Root Canal Politics?

This article about root canal politics captured my interest, http://www.nytimes.com/2010/05/09/opinion/09friedman.html

What is root canal politics? According to the editor-in-chief of the Economist, the British election may be the first Western election "based on pain". Apparently, politics in the West will take away benefits this time, instead of giving things away to the voters. Oooch, that's PAINFUL.

A misconception about root canal treatment (RCT).

We usually associate pain with RCT. I think this misconception was created because most patients who need RCT are already experiencing some kind of toothache. It is not true that RCT is painful. The root canal actually eases the pain. Perhaps, some patients may have experienced a painful RCT and afraid to go through the ordeal again. My advice is you should always let your dentist know that the tooth is still hurting during treatment. Do not suffer in silence!

Usually, I will numb the affected tooth and surrounding area before RCT is carried out and the procedure is quite painless. When the patient do feel pain, I will give another anaesthetic injection and if all attempts fail, it is best to place a medication or temporary dressing on the tooth to let the pulp settles and continue treatment in another appointment. When the numb effect wears off, I always warn my patients that some pain may set in. I routinely prescribe a painkiller after the treatment but some of my patients said that they don't need it at all.

I think with the advancement in medical science and dental technology, RCT is not as painful as it just to be. If you need one, you have to have it. Just like root canal politics, no more tooth fairy!

Tell me your pain...

Most Malaysian adults do not go for their regular dental check-up and visit the dentist only when they have dental problems. When patients who are in severe pain come to me, I will usually detect dental conditions that are serious, for example a tooth with deep cavity and extensive decay, and this leads to expensive dental treatment, possibly a root canal treatment in this case, that if the tooth is still restorable. Otherwise, it need to be removed or extracted.

When a patient with toothache walks into my office, I will pose a series of questions to the patient and spend the next fifteen minutes at least talking about his or her pain before examining the oral cavity. Ever wonder why your dentist have to ask you so many questions and waste your time? Let me explain, these answers will help me arrive to a diagnosis or conclusion to the dental problem.

Take an example, if a patient complains of toothache, it is important that I know:

Characteristics of pain

Duration and intensity of pain

Methods that relieve pain

Associated swelling or discharge

Nerve fibers, which produce pain sensation, are within the pulp of tooth. This history taking will assist in assessing pulpal or nerve condition of the diseased tooth. Based on what the patient is telling me, I will have an idea of what the pulp status is. Some pulpal conditions are reversible, others are when nerve tissues are permanent damaged.

Pulpal pain has a wide range of experiences. It may range from a slightly increased in sensitiveness or hypersensitivity, pain triggered by cold or hot food to severe and intense pain that disturbs your sleep. At a later stage, pain elicited by chewing and touching the associated jaw area means that inflammation has extended to the roots and supporting tissues of the tooth with pulpal disease.

Of course, after all the talking, I will do a complete oral examination before telling the patient what his dental problem is. In conclusion, a good dentist is a good listener.

Dental Clinic Website

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Working with a Dental Dam

I routinely apply rubber dams in all root canal procedures. It is a piece of rubber sheet that isolates the tooth that I'm working on and it is kept in position with a clamp. The advantages of using the dental dam include:

I get a better view of my working area.

Root canal treatment is all about infection control and bacterial elimination. Hence, the rubber dam gives complete isolation of the tooth and removes contamination from saliva and the oral cavity.

Protects the patient from swallowing or inhalation of a root canal file or instrument. There have been case reports of these occurrences!

Most patients feel more comfortable when treatment is carried out with a rubber dam. Irrigating solution or medication used during root canal treatment will not leak into the oral cavity. The irrigating solution is toxic to soft tissues (gums and mucosa). There is also no need for the patient to sit up and rinse during treatment.

The rubber dam is easy to apply and it is usually placed at the beginning of root canal treatment after the local anaesthetic is administered. Patients who are allergic to rubber can opt for the latex-free dental dam.

Missing teeth

We have two sets of teeth. Primary dentition consists of 20 teeth and secondary or permanent dentition 32 teeth. The roots of primary teeth will usually dissolve or resorb between the age of 6 to 14, to allow these teeth to drop off and new teeth to come up.

I have encountered cases where the patients have congenitally missing teeth. The medical term for this condition is called 'hypodontia'. The common teeth that are missing in the permanent dentition are upper lateral incisors and lower second premolars. Sometimes their primary/deciduous teeth still remain in the jaws. The patient usually is not aware that the tooth has not been replaced by a permanent one, unless being told by his or her dentist during a routine check-up. I usually confirmed this occurence by taking a radiograph.

There are also cases where the patients complain of toothache due to large decay on these teeth. Sometimes, I perform a root canal treament, provided the root are not resorbed, in order to keep the tooth functioning in the oral cavity for as long as possible, especially for a young patient. However, the prognosis maybe be guarded. It is also possible that the retained primary tooth is fused to the jaw bone (ankylosed). I supposed one will just have to accept the fact that he or she is born with less teeth and ultimately, will need dental implants.

My Friday morning routine

I have been teaching dental students at the Dental Faculty, Universiti Kebangsaan Malaysia, for the past eight years. This is the place where students are trained to become one of us, the dentists.

I supervise them in the Restorative clinic. This clinic is in a large room with about twenty cubicles. Each cubicle has a dental chair. Dental treatment here is free and is open to public. A registered patient will be treated by dental students, who usually work in pairs. Most of the Year Four students are good and eager to learn. They remind me of my dental student's days. This is the time when you feel like a 'sponge' and you are required to absorb as much knowledge as your brain can take. Glad that this chapter of my life have ended. My duty is to guide them and check their work, step by step. I always tell my students that it is better to make a mistake here in dental school than when they are out on their own because they can learn from their mistake and I will be there to help and rectify it. That's the purpose of supervision.

Eight years is a long time. Perhaps, I should tell the Deputy Dean, who is a good friend of mine that it is time for me to close this chapter of my life too....

X-ray Vision

As a dentist, I sometimes wish I have X-ray vision so that I can see through those teeth and jaws...

Radiography is essential in dental practice. Radiographs are useful in detecting tooth decay during a routine dental check-up, especially decay under an old filling (secondary caries) and decay in between teeth (interproximal caries). It is better to detect interproximal cavities early to avoid a more complex and expensive dental treatment when decay becomes large. Some of these cavities are consealed and difficult to detect by just doing an intraoral examination. After explaining this to my patients, they usually agree to do the radiographic examination. Most dental procedures require taking radiographs. For each root canal treatment, at least three radiographs are required.

Many are concerned about ionizing radiation from the dental X-ray. X-ray machines nowadays are more sophisticated. I assure my patients that the radiation dosage is very low, which is 1-8 microSv for an intraoral radiograph (Bitewing/Periapical). We are exposed to more radiation from natural sources everyday, for example, cosmic ray, gamma radiation, foodstuff etc. To put you in perspective, the average annual dose of radiation from cosmic rays and gamma radiation are 300microSv and 400microSv, respectively.

X-ray facilites in private dental clinics are regulated by The Ministry of Health , with specific guidelines, for example, minimum size of the X-ray or treatment room and lead-lined walls of the room, to ensure safety radiation.