontics
much easiei anu fastei. The basic concepts still have not changeu, but this has maue
Tiansciibeu by Kyuun Lee '17

life easiei foi us. I was having some woik uone at the house anu I was watching the
caipentei with all his powei tools, saw anu uiill anu eveiything. Anu I iemembeieu
caipenteis way back because you coulu look anu tell if they'ie iight hanueu oi left
hanueu because the bicep just was way biggei. S0 I saiu to the caipentei, cmon
you'ie wimping out, with all those powei tools, the olu way you uon't have to go to
the gym to woik out eithei, he saiu to me Boc, the objective is to woik smaitei, not
haiuei. So I saiu you know what, you'ie completely iight. I was able to uo veiy goou
enuouontic tieatment befoie all this technological stuff, but it took me longei anu it
was haiuei, this has just maue life easiei. We will teach you how to use all of this in
the clinlc. The only thing you won't be using in pie-uoc clinics aie the micioscopes.
Which leaus me to something else I uo go off on tangents sometimes. Eveiy one of
you may go up anu visit the postgiauuate enuo clinic whenevei he oi she wants. If
you have fiee time anu think you may have an inteiest in enuouontics you can go to
the PB clinic, you can obseive, assist, you'ie welcome to uo it the stuuents up theie
I'm suie woulu love to have assistants helping out anu you'll get a lot of it. You'll
have a leg up in tieating the patients youiself because you'll see moie of what's
being uone. If you think you'll want to apply to postgiau enuo in the futuie it
ceitainly behooves you to uo it because we get a lot of applications foi people to the
piogiam anu if you have been up theie fiequently when youi application comes in
you'ie not just anothei name, we can put a face to the name anu see this peison hau
a lot of inteiest anu that's something I always wanna mention but sometimes foiget
to.

!"#$% G 0 (4 *2% *,,*2 $%3$ 3A*%+ <=>6
!"# %&'( ) veiy commonly askeu question by patients: if you uo the ioot canal is the
tooth ueau. What uo you think ueau oi alive. Its both! 0k. What aie we uoing. we
aie taking the pulp tissue out fiom within the tooth. Aftei ioot canal theiapy is uone,
aftei all the pulp tissue is iemoveu, the tooth will no longei be sensitive to
hotcolusweet aliight. Because theie is no pulp tissue in theie. Theie's also no
bloou supply to the insiue of the tooth that's why the tooth will become moie biittle.
Bowevei you still have the PBL going aiounu outsiue of the ioot. The PBL still
attaches the tooth to the bone. So the outsiue, exteiioi pait of the tooth still gets
nouiishment, you still have the sensitivity of peicussion. If you tap on the tooth bite
on the tooth chew on the tooth, you will still know the tooth is theie. Anothei basic
fact which is gonna happen in clinic. A patient I tieateu with a veiy goou ioot canal
theiapy anu eveiything looks gieat, eveiything was out, lets say it was an uppei
cential. Single canal, I know all the pulp tissue is only in the one canal aliight.
Patient comes back to me, uoc you know I still have a pioblem on that tooth. Patient
comes back in I say to the patient what's the pioblem, whats botheiing you. The
patient says eveiy time I have something hot oi colu I still have pain. I go whewww.
Why. I just tolu you the answei. It's not that tooth! 0k. 0nce the pulp tissue is out,
the tooth is no longei sensitive to hot oi colu oi sweet. That uoes not mean that the
tooth can't be sensitive to peicussion oi palpation. So the patient comes back anu
tells me that he oi she is sensitive to colu, I know that's a uiffeient tooth. If the
patient comes back anu says you know uoc eveiy time I push iight up above heie oi
I'm chewing oi biting it botheis me, now I'm woiiieu because now I know it can be
Tiansciibeu by Kyuun Lee '17

that tooth - it may not be, but now I know I have to check anu uo vaiious uiagnostic
tests to ueteimine if its that tooth oi not. So that's why when stuuents come to me
anu tell me the patient hau a ioot canal uone in the clinic anu theie's a pioblem with
that tooth it neeus an apicalectomy because the patient is still sensitive to colu, I'm a
little upset because you guys shoulu have the basic concept that it's not that tooth.
So when the patient asks you if the tooth is ueau oi alive you have to be able to give
that patient a piopei answei. Anu now you know the answei. 0k.

!"#$% H 0 @-"B3" $#4%34%4 0 I#*3" *%%*2
!"# %&'( ) Biffeient pulpal uiseases, uiff ieasons we uo the ioot canal tieatment.
These aie going to be teims that you'ie going to get on the exam, you'ie gonna get it
on oui exam anu national boaius which is why you have to know it. Bottom line
when you see a patient heie oi in school oi in youi office it's gonna be uoes youi
patient neeu ioot canal oi not, what's the pioblem. You'ie gonna have to know
these vaiious teims anu ieasons. Patient comes in with no symptoms,
asymptomatic, its noimal pulp aliight. Now one of the biggest aieas of confusion is
ueteimining the uiff between ieveisible anu iiieveisible pulpitis. Now something I
want you to all iealize is when you heai these teims pulpitis, whethei it be
ieveisible oi iiieveisible, -itis is inflammation you all know that. Pulppitis means
it's an inflammation of the pulp. Is it vital oi a non vital tooth. Well it says heie vital
that wasn't uifficult. So if the patient has a pulpitis it is a vital tooth. So now eveiy
time you uo something to the tooth it is an insult to the pulp. Sometimes it's enough
of an insult to the pulp that it causes inflammation, pulpitis, anu the tooth is gonna
be sensitive aliight. By uefinition, ieveisible pulpitis means that the inflammation,
the pulpitis will go away by itself in time. Eveiy time you guys uo a ueep iestoiation
oi any kinu of iestoiation, whethei you'ie uoing ciown piep oi whatevei, you
always wain the patient that you may have some sensitivity aftei. Anu explain to the
patient, because the pulp, the neives aie insulteu, so its not unusual foi you to have
a little bit of hypeisensitivity to theimali stimuli aftei the pioceuuie. It goes away
aftei a few uays. Bon't tell them the specific numbei of uays. Anu that's wheie the
confusion comes in, because if it's a typical ieveisible pulpitis fiom the pioceuuie
you've uone, the patient is moie sensitive to colu, not suipiising ok. What uo you
think the tieatment is foi ieveisible pulpitis. Tinctuie of time. Theie is no
tieatment. It's ieveisible, it's going to away by itself. Aliight so now we have a
symptomatic iiieveisible pulpitis. So now you've uone a pioceuuie, anu it was a
veiy ueep uecay, but it was not a pulpal exposuie. The patient hau sensitivity to hot
anu colu piioi to coming in, you take a look anu see this ueep uecay theie anu you'ie
not suipiiseu that theie's this sensitivity. 0f couise it's sensitive with that uecay
theie. So now you explain to the patient that I'm not suie if the uecay is going to the
pulp. If when I excavate anu clean out the uecay it goes into the pulp, then you'll
iequiie enuouontic theiapy. If it uoes not go into the pulp we'll place a iestoiation.
Naybe we'll place a tempoiaiy oi maybe we'll place a peimanent iestoiation. Anu
you tell the patient, that even though the pulp was not exposeu we uon't know if
you'll neeu a ioot canal; howevei since it was so close theie is still a possibility that
the pulp is iiieveisibly uamageu, which is enuouontic theiapy. So you place the
iestoiation anu the patient calls back saying that yes, I uo have that exaggeiateu
Tiansciibeu by Kyuun Lee '17

theimal sensitivity, now you have to ueteimine is it ieveisible oi iiieveisible. The
teim you'll see on exams. So now the patient comes in anu you put something colu
on the tooth anu it huits the patient. You iemove the stimulus anu the pain goes
away. That's usually inuicative of a ieveisible pulpitis. So I'm giving you the answei
to at least one test question ok. Pay attention. You put the colu on anu iemove the
stimulus anu the patient gets lingeiing pain, now the pain lingeis, that is a classic
symptom of an iiieveisible pulpitis. The big question is how long is lingeiing. I can't
give you specific numbei of seconus. But that's the teim you'll always see, the colu
oi theimal stimulus is put on anu the patient has lingeiing pain. Lingeiing pain is
inuicative of an iiieveisible pulpitis. What is the tieatment foi iiieveisible pulpitis.
Enuouontic theiapy. Iiieveisible - it's not going away by itself. The only way is by
iemoving the pulp tissue oi extiacting the tooth that's why we say enuo is to save
the tooth. Now you'ie going to get the vaiious opinions of what kinu of emeigency
tieatment is necessaiy when you have an iiieveisible pulpitis. When the patient hs
an iiieveisible pulpitis, one way to alleviate the pain is by initiating ioot canal
theiapy. The initial step of ioot canal theiapy is pulpotomy - iemoving the pulp
tissue fiom the chambei. By uefinition pulpotomy means iemoving pulp fiom the
chambei. Pulpectomy is iemoving all the pulp tissue fiom the entiie tooth. Luckily
I've been uoing this foi a lot of yeais, anu luckily pulpotomy is sufficient to alleviate
the patient's pain ok. We'ie in the office, you'ie backeu up in a successful piactice
with many patients scheuuleu, anu now you get a patient comes in in a lot of pain oi
in an emeigency. In piactice you wanna see that patient as quickly as possible anu
alleviate that patient's pain as quickly as possible. By just uoing a pulpotomy, by
iemoving all the pulp fiom the chambei, it will alleviate the pain. Nothing is 1uu%
successful, howevei this is close to it. You uo not have to uo a pulpectomy. You uo
not have to iemove all the pulp tissue. Now some people will aigue that. Theie is
nothing wiong with uoing a pulpectomy anu iemoving all the tissue, if you have the
time to uo that that's fine, but foi a lot of stuuents it's fine so thankfully I can get that
patient uone quickly anu can see all those patients in the waiting ioom that hau
scheuuleu appointments who won't be too annoyeu to be kept waiting. So the
initiation of the ioot canal theiapy will alleviate the pain of iiieveisible pulpitis. We
use gutta peicha to fill oi obtuiate the canal aftei this pioceuuie, it is useu last when
we obtuiate. So just by uoing the pulpotomy I am not close to completing that job,
because theie is still pulp tissue in the canals. I have uone a pulpotomy just to
alleviate pain. It is not a uefinitive pioceuuie on a peimanent tooth. You can uo it on
ueciuuous teeth as uefinitive pioceuuies when it's inuicateu, but it not a uefinitive
pioceuuie on a peimanent tooth. It is the fiist step in complete enuouontic theiapy.
All you have to uo is put a uiy cotton pellet in theie, I can put some Ca0B in theie if I
want, I uon't believe its completely necessaiy noi ceitainly is it haimful. So you put
youi cotton pellet in theie anu youi tempoiaiy iestoiative mateiial in theie. The
most common tempoiaiy iestoiative mateiial we use in enuouontic tieatment is
calleu Cavi-u. Sometimes we use IRN, but the most common one is Cavi-u. Cavi-u is
an excellent tempoiaiy filling mateiial foi sealing, anu stuuies have shown that it
seals bettei than IRN. The uiawback is that it is not as stiong as IRN. When I'm
tieating a patient, if the only access I have to uo is an occlusal opening, I will always
close it with Cavi-u. If theii pioximal wall is bioken uown anu I neeu a stiongei
Tiansciibeu by Kyuun Lee '17

contact, then I will use a stiongei mateiial like IRN oi piobably something like that.
Now again this is wheie I'm talking about wheie philosophies have evolveu. Because
I was in the piogiam heie, we weie taught that if we uiu pulpotomies on vital teeth
you woulu always put a little bit of eugenol on the cotton pellet. Because it's a
seuative anu you'ie still leaving pulp tissue in theie so it makes sense that you put
some on the pellet anu leave it in theie. It makes peifect sense but it's not necessaiy.
0k. I uiu that foi gou knows how long because that's how I was taught - it makes
sense - but now it tuins out that the uiy cotton pellet, it's the same thing. It's not the
eugenol that was ielieving the pain, it was the piocess of uoing the pulpotomy that
was ielieving the pain. It was also taught that insteau of using eugenol foi non-vital
teeth, we use foimacieosol (sp.). If you guys go to youi uentist's office oi whatevei
a lot of piacticing uentists now who have not kept up with the liteiatuie they will
still use the olu philosophies of eugenol anu foimacieosol. Foimacieosol has fallen
out of favoi because of the possibility of iiiitation, caicinogenic, etc. But the
meuication of choice now is calcium hyuioxiue. Aliight asymptomatic iiieveisible
pulpitis. 0nce again once it is iiieveisible pulpitis, by uefinition you have to uo the
enuouontic theiapy. So I talkeu about the symptomatic iiieveisible pulpitis, that's
the patient that comes in with a lot of pain, anything colu oi hot causes a lot of pain
anu it's a pulpitis anu they have to uo a ioot canal.
The asymptomatic, is the one who comes in anu uoesn't ieally have pain oi minimal
pain but has a laige caiious exposuie. So now youie excavating the uecay anu the
uecay went into the pulp anu because the uecay went into the pulp you have to uo
ioot canal theiapy. That's asymptomatic iiieveisible pulpitis ok.

!"#$% 'J 0 @%+#+3$#.-"3+ $#4%34%4E),) C#*3" *%%*2
!"# %&'( ) I'm not gonna go too much into the teims iight now anu the specifics.
These teims eithei way you'ie going to have to know the uefinitions of. I will senu to
the class a sheet which has all these teims, all the uefinitions. You must know the
uefinitions. I uon't ieally have to go ovei all of them iight now, I've uone some anu
I'll go ovei some biiefly. When you see the teims chionic anu asymptomatic they aie
synonymous. If it's not painful if its asymptomatic its chionic. If its acute, its
symptomatic, it means theie's pain. We uon't use the teim chionic heie like chionic
uisease. We use it as pain fie. Chionic apical abscess, theie's an abscess theie but
theie's no pain. The chionic apical abscess has a uiaining sinus tiact oi a fistula. The
acute apical abscess has swelling anu pain. So the chionic apical abscess, even
though it's an abscess filleu with pus, if you have a chionic apical abscess theie's no
pain because that fistulasinus tiact is an escape valve. The pus can uiain out of
theie so theie's no piessuie cieateu. Acute apical abscess you'ie going to have
swelling anu pain. Noimal apical tissue, pietty self explanatoiy. Conuensing osteitis
manifests itself iauiogiaphically as an opacity iathei than a iauiolucency. Stuuents
come to me anu I say is the tooth vital oi nonvital. Well again the -itis means
inflammation, pulpitis is vital. Is it vital oi nonvital. Anu the stuuent will say well
theie's pain so it has to be vital. So I say so you mean nonvital teeth cant have pain.
"I uunno." Well if you have an apical abscess why uo you have an apical abscess. The
tooth is neciotic, it's not vital, theie's going to be exquisite pain with an apical
(acute) abscess. You might see a question like this on the test also. Anu I just went
Tiansciibeu by Kyuun Lee '17

thiough asymptomatic iiieveisible pulpitis. Is eveiy vital tooth iequiiing
enuouontic theiapy painful. No. 0k. Aie some vital teeth iequiiing enuo theiapy
painful. Yes. Is theie a non vital tooth iequiiing enuouontic theiapy painful. No. Can
some non vital teeth iequiiing enuouontic theiapy be painful. Absolutely. (!
seiiously have no iuea what he was tiying to say, I think he misspoke.) veiy
impoitant concepts to have.

!"#$% '' 0 >:, A,+ K)%
!"# %&'( ) Actually I'm piobably gonna show you this in the next pait of the lectuie
also which is gonna be on enuouontic uiagnosis. What you see heie is I saiu theie
aie multiple ieasons to uo enuouontic theiapy. You see this iauiolucency heie ok,
this iauiolucency is inuicative of a chionic infection oi a chionic abscess. 0i an acute
abscess. Fiom the iauiogiaph you cant tell you have to see the symptoms of the
patient. Then you get ovei heie anu see a tooth bioken uown w caiies, piobably a
caiious exposuie which can mean a ioot canal, anu you'ie gonna piobably expose
because the tooth is so bioken uown, this is anothei scenaiio that we've talkeu
about, you can't iestoie this tooth because you'ie going to have to uo a ciown, but
you can't put a ciown on this tooth without uoing enuouontic theiapy. So again we
talkeu about some of the ieasons foi uoing enuouontic theiapy aliight.
So I was supposeu to black out the eyes, pietenu you uon't see the patient. You see
some swelling heie, this was fiom the pievious xiay. Aliight. Be was in a
tiemenuous amount of pain, this is an acute apical abscess. Be is in a tiemenuous
amount of pain. So the question is I tolu you that with an iiieveisible pulpitis you
initiate ioot canal theiapy aliight. So now you have this guy, the tooth is the cause of
the abscess is a non vital tooth. So it's a non vital tooth anu he has quite an infection
theie, the question is uo we have to put this patient on antibiotics to contiol this
infection piioi to initiating ioot canal theiapy to alleviate the pioblem. What uo you
think. You guys weie taught iight that if you have an infection like that that
anesthesia won't woik. You'ie gonna leain that in an infecteu aiea like that local
anesthesia uoesn't woik because the natuie of the aiea, the answei is no, theie aie
still some people that believe that you cannot initiate ioot canal theiapy when the
patient has an infection that is going on like this. It's absolutely wiong aliight. The
cause of the pioblem is the neciotic tissue anu the bacteiia associateu with the
infection, what you want to uo is iemove the cause of the pioblem so you initiate
ioot canal theiapy. So now this is wheie some people think that I'm a little stiange,
because I love seeing pus!

!"#$% '7 0 ( ",C% 4%%#); B-4
!"# %&'( ) I saiu I love seeing pus, I love pus. Why. I'm not suie you can tell what this
is heie - this is the pus coming out of the tooth. I openeu up that tooth anu pus
staiteu to poui out. Why uo I like it. Because I know I just gave that patient ielief.
Be hau pain fiom the piessuie built up fiom the infection anu pus. Bau I openeu up
that tooth anu hau no active uiainage, I uon't know if he woulu have hau ielief. Be
piobably woulun't have. Theie's also a pioceuuie calleu incision anu uiainage which
I uo a lectuie on in tieating emeigencies I will show you. But this was the iight
tieatment to open up the tooth to tiy to get uiainage. I know he's gonna feel bettei
Tiansciibeu by Kyuun Lee '17

because that pus is coming out. So I love seeing pus because I know I'm gonna be
successful anu this patient is gonna like me because I'm making him feel bettei.

!"#$% '9 0 (4 5)$, *2%+3B8 4-..%44A-"6
!"# %&'( ) Is enuouontic theiapy successful. 0f couise it is. You all have uiffeient
uefinitions of what is successful. Bowevei theie is a stuuy we enuouontists always
quote which is the Belta uental stuuy, which shows that the uefinition foi success
theie is that 8 yeais aftei the patient hau enuouontic theiapy, was the tooth still in
the mouth anu functioning. That was the ciiteiia anu uefinition foi success anu they
hau a 98% success iate. Theie aie othei uefinitions, some people will say even if the
tooth is in the mouth anu functioning, if theie's still a peiiapical aiea theie in the
patient's tooth of infection it is not a success, that's why I say theie aie uiffeient
uefinitions. But 98% success iate ok that's pietty uamn goou. Is enuo 1uu%
successful. Absolutely not. 0k. But a lot of times case selection is impoitant. You can
maybe be able to tell befoie you stait the piognosis foi the success ok. Aliight so

!"#$% '? 0 L%3"#); ,A M,)%
!"# %&'( ) What we'ie looking at heie, see the iauiolucent aiea theie. It's inuicative
of bone loss. That's why we see it that's what it means, theie's a RL aiea in the apical
aiea, one along the siue of the ioot, I uon't iemembei the exact timefiame, the ioot
canal is completeu, theie is complete bone fill. Can bone iegeneiate aftei enuouontic
theiapy. Absolutely it can. 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 anu fuication. You see calculus ovei heie. You
uon't know anu also what you see is an elevation of the tooth in the socket. Which ss
inteiesting because uown the ioau the tooth went iight back uown the socket anu
you have the same occlusal level iight. If the bone loss heie weie causeu by
peiiouontal pioblems, uoing ioot canal theiapy woulu uo nothing to iegeneiate the
bone. Bow uo we uiffeientiate if this is an enuo oi peiio pioblem. The best way to
uiffeientiate is with vitality testing. If this tooth weie vital all the bone loss woulu be
peiiouontal uisease. I uon't know if peiio tieatment woulu be successful to uo this,
but I wont go into that. But if the tooth was vital uoing ioot canal theiapy woulu
have no beaiing on iegeneiating the bone. Because the bone loss has nothing to uo
with an enuouontic ieason. If this tooth is nonvital, which this tooth was, by uoing
enuouontic theiapy anu iemoving all the bugs anu the schmutz in the canal, we may
have set up an enviionment foi healthy bone to iegeneiate anu fill in. Anu that's
exactly what happeneu. Next question is so now you guys aie uoing ioot canal,
we've ueteimineu that this tooth neeus enuouontic theiapy, youie in clinic anu
you've uone all the access anu cleaning anu shaping anu you'ie ieauy to obtuiate,
the patient is asymptomatic but you take an xiay anu still, a week oi two weeks latei
aftei you've initiateu the theiapy, you take a look anu still see the iauiolucent aiea
theie. You say can I 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. 0ntil you notice it iauiogiaphically that the bone is filleu in.
About 4-6 months! 0k. So that uoesn't mean because the aiea is still theie it uoesn't
Tiansciibeu by Kyuun Lee '17

mean that theie's still a pioblem. You've iemoveu the pioblem, you've uone youi
thoiough cleaning anu shaping anu 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 say that enuo is not 1uu% successful, when
we 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
wanna see the patient befoie then even though it may have somewhat filleu in
befoie then, I know by 6 months even if it's not completely filleu in theie shoulu be
significant change. So that's a veiy common question, can we complete the ioot
canal tieatment if it's still theie.

!"#$% 'D 0 12%) $,%4 3 *,,*2 )%%$ <=>6
!"# %&'( ) Lot of you aie being tolu how gieat implants aie. Its not woithwhile uoing
ioot canal theiapy anymoie, uon't bothei being enuouontists because ioot canals
aie gonna be a thing of the past because implants aie what's gonna be uone anu
theyie 1uu% successful. Beie's an implant with bone loss all aiounu heie, this is one
of the faculty who 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 this faculty many yeais ago is still theie. 0k so
case selection is veiy impoitant.

**SKIPPEB TBE LAST FEW SLIBES F0R S0NE REAS0N ANB N0vEB 0N.**

5NOKOKN>(= O(PQNK!(! R5=>S<5 T!"#$%4 :%+% ),* B,4*%$U

!"# %&'( ) Now in the pieclinical, I uon't know maybe you weie tolu maybe they saiu
the steps of enuo aie access, instiumentation, cleaning shaping anu obtuiation. Lot
of people think theie aie S basic steps. I completely uisagiee, the fiist anu most
impoitant step is uiagnosing the case. If you can't uiagnose it it uoesn't mean
anything. *Long stoiy about how a physician in Floiiua misuiagnoseu his fathei in
law. TLBR: uiagnose coiiectly please.
If you can't uiagnose it piopeily you cant tieat it piopeily. If you aie stupiu enough
to make a uefinitive uiagnosis anu tell people exactly what it is without having gone
thiough the piopei uiagnostic tests to come up with the piopei uiagnosis, then
you'ie making a big mistake. So that he uiu that was unconscionable, I embaiiasseu
him at the hospital in fiont of the nuises anu eveiything, he was veiy upset with me
but I coulu've caieu less. If you have any ielatives in Floiiua uon't go to Bi. Stephen
Noiiis. 0k so. You have to have a sequential step by step sequence to make youi
piopei uiagnosis aliight. Anu you want to make youi uiagnosis baseu on what you
know, not what you think. As I saiu when I was tolu my fathei in law hau lung cancei
fiom the things that hau been going on what showeu up on the xiays anu symptoms,
it wasn't a complete shock. It was wiong, but it wasn't a complete shock. So the
uiagnosis was maue on what he thought opposeu to what he knew. So what I'm
going to now is gonna tiy to go thiough some uefinitive steps to tiy to make
uefinitive uiagnoses baseu upon what you know. So now.

Tiansciibeu by Kyuun Lee '17

O#3;),4*#. @+,.%$-+%4
!"# %&'( ) Impoitant: Speak to youi patient. Ask peitinent questions. Stuuents come
to me all the time saying I have an emeigency patient. 0ne of the pioblems we have
in the clinic is that any patient that 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 came out. Then you'll heai an announcement in
clnic I neeu a stuuent foi an emeigency patient. Fiist thing I say is what's the
emeigency. I think a lot of pain is a valiu emeigency. If I have the ability to alleviate
someone's pain anu I can uo it, it's up to me to uo it. So theie's uiffeient levels of
pain anu youie going to see with uiffeient patients anu I've often saiu how uo you
uiffeientiate between soieness anu achiness anu pain. Lot of times its just
peiception of the inuiviuual peison whethei its soieness oi achiness oi pain ok. But
if someone has a lot of pain I feel its an emeigency we shoulu be able to take the
patient out of pain. Swelling can be an emeigency, but not eveiy swelling is. If it is
blocking the patient's aiiway theie's no question that it is. If you have a patient with
swelling that'll maybe, the eye will close, some pain, I guess I'll go along with that.
Bleeuing can be an emeigency. 0k. So those aie some of the things which I classify
as emeigencies. Some will say pain is not. So again I talk about builuing a piactice,
sometimes if I got a call at 2am fiom a patient in a tiemenuous amount of pain anu I
felt the patient hau alieauy taken some soit of analgesic 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
uiu that the patient woulu tell eveiybouy hat a gieat guy I was. So that's nice but
woulu get me nuts is when a patient calls me at 2am anu says they uiun't take
anything. Well take the uamn pill maybe we uon't have to go in anu I'll see you at 8
oclock in the moining. So peitinent questions. What's a peitinent question. Patient
comes in anu says I'm in pain. Patient sensitivity what's a peitinent question. What
aie you sensitive to. When you guys come up to me anu tell me the patient has
sensitivity the fiist thing I say is tell me what. Tell me what the patient is sensitive
to. I gave you the scenaiio of the pt that comes in aftei the ioot canal anu complains
about pain, I know if it's hotcolu it's a uiffeinet tooth. So what the patient is
sensitive to can be peitinent anu mean something. So you ask that, anu you think
about the answei. Anu you wanna ielate the answeis to the pioblem. You have to
ueteimine when the patient tells you what is botheiing him oi hei you then ueciue
which of the uiagnostic tests you have at youi ability you shoulu peifoim. Anu then
aftei you have peifoimeu the uiagnostic test anu you have gotten the iesult of youi
uiagnostic test, 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'ie a S
iu
yeai stuuent, you uon't have a lot of enuouontic iequiiements. In youi
S
iu
yeai you have two enuo iequiiements. By the time you finish S
iu
yeai you must
have completeu at least one ioot canal on a patient. Some uo 1u, to uo 1 is not a big
iequiiement. Then you have to fill out a uiagnostic case iepoit. This is basically
what we'ie going ovei touay. The patient comes in with a pioblem, uoc such anu
such huits me, I wanna see if you can figuie out what to uo to tiy to ueteimine what
the patient's pioblem is. To figuie out what uiagnostic test is appiopiiate, uo the test
anu come up with the iesults. I uon't even caie if you've ueciueu aftei uoing
eveiything that it's not an enuouontic pioblem. Not eveiy patient that comes in with
Tiansciibeu by Kyuun Lee '17

a pioblem is enuouontic. You have to wiite up this iepoit on papei, it's ieally pietty
simple. Anu that is what is going to be youi giaue foi the yeai. Bon't uo it half asseu,
uo it iight. But it uoesn't have to be an enuouontic patient. It uoesn't have to be an
enuouontic patient. You have to ueteimine what to uo to ueteimine what the
pioblem is.

O(PQNK!>(= >5!>!
!"# %&'( ) Rauiogiaphs - I'm at ouus with a lot of people heie with the ALARA anu
the lack of iauiogiaphs that they want you to take. Theie aie many cases wheie you
just uon't take enough anu you cant make a uefinitive uiagnosis oi make a tieatment
plan without a full set of xiays. Patient comes in anu you have to ueteimine what
iauiogiaphs to take anu wheie to take them. We'ie gonna go thiough each of these.
vitality testing I'll go thiough that. Peicussion, tiacing fistula, palpating, anesthesia,
anu test cavity I'll go thiough all of these.

128 ( P":384 *3V% 3 @P
!"# %&'( ) Patient comes in with a pioblem in his posteiioi iegion - I uon't want to
just take a PA, I want you to take a peiiapical anu a bitewing iauiogiaph. I leaineu
this fiom the veiy fiist enuouontist I woikeu foi anu he was completely iight. 0k PA
anu bitewing. Why. So this pt came in complaining of bau pain on the iight siue. You
take youi PA anu look at all that uecay - no biainei this tooth is the pioblem. As it
tuins out this tooth is so bombeu out that although I coulu uo enuouontic on this
tooth which woulu be iequiieu to ietain the tooth, it's pointless to uo it because
theie's no way it can be iestoieu. So that's anothei issue, a lot of times it's a question
of whethei I SB00LB uo the ioot canal. If the tooth cannot be iestoieu aftei theiapy
its pointless to uo it. So it's impoitant to think of that piioi to ioot canal theiapy
whethei the tooth can be iestoieu. Then I take a bitewing anu I'm not suie if you can
see fiom theie, but theie's extensive uecay. Theie's a tiemenuous amount of uecay
unuei the maigin of this ciown. Its veiy eviuent on the bitewing iauiogiaph you
cannot see it on the PA. The uiffeience when you take a PA anu bitewing they aie
uiffeient angulations anu uiff angles will show you stuff. I ve hau a lot of uentists
that uon't agiee with me till I show them this anu they say wow what a uiffeience.
That uoes not mean that eveiy time you take a bitewing you'ie going to see
something. Sometimes you'ie not going to. But you uon't know. Since you uon't
know what it's going to be you can always uo it.

W,+% P);"%4 L%"B
!"# %&'( ) I'm ielatively ceitain this peison has a heau. Fiom this angle you cant tell
but if you took a pic fiom a uiffeient angle you'u see a heau theie. So tiust me when
I say taking iauiogiaphs fiom uiffeient angles will show you uiffeient things.

I#*3"#*8 >%4*#);
!"# %&'( ) Lets look at vitality testing. If the pulp is ueau oi alive, the neive is ueau oi
alive. If you'ie uoing vitality testing, the ieason is to ueteimine pulp = ueaualive.
Not how ueau oi how alive, just ueau oi alive. The case I showeu you back theie
wheie I saiu you have to ueteimine whethei its peiio oi enuo, anu I saiu it's peiio
Tiansciibeu by Kyuun Lee '17

anu that bone woulu not have filleu in, what you wanteu to uo theie was vitality
testing to see if it was ueau oi alive. If the pulp was vital you know it's a peiio
pioblem, if it's not you know its enuo. So that's pulp testing. Theie;s a couple of
ways to pulp test- what I'm showing you heie is a pellet of cotton satuiateu in enuo
ice. We put it on the suiface of the tooth anu tell the patient, I've put something colu
on the tooth, tell me if you'ie awaie of the colu oi not. If the patient is awaie of the
colu it's vital, if not awaie it's non vital. This is an electiic pulp testei, piobably even
moie uefinitive than the enuo ice foi vitality - you put a little toothpaste on theie,
theie;s a giounu wiie you place on the patient, anu you ieally cant see heie but
theies a uial which incieases the electiic cuiient. You put it on the suiface of the
tooth anu tuin the uial up to inciease the cuiient, if the patient feels it the tooth is
vital, if the patient uoesn't feel it it's non vital. I use the colu test fiist since it's the
easiest, if I get a vital iesponse it's not necessaiy to uo the pulp test because I
alieauy know it's vital; if I get a non vital iesponse anu suspect that it may be vital
then what I'm going to uo is get the pulp testei anu uo that also. Anu if both of them
tell me the tooth is non vital then I believe it. But if the pulp testei tells me it's vital
then I'll go along with that.

<3$#,"-.%)* 3+%34
!"# %&'( ) I'm not suie if you'ie awaie of iauiogiaphs, what you'ie seeing on
iauiogiaphs. Right heie you see the white line on the tooth someone has uone enuo
theiapy. You weie taught that you want to get to within a millimetei of the apex, this
ioot canal theiapy was shoit. It uoesn't look veiy goou. Theie's a iauiolucent aiea
heie. This ioot canal was uone by a geneial uentist. Now theies a iauiolucent aiea in
the apices of this molai, anu a veiy laige iestoiation. These x-iays people in my
geneiation typically these aie what the iauiogiaphs all look like, tiemenuous
iestoiations befoie fluoiiue when we hau a lot of uecay anu a lot of fillings. Ny kius
anu piobably most of you wont see this as much. But any time theie's a laige
iestoiation oi a ciown, theie's a potential foi that tooth to ultimately neeu ioot
canal theiapy. Take a look at this anu see the iauiolucent aieas theie, laige
iestoiations, kinu of a no biainei. The tooth must be ueau, non vital because of the
peiiapical pathology heie, anu theie is iationale anu ieason foi the ioot canal. So the
geneial uentist that uiu this ioot canal anu saw the aiea foiming saiu ah, I bettei
senu this to the enuouontist because the one I uiu is failing anu this is much moie
uifficult. So the enuo goes in, not suie if he uiu vitality testing befoiehanu, if he uiu
he knew theie was something wiong, he went in anu openeu it up anu founu that
theie was vital tissue in this tooth, the pulp was vital, so he says theie's something
going on. These iauiolucent aieas, if they aie peiiapical pathologies, these
pathologies only come fiom a non vital tooth. Although these exactly mimic PA
pathologies iight at the apices, iight wheie you'u finu it, because the tooth is vital
theie's something wiong. So he uiu a veiy nice job completing the ioot canal
theiapy, but because he knew theie was something not koshei going on heie he sent
the patient to an oial suigeon to uo an apical biopsy of the tissue. Came back as
metastatic bieast cancei. I uefy anyone looking at that xiay with those iauiolucent
aieas theie anu that iestoiation, to make the uiffeiential uiagnosis that that is going
to be bieast cancei iathei than peiiapical pathology. It fits eveiything except foi the
Tiansciibeu by Kyuun Lee '17

fact that the tooth is vital. So uoing the vitality test befoie initiating the ioot canal
theiapy you woulu know that theie's something going on anu you have to go
fuithei. 0ne thing I uiun't tell you that I shoulu've anu no one askeu me about it. You
know what the most common canceis that metastasize to the jaw aie. Nost aie not
piimaiy. What aie the most common aieas that metastasize to the jaw. Bieast anu
piostate. Tuins out this woman hau hau a histoiy of bieast cancei befoie. Knowing
the histoiy of the cancei anu that the tooth was vital shoulu have put the woiiy in
the piactitionei's heau that it might be metastatic. Typically if it's metastasizeu to
that point it's not going to be goou.

@%+.-44#,)
!"# %&'( ) Peicussion testing - it is anothei mouality, so now again you ask peitinent
questions. Patient comes in anu I get this with stuuents all the time, the patient came
in complaining about hot anu colu, so they peicuss the teeth; so I say well is the
patient's complaint chewing oi biting. "No but I peicusseu it anyway." I have no
pioblem with you peicussing the teeth, but iealize that is not the patient's
complaint. The patient's complaint is theimal sensitivity, test it with that stimulus. If
the patient comes in saying that eveiytime I bite uown oi chew it huits, then the
peicussion is a significant test, ok. If 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 foi
any of a numbei of ieasons. It may be an enuo ieason. It may be a piece of foou stuck
in the teeth causing an iiiitation. Peicussion sensitivity is a helpful anu fiequent
way of ueteimining if that is offenuing a tooth. But it is not a test of vitality. The way
I test peicussion, also I saiu you will see when you stait to tieat patients, you'll stait
to see some patients come in they sit in the chaii anu say aliight uo whatevei you
have to uo. Then theies the patient that comes in neivous about any pioceuuie, anu
if you uo this to the patient he oi she will piobably choke. You want valiu ieauings of
youi uiagnostic tests, so that veiy yneivous patient, when any of you have evei
maue anybouy peicuss youi teeth with the miiioi hanule, it's not a veiy pleasant
situation. S0 if you'ie looking to see which tooth is the offenuing tooth foi
peicussion, you shoulu have an iuea, the pt is going to tell you what aiea is
botheiing him oi hei so you stait the peicussion in an aiea away fiom wheie you
think the pioblem's going to be. Because you want the patient to have the noimal
sensation of what it feels like - "no that's not wheie it is, we'll get to it." So you stait
a few teeth away anu uon't peicuss haiu, because some teeth aie exquisitely painful
to peicussion anu the slightest tap can be painful. So you uon't ieally have to bang
the teeth to elicit the pioblem. So you stait a few teeth away, lightly, anu move uown
to see which is the offenuing tooth. This is not the uiagnosis, it gives you an iuea of
which is the offenuing tooth anu you go fiom theie.

@3"B3*#,)
!"# %&'( ) Palpation is you take a fingei anu you move it along up the gingiva to see
wheie its tenuei. Say again with peicussion you uon't stait exactly wheie you think
the pioblem is, typically if theie's swelling anu you palpate it its veiy common that
the swelling will extenu ovei moie than one tooth anu it can be tenuei to one tooth
Tiansciibeu by Kyuun Lee '17

away fiom the tooth attacheu to the cause of the pioblem. So as you move youi
fingei along anu the pt staits to feel it, also foi the palpation typically if its an
enuouontic pioblem they aie manifesteu in the apical aiea. If the pioblem is the
tenueiness of the palpation with an enuo oiigin it is usually in the apical aiea.
Estimate how fai up the ioot woulu go anu if its at the apical aiea of the ioot is an
enuouontic pioblem. If its moie along the maiginal gingiva, it's piobably a
peiiouontal pioblem aliight.

L%3*
!"# %&'( ) Sometimes eveiy once in a while they talk about the iiieveisible pulpitis,
most often the pioblem is sensitivity to colu. Eveiy time I have something colu it
huits, again not eveiy sensitivity to colu is iiieveisible pulpitis oi ioot canal but you
have to figuie out anu see what it is. Now I come into the opeiatoiy anu not eveiy pt
comes into the office with a consultation neeuing ioot canal. The two types of
patients aie the ones in exquisite pain that get anesthetizeu, anu the othei is the
kinu that gets a uiagnostic test anu uoesn't neeu a ioot canal. That thiills them. But I
come in the opeiatoiy anu the patient is sitting theie holuing a bottle of ice watei. I
know this pt is going to neeu enuo theiapy, because the ieason he oi she has that ice
watei is because he oi she gets spontaneous pain anu when he oi she puts colu on it
it goes away. So spontaneous oi any kinu of heat will cause pain. Bot foou exquisite
pain, anu putting colu on it goes away. It is anothei foim of iiieveisible pulpitis, the
most common is sensitivity to colu but in this one colu will ielieve the pain. So now I
come in anu see the ice watei anu know he's gonna neeu ioot canal, uon't know
what tooth it is but I know anything hot will cause pain. So what I uo is I test it with
something hot. What you have heie is a stick of gutta peicha which I have put a
flame on, anu the flame cuils the gutta peicha quickly anu it has a little ball theie,
you heat that up anu it caiiies the heat a lot anu you put it on the vaiious teeth.
When you get to the one causing the pioblem the patient has pain tiemenuously,
anu you have youi S-way syiinge ieauy because as soon as the pt expeiiences pain if
you spiay it with watei it goes away immeuiately. Know that that is the tooth
causing the pioblem. Anothei way is to just take one of the instiuments amenable to
being heateu, heat that up anu touch it to uiffeient teeth. 0k.

>:, !*,X34 @+%4%)*
!"# %&'( ) Stoma is significant with the woiu fistula ok, fistula is the olu teim, stoma
is now. You'll heai them useu synonymously. It is a uiaining tiact leauing fiom the
site of infection, buiiowing thiough the bone anu gum, anu uiainage goes thiough
theie anu theie is no pain. You'll eithei call it a fistula with a stoma oi a sinus tiact
w a uiaining stoma. I just explaineu to you what it is, it's a tiact going fiom site of
infection. You uon't always know wheie its coming fiom. Whenevei you see a sinus
tiact what you shoulu uo is tiace it. We tiace it by putting gutta peicha in theie. We
take a stick of gutta peicha anu stick it in the opening, as fai as you can go, anu that
is the site of infection it'll stop. Theie'll be iesistance. No iesistance till you get theie.
0nce you have the gutta peicha in place you then you take a iauiogiaph to see
exactly wheie it goes to anu that will tell you wheie the souice of the infection is
coming fiom anu what you have to uo. This one is unusual because theie aie two
Tiansciibeu by Kyuun Lee '17

openings, two stomata, so I tiace them both anu I uon't know wheie they aie going
to. Tuins out typically when you see wheie it's going to that can tell you wheie the
cause is. Typically if its an enuouontic pioblem the gutta peicha will go iight to the
apex of the ioot. If it goes to the apex its an enuouontic pioblem, if it goes
somewheie else it coulu be a peiio pioblem. Not suie if youie awaie of what's going
on heie but this gutta peicha, uo you know what these aie. These aie ciowns. Xiays
aie a measuie of uensity anu thickness. The thickei something is the whitei it is, the
thinnei it is the uaikei it shows up on iauiogiaphs. When you see that aiea, we see a
iauiolucent aiea of infection, the ieason the patient says I have a black uot theie
what uoes that mean. You explain to the pt what iauiogiaphs aie, anu that its
thinnei theie because bone has been uestioyeu. Anu that's why its showing up uaik.
So these aie ciowns, that white aiea in the ioot of the tooth is not gutta peicha,
because it's too opaque, it's metallic. It is a post. When you see the gutta peicha
going iight up to the siue of the post, you know that it is a ioot fiactuie. 0k. When
you have a veitical ioot fiactuie, the tooth is hopeless it must be extiacteu. So piioi
to tiacing the gutta peicha, I coulu have assumeu that it was going iight to the apex
heie, so hau I not tiaceu it with the gutta peicha I woulu not have known that the
pioblem was at the post, I woulu have thought it was at the apex. Now I know that
the tooth is hopeless.

5Y*%+)3" Z#4*-"3
!"# %&'( ) 0k exteinal fistulasinus tiact. You can get that also. Beie this was on the
outsiue of a woman's cheek ok. Bon't know wheie it's coming fiom. Put a piece of
gutta peicha iight into the sinus tiactstoma on the woman's cheek, went iight to
the lateial aspect of this molai. 0k. Testeu the molai, vitality testeu it, the molai was
non vital, we knew the souice of this out on the cheek was the ueau tissue insiue this
tooth. Bau an aigument with an oial suigeon, saiu that when you hau that the only
way to get iiu of it was by extiacting the tooth. I saiu what aie you talking about, if it
was vital it's a uiffeient stoiy but since it's non vital you know that the entiie cause
of this whole sinus tiactinfection is the neciotic tissue in the tooth, by uoing the
ioot canal theiapy you will cleai up the pioblem. Be saiu no you have to extiact the
tooth.

Z#4*-"3 L%3"%$
!"# %&'( ) Well ioot canal theiapy was uone, anu it closeu up. A lot of what we uo, a
lot of uiagnosis is common sense. You have to have the basic knowleuge, if you apply
it, I say this to stuuents all the time I ask them questions anu the questions I aks
them aie a lot of times stiaight fiom this anu the next lectuie; they look at me anu
talk anu think it out anu I say 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 put it
togethei piopeily you'ie gonna come up with the piopei uiagnosis but you have to
stop anu think.

@%+#, P[4.%44
!"# %&'( ) 0k swelling iight anu a stoma iight heie, this is a peiio abscess. Again I
saiu to you befoie if the palpation is the apical aiea its usually enuouontic, if its up
Tiansciibeu by Kyuun Lee '17

highei in maiginal iegions it's piobably a peiio abscess. If theie's a ciown on the
tooth its uifficult to uo a pulp test to uiffeientiate. No ciown on the tooth, I uo a
vitality test anu its vital, I know it's a peiio abscess not an enuo. Beie if I put a gutta
peicha in heie it woulu not have gone to the apex, it woulu have gone iight to the
fuication aiea so I know it's peiio.

@#.*-+% ,A ;-8 :#*2 2,++#["% 2%+B%4 \,4*%+
!"# %&'( ) 0k so this guy came into the metiopolitan hospital anu saiu he was having
an alleigic ieaction. Be hau pain, toothache, anu he put Ambisol on the aiea last
night anu it blew up like this so it's an alleigic ieaction. It's not an alleigic ieaction,
uoes anyone know what it is. Not eveiy patient comes in with a uental pioblem you
have to know the uiagnostics; as long as you have gone thiough the piopei
uiagnostic tests. This was heipes zostei.