From the entire Protrusive Community – we wish Sanj a speedy recovery – keep smiling Sanj and stay strong!
In the previous episode with Sanj Bhanderi on ‘how to extirpate properly and efficiently‘, we briefly touched on postoperative pain control. In this episode, we’re focusing more on postoperative pain and the dreaded severe pain after the obturation appointment (or in-between visits).
Highlight of this episode:
- 2:27 Post-op pain after endodontic treatment
- 7:43 Flare-ups
- 9:46 Guidelines in antibiotic microbial management
- 11:03 Flare up in between visits (RCT has not been finished yet)
- 13:40 Crown Down approach
If you enjoyed this, you might also like my episode with another talented Endodontist, Dr Ammar Al-Hourani, on Is Single Point Obturation Acceptable?
Click below for full episode transcript:Opening Snippet: I wanted to start this podcast with a get well soon message for our guest, Dr. Sanj Bhanderi who did such a brilliant job with our last group function on how to extirpate quickly and properly. Now, unfortunately, after we recorded that episode, and after we recorded this one, Sanj felt acutely unwell. It was actually scary hearing the news of him being ill. But I'm getting some positive updates. And so we the Protrusive Dental Community, and then all dentists around the world. We wish Sanj a speedy recovery. We hope you get well soon. We're so glad you're okay and on the mend. And we want to pass on these wishes to you. It's been quite clear on social media, what a likable guy you are, and how much we all want you to make a speedy recovery mate. So wishing you all the best and get well soon from Team protrusive.
I bet this scenario sounds very familiar to you imagine you’re on a course you having a great time. I personally love courses, I think you all know that. You’re on your fifth coffee, and everything’s going great. And suddenly your pocket starts vibrating. You’ve got a call from the practice or text message informing receptionist saying that, ‘Mrs. Smith, you know, the root canal that you saw yesterday, she’s in absolute agony.’ And you curse because you think wow, you know, that was a completely straightforward root canal procedure. The patient was asymptomatic before you even started. Why is this happening for me? Look, post-op pain after endodontics is an absolute bitch. It’s one of those annoying things ever actually puts me off doing root canal treatment because of the one in harmony of a chance that post op pain instance is going to happen. And I’m going to discuss with Sanj Bhanderi who does such a brilliant job in that GF016, where we talk about how to extirpate properly and efficiently. So if you haven’t listened to that one, oh my goodness, you are in for a treat. Go back and listen to that one. But in this episode, we’re focusing more on post op pain like how do you manage that kind of scenario? What do you say to the patient? How can you prevent this from even happening in the first place? You know, it’s funny I’ve actually had four root canals on my own self and before you think, ‘Oh, Jaz is disgusting, you got caries, etc.’ No, it’s actually trauma from orthodontics. Can you believe it? Orthodontics devitalize, my lower four incisors, and I’ve had all sorts of issues and root canals and fractures, etc, etc. And now have a resin bonded zirconia bridge, hence why I’m so passionate about those bridges. Anyway, I experienced post op pain myself, it was a nasty thing. It was lots of inflammation. And so I’ve been there and I totally empathize with my patients. Before we joined the main episode I want to say yesterday I released new tickets to Finlay Sutton’s mass class. So Finlay Sutton, he travels all around the world. He’s in USA last week. He goes Scandinavia a lot. He teaches us everywhere. If you think removable prosthetics you think Finlay Sutton. He’s just a phenomenal educator and the best in the space when it comes to removal pros. Now he came on for episode 56. How to make Chrome dentures easier. So check that one out if you haven’t already either. But he’s doing a live one day partial dentures maths class on Saturday, the 14th of January 2023. So if you’d like to join us go to protrusive.co.uk/finlay, that’s F-I-N-L-A-Y. It’s limited to just 12 delegates only. And it’s very rare chance to see him down south usually have to go to practice up north, or you have to go abroad. So this is very rarely comes south. And so if you’d like to join us, including the dinner, the night before, it’d be great to have you. So once again, the link is protrusive.co.uk/finlay. And there’s also a payment plan to split your payment into three if you need that.
Anyway, let’s join the main episode.
I recently created a gentleman I talked about this gentleman on the podcast necrotic canine very strange, severe bruxists, I think I suspect some airway issues we’re investigating at the moment, like to the extent that 50% of his canine is just shot. That canine was dark in color. My dentist who I inherited his list has been putting his, he’s had a couple of bouts of antibiotics in the past for this tooth, and he just felt he’s too young. He’s late 20s To have a root canal on a canine and he just couldn’t figure out why it went necrotic but it did. I tested everything. It was necrotic I went inside his canine. It was necrotic, it was infected. So I confirmed that, and then I did a root filling. And my goodness, and I’d followed all the right protocols hypochloride, gutta-percha, everything was done, took a high standard radiograph look good. There was no extrusion of the GP or anything. But my goodness was this chap in so much pain, and he ended up in a&e. They did some bloods on them. They didn’t find any sepsis, but they found high inflammatory markers in his blood is actually interesting enough. So that was my one really bad experience about four months ago. Otherwise, I don’t tend to get significant post op pain. But I’ve been with dentists at conferences and we’ve been at a conference on a course and the dentist nips at 11am because there was a root canal heated yesterday, the patient’s now in agony after finishing the root canal. What do we know in terms of Iiterature? You’re probably there lecturing and speaking your phone were vibrating. Mrs. Smith from yesterday? What is behind that? What causes that? Even in your expert hands, is it just bad luck? Or do you, do we know what causes it and then therefore, what steps can we take to minimize its occurrence?[Sanj]
I think it’s quite multifactorial, some of it is, it is unpredictable. There are certain conditions that seem to predispose patients having what’s called a flare up of flare up by definition, the endodontic definition of flare up is this is in between treatment after treatment of treatments been performed, and the patient gets acute pain that requires treatments they have to attend to. That’s the definition of a flare up. There are a few things that I suppose we break down to patient factors, which are we told the anxiety levels we’re talking about. There are some certain genetic factors, some patients are more predisposed to pain, period. And definitely there’s a- [Jaz]
yes, yes, absolutely. We know that from TMD, chronic back pain, the study of pain itself is we know that people are much more susceptible pain than others. Yeah, yeah. [Sanj]
So on those physicals patients, and also talked about this symptomology, it’s patient management, if you pre-warm them, it doesn’t mean that there’s not gonna be out of pain, but they can handle it, it’s when they’re not expecting their pain. That’s when it the problem started in the, you know, just increases anxiety. And so it’s been a patient management and those patients who you’re going to kind of arm bells, these patients are a bit tricky. Or if you’ve seen patients before previous treatment, they’ve always taken the two second ages to settle down or even root. So that’s the first thing in terms of the actual tooth itself. It’s the inflammatory state of the two. So pre existing lesions, if there’s an apical lesion, radiographic lesion, those teeth are more susceptible for post operative or interrupted pain. Okay, so for me, the before the endodontic treatments, we always preload our patients with anti inflammatories, not just emergencies, but routine root canals, and especially retreatment. And especially if there’s a lesion already on the tooth. We know that they’re more predisposed to flare up. So, just preload them anyway, with anti inflammatories or painkillers. And then during the procedure, you’re going to do utmost to follow what we now call is everyone knows a crown down protocol, you do not want an necrotic case, the whole majority of that canal space is going to be infected. Often, it’s actually not the apical tissues are actually not infected. Just because there’s an apical lesion that apical lesion unless there’s an abscess, or separation, it’s not infected. It’s just the inflammatory process, we need to remember that. Because the last thing you want to do is put bugs into the apical area or even worse through and it can happen easily, I do. I’m sure one of the main reasons you get a flare up is because we’ve inadvertently push biofilms through, it happened some time. So we’re just gonna do our utmost to go down, Crown down. And so as you as you do that, part of the reason for that approach is you’re flushing out bacteria progressively without with minimal risk of pushing it ahead of the instruments. This is one reason going back to emergency treatment, you don’t fish around the root canals because if the canal happens to be necrotic, in that module, two of them are flying the other one and he shoved bacteria further down, you’re going to inoculate areas which weren’t actually infected. So that’s another reason not to fish around the root canal going back to the emergent situation. So this, in this situation, when it’s necrotic, that canine, you do your utmost just to work your way down. Now some endodontists, traditional endodontist, say you should be dressing all those cases, you don’t do those in one visit. That’s another area just decrease the bacterial load because calcium hydroxide. That’s the evidence suggests it’s probably doesn’t matter. He can do those in one visit. But there is the evidence for one visit. [Jaz]
That reminds me actually that yeah, I think we’re coming to the same point. I believe there was a systematic review comparing one visit, two visit, and they found that they’re both equally successful, but you might get more flare ups and one was it is that where you’re gonna come to the [Sanj]
Post-operative pain may flare up beat the patient, they will get more post operative pain that is [Jaz]
post op pain. Yeah, that’s what I mean. So yeah. [Sanj]
Flare ups a different situation. There’s also the patient factors in terms of their immune response. Everyone’s different, we’re dealing with immune responses, which are we can’t control apart from maybe anti inflammatories. And I think the body, when this happens, again, this happens in, they’ve got lesions, apical lesions, there’s an inflammatory process been going on for a long, long time, the patient has been asymptomatic. The body’s kind of, in simple terms, the way I explained to the patients, the body’s got to use to having an infection in the tooth, and it’s reacting slowly. Sometimes when we go in, it may not being that we’ve pushed every through, we’ve changed the balance, whether it’s pressure, whether it’s something else has changed. And we just disrupt that. And it’s a short term reaction they’re going to get I gotta warn them, when there’s a big you know, radiolucent area. You think these, these are cases they’re gonna kick off with doesn’t matter what how well you do the endo is going to kick off. I pre warn those patients. There’s a chance this is going to kick off. Okay? So it’s patient management, and if it does kick off, then you can deal with that. But it’s the fact that they know about it, they often won’t bother contacting you. They’ll say I just took anti inflammatories you see them on the second visit, visit to visit and thing was fine. It was settled down. So there are those situations you are- [Jaz]
Now, Sanj you speak to your patients afterwards. You warn them big time, you document it, and you still have that you know you’re teaching at a conference and your your phone is buzzing. And you speak to Miss Smith from yesterday who had that feeling finally finished, and then she’s experiencing post op pain. Now, the temptation, oh my goodness, the temptation is so much for her to come in and then to do something and use that something is his amoxicillin 500 mg, or something like that. And that temptation is there and I don’t cave in. And that time he ended up in hospital and the hospital doctors gave him antibiotics. He got better, eventually. Okay, but do I honestly think it was due to antibiotics? I think he would have got better anyway due to inflammation is what because they found no microbials in his body. They found a high inflammatory marker in this particular instance, how should we manage it? Is it okay just to say ‘Look, don’t worry, you’ll be fine. Give it time’. Or is there ever a situation where antibiotics is justified? [Sanj]
I think in antibiotic- [Jaz]
and post op pain. [Jaz]
Yeah, I mean, with the current guidelines and antibiotic microbial management, whether it’s nice or whether it’s endodontic European whatever. I think, if you start with a systemic involvement, now it’s again you got to be practical about this. If they’ve got, there’s an abscess like you say, fluctuation swelling can be cellulitis kind of symptoms. You know, this is not just localized. An apical periodontitis kicking off there’s definitely soft tissue involvement. Then I think, in the short term, even a short course of an antibiotic with anti inflammatories dosed up, I think that’s justified. If there’s no obvious signs of an abscess, cellulitis spreading infection, then you know, it is high dose and painkillers with or without codeine, if you know if it’s affecting the sleep, something like dihydrocodeine, DF 118, something like that, just to get them through that pain. And hopefully it’ll calm down. It is a tricky one, though, because it’s a nice, there’s a theory [Jaz]
It’s so tricky. [Sanj]
When you’re in practice, and you’ve got the patient there, but you shouldn’t really throw them antibiotics, you’ve got to have good justification for doing it. If there’s a fluctuation swelling, incise it, free the area, incise it. If you haven’t finished the endo open the tooth up. In terms of leaving open drainage 24 to 48 hours, you can leave on open drainage just to relieve that pressure, but you’ve got to go back and get them back in. Okay, go back and try and get some drains, so it’s back to surgical. [Jaz]
Now in those scenarios, let’s say we we are in between visits. And let’s say we’ve done our crown down protocol where we’ve got the canals as clean as we can and we aim to obturate at the next visit. And it’s in between that initial cleaning of the canals and actually obturating the patient comes up with a flare up in between those two visits. So you’re not quite ready to obturate because you haven’t got that diary time to obturate. But the patient’s now sat there. If we were to go back into that tooth, let’s remove our a Cavit or Kalzinol and go back in, in this instance, would you recommend taking the file all the way to the apex? Or how would you manage that scenario? [Sanj]
If you’ve got the working length, and yeah, just go back in and kind of semi re-prep getting just get the calcium hydroxide out. It may be the fact that you haven’t got the dressing material later length. One thing that actually worth mentioning between appointments always dress the tooth, never leave it dry and empty. Never. Always put something in it, a calcium hydroxide, the thing to do. The difficult thing is getting a calcium hydroxide in volume to length. You can be only squirt at the top end of the crown. So it’s going to have any effect apically, you don’t get the benefit of the properties. So open it up. The fact you open the system up you relieve pressure, because it’s usually apical pressure that’s causing the pain. Whether you get separation, it doesn’t really matter. I think you just opening up the pressure, some endodontists would say you go you got your work length, go a little bit patent, you’re not gonna do any harm. If anything, you might release or relieve any microbes that sits down there. And then wash out again hypochlorite redress and close up. And then your, your chemotherapeutics your anti inflammatories and things like that. Painkillers and things like that after that. [Jaz]
Well, this was a tough question compared to an emergency one because it’s a scenario we hate, you know, as dentists and as an endodontist as well. We hate this scenario of finishing an endo and then they have that initial acute inflammatory reaction what we believe and they just, you know, just kind of wait it out and eventually it will get better. We know that. Okay. But it’s that, that patient at the end of the chair who’s suffering and we feel bad for it, I felt devastated sounds when that happened to to my patient, but I really do in my heart of hearts believe it wasn’t my fault. And I do think perhaps I shouldn’t have been so heavy handed, maybe. I was using rotary instruments for a canine and maybe some extrusion of the debris or dentin on debris could have happened. Exacerbating that inflammation. I put my hand up there that could, that could have been it. But in those scenarios, I think the lesson is, let’s not be too hard on ourselves. Let’s promote anti inflammatories. Let’s warn them that this could happen. And they can then self manage and not expected. But if it happens, they’re not like completely in shock. And then only if justified with swellings and cellulitis. Consider antibiotics and then I guess during the treatment, the Crown down approac. Now just for any students listening, last thing we’ll ask you is just describe, make it tangible, an example of a crown down approach for a molar inside a molar root canal, for example. [Sanj]
Okay, I’m glad you asked this question because I think this is quite important from a technical point of view, but also from an antibacterial preventing a flare up. Because I think maybe majority of flare ups are due to back to stuff being pushed to the end, debris infected material. I think that’s the most common reason why. So the protocol is, you found the orifices this is when you got to time. Okay, so going back to the emergency dressing, the golden rule is just to recap the emergency dressing unless you’re going to you’ve got time to go down to full working length and confirm it. Don’t go into root canal space. Okay, that said, see your second appointment you can got the time. You booked into the root canal, you find the orifices and the only thing you’re going to do now is you’re going to confirm the orifice and we what we call the endodontist called scouting and here’s a 10 to 15 size file just to confirm that there is a patent canals there and what I mean patents, I mean patent coronal not to patency we’re talking about the end. Once you canal is there, then you go on to most people using rotary systems or reciprocating. I’ve got slight reservation about reciprocating systems, they’re not as efficient as removing debris. So if you prefer a reciprocating system, way one reciproc, or whichever one, just be careful you wash out more frequently, you clean the files more frequently, because they get clogged up because of the nature of the mechanism the way they think through its work. With rotary, you’re going to use the system in its sequence. Okay. My role is, and this is this, this goes against a lot of what the manufacturers suggest, once you’ve found the orifice, they often say ‘Get down, get a working length’. And then you go through the system. That goes against the principles of of disinfection, because you you could shove coronal bacteria, majority in necrotic teeth, majority of bacteria is at the top end. It’s not actually the apex, which I mentioned. So the last thing want to do is shove biofilm further down. So you’ve got to get rid of that. So the coronal preparation, the mid third is really important before you worry about working length, I do the majority of the preparation up to the estimated working length and knock off a quarter of that, I’ll do that blindly. Without an apex locator reading. How do I know that estimated length? I’ve got a decent pre op radiograph, and knock out a quarter, I’m safe. I know I’m gonna be well short. And I’ll go through the whole preparation sequence to that point. So that all I then got to do once I’ve prepared the canal to three quarters is confirmed the working length, I know everything’s clear, because apically, there’s gonna be no virtually no bad biofilm bacteria. And there’s less chance of me pushing any rubbish through. And also, because I’ve opened the system up, your working length determination is more predictable, it doesn’t change, because working length changes from the start of the preparation to the end, it gets shorter. So another reason if you do your working length at the beginning, by the time you’ve finished, you fled that, you prep, you’re probably going through the apex. If you keep that working length, as do the geometry in the curve canal. So I do the coronal three quarters prep without working, without worrying about the working length. And then I’ll confirm the work and then all it’s doing is finishing off. And you know you’ve disinfect every point with less risk of pushing debris through. So I think that’s really important, which goes slightly against a lot of manufacturers and some endodontic teachers teach. And I’ve stuck by that. [Jaz]
Biologically, it makes so much sense to me, I think because otherwise in practice, it’s like a race to the apex which it shouldn’t be. It should be clearing just like you said the coronal portions first to allow you to get better access to the apex. So it’s very much. I listen to your lectures Sanj. Listen. I listen to your lectures. Sanj, listen, thank you so much for for giving up this afternoon to speak to me. We’ve made two episodes out of this space you so called group functions where we are answer one key pressing theme. So we talked about extra patients. So if you haven’t listened to that one, go back and listen to that one. It was it was brilliant. And now he’s covered his post op pain and flare up at the end you covered really beautifully. Just a good description of a crown down approach for young dentists and students to really connect and even just the oldies, I know what I should probably go back to doing that rather than going straight to the apex. So Sanj, please tell us about, I know you teach at the moment with institutions, but what kind of private courses do you do? Where do you do them? Is it all in Manchester? Tell us more. [Sanj]
Yeah, so at the moment, I do, we do a good friend of mine, Ammar Al-Hourani was my post grad student. He’s now established in London. So we both run courses two and four day courses in London and Manchester, for convenience because I’m in Manchester and he comes out and I go down to London. it’s quite good, quite good fun. So we do four day courses and we’re going to be doing a longer program next year. We’ve got plans for doing a longer, summer like a diploma course next year. So we’re looking forward to that. And also do a, it’s a microsurgical course. We did our second one a few weeks ago and it’s the only, it’s a human cadaver course. It’s the only endodontic course that I’m aware of in Europe and that’s been going really well in Coventry so West Midlands we’ve got another one coming up in March I think is gonna be fully booked so that’s quite good and microsurgery is another little area of mine pet subject of mine so and a lot of people live with with interest in endo or specialists don’t come across good surgical training. So that’s something I think it’s really needs to be shared and then- [Jaz]
Any website you can recommend for us to check out these courses? [Sanj]
Now, most of the things, when once we’ve got days we wish you on social media and the usual dental forums and instant things like that. I’m very old fashioned like that. I’m getting into that or that sort of thing. But so yeah, that we put posts out we haven’t got a website as such yet so that’s that’s an ongoing thing. So should we getting any website for the practice all the courses will be there but essentially keep a lookout on social media. [Jaz]
When you do give it to me, so I’ll put it on the on the YouTube and on the podcast in the summary. Because people want to know, you know people people enjoy the content let you know identify with this educator. I like the way he thinks. I like the way he or she speaks. And so therefore, I wanna be able to connect people who want knowledge to person who can help them upskill so please do send me those links when you can. And it’s no surprise that you work with Ammar Al-Hourani . He came on as a guest actually in the podcast some time ago. And we talked about, ‘Is single point arbitration adequate?’ Is it okay for dentists to do? And you know, he gave such a lovely just like you did a very real world, very diplomatic, very sympathetic to the plight of the GDP. So hats off to both of you. I love clinicians like this who don’t have that ivory towers there has to be this way. I hate dogmatic approaches. And so Sanj and Ammar if you’re listening to this, thank you so much, guys. It’s obviously great to have you as the endo buds on this podcast. Thank you so much, Sanj. [Sanj]
Thank you as well.
There we have it guys. The joys of post op pain now covered by Dr. Sanj Bhandari. Sanj, thanks so much for creating these two amazing episodes. And thank you protruserati for listening all the way to the end. Now you come this far, why not answer a few questions to claim CPD for listening to this. I think of all the different memberships that you have or the online memberships. And think when was the last time you logged in? When was the last time you used it? Well, you just listened to a podcast episode and you’ve learned something, hopefully. So once you actually test your knowledge, get the CPD certificate, and actually get some reflections as well. So if you’re on the app, you can do that. Now as a premium member, you get CPD certificates, a whole lot of exclusive content. So if you haven’t already, do check it out. Otherwise, I’ll catch you same time, same place. Bye for now.