ROOT CANAL POST OP INSTRUCTIONS

WHAT TO EXPECT
 -     It is not uncommon for a tooth to be uncomfortable or even exhibit a dull ache immediately after receiving root-canal therapy.  This should subside within a few days (or even weeks)

 -  This occurs because of conditions, which existed before treatment was started.  Experience shows that if there was pain prior to treatment there maybe a degree of pain that will continue for a few days after the procedure.  Remember that pain radiates.  You may feel sensations of discomfort that are not related to the treated area during the healing process. This can be created by inflammation in this area and/or due to increase in blood volume that natural occurs in the  healing process.

 -     Your tooth will be sensitive to biting pressure and may even appear to feel loose.  This feeling is a result of the sensitivity of nerve-ending in the tissue just outside the end of the root, where we cleaned, irrigated and placed filler and sealer material.  Discomfort in this area for a few days to a couple of weeks is common.   Warm salt-water rinses for the next two days will help, and avoid chewing on this side until all tenderness is gone.

 -     Occasionally, a small “bubble” or “pimple” will appear on the gum tissue within a few days after completion of a root canal.  This represents the release of pressure and bacteria which no longer can be sustained around the tooth.  This should disappear within a few days.  

-     The gums may be sore and the tooth may be tender when biting or chewing. These conditions exist because the nerves around the tooth have been inflamed because of the conditions that existed before treatment was started and due to the manipulation of the tooth during treatment.

A crown is now needed to protect this tooth

WHAT TO DO :
- Please do not chew or attempt to eat on the side of your mouth that has been worked on while this area is still numb.   
- You may want to put an ice pack over area where the procedure was done for 1/2 hour when you first get home to minimize swelling.  Apply the ice pack (or use frozen vegetables like peas) every hour for 10-15 minutes during the first 4-6 minutes.
 -Sleep with your head in an elevated position for the first few nights if you do not have any physical limitations.
-  Eat a soft diet for at least two days and remember not to chew on the treated side.  Avoid very hot or cold foods during the healing process.     
- We recommend you take something for pain-relief within one hour of leaving our office, to get the medication into your blood system before the anesthesia we administered begins to subside.  Generally, only one dose is needed.  We recommend ibuprofen (Nuprin, Advil, Motrin)-800 mg (four tablets). Two to four tables may be taken four times a day for the next 3-4 days to help control the sensitivity in this area.  If you have a medical condition or gastrointestinal disorder which precludes ibuprofen, acetaminophen (Tylenol, Excedrin) is a substitute, although it does not contain anti-inflammatory properties, Aspirin and aspirin-containing products are NOT advisable, as they tend to increase bleeding from the area that was treated. 
-  Please take prescribed medication (antibiotics and /or pain medication) as directed. If you are given PenicillinVK take 2 pills every 4 hours for 48-72 hours, then complete prescription taking 1 pill very 6 hours. Please take the full course of antibiotic medication.  If you were given a prescription for pain, it is meant to help you with more serious discomfort only for a couple of days.  Refer to pain control article 
- Whenever possible, try to chew on the opposite side from the tooth we have just treated, until you have a crown place.  Until that time, your tooth still is weakened and could fracture.   
- Do not smoke during the first 24 hours and minimize the number of times you smoke during the remaining healing process because smoking delays the healing process.  Avoid drinking alcoholic beverages.  Avoid strenuous exercise for 24 hours.
- Please avoid crunchy or hard foods which could cause the tooth without a crown to fracture.   
- Frequent rinsing with warm salt water for the next two days 
- We recommend you take something for the increased sensitivity in this area within one hour of leaving our office, to get the medication into your blood system before the anesthesia we administered begins to subside. Generally, only one dose is needed. We recommend ibuprofen (Nuprin, Advil, Motrin)-two to four tablets, which may be taken four times a day if needed. If you have a medical condition or gastrointestinal disorder, which precludes ibuprofen, acetaminophen (Tylenol, Excedrin) can be a good substitute, although it does not contain anti-inflammatory properties. 
Delay in obtaining final restoration (crown)  may result in fracture and/or possible loss of the tooth

WHAT TO DO FOR NON-HEALING AFTER ENDODONTIC TREATMENT
     Fortunately for everyone, most root canals heal with about a 95% success rate. When they don't heal, we would prefer to call this "non-healing". Be aware that this is not mere carpentry -- it is a medical procedure and all medical procedures do not heal 100% of the time, including root canals. Generally speaking, the non-healing takes one of two avenues:

1. Pain (mild too severe) with or without swelling, or
2. No symptoms at all, but rather changes on the x-ray suggestive of non-healing (i.e.: bone dissolving around the root tips).
Typically, the non-healing is caused by one of two things:
1.  Inflammation-The inflammation may be from the tooth being inflamed prior to treatment, or the treatment itself may elicit more inflammation. Usually time, and medication like Advil, or steroids can resolve this.
2.  Infection can be from three main causes:
1. The original infection persists

2. There is a crack in the tooth,

3. There is leakage through the top of the tooth (i.e.: the filling) that re-infected the root canal filling.

If the non-healing is due to infection, usually time and antibiotics will resolve this. If signs or symptoms persist, there are three options:

1. Retreat the root canal, or

2. Surgically clean the bone that surrounds the root tip and seal

    the tip of the root, or

3. Extract the tooth.

Reasons for people grinding their teeth

Grinding teeth is a habit you can see with some people and they are seen to do it unconsciously and usually when they sleep. The medical term for this habit is Bruxism.
The exact cause for Bruxism or grinding teeth is not known and there are a number of suggestions on the causes. One factor thought to causes teeth grinding is stress. When a person is angry, in pain or frustrated they grind their teeth. So, negative emotion is definitely a source of this habit.
People who are aggressive in nature are seen to grind their teeth too. People who are too busy and have a hectic work schedule everyday grind their teeth because of their wok overload. Sleep disorder are also seen as a cure to teeth grinding.
Whatever be the cause of teeth grinding it has a definite bad impact on teeth. In teeth grinding, a person applied twice the force they would normally apply when chewing food. The result of teeth grinding is cracked enamel, teeth with hairline fractures, gum damage, worn out or traumatized teeth. This in turn results in sensitive teeth. One of the factors that dentist look into when treating people is if they have the habit of teeth grinding. Sometime their teeth can be so badly damaged due to tooth decay, that cosmetic dentistry is suggested as a way to bring teeth to normal look.
People with Bruxism even see a misalignment in their jaws and have other jaw related complaints. Some symptoms seen in people who have Bruxism are headaches, earaches, insomnia, depression and eating disorders.
Those suffering from Bruxism are asked to practice stress management techniques to overcome the stress which causes this habit. Through relaxation techniques face muscles can be relaxed. Through stretching exercises, muscles will not become so tense and they need to be learnt and practice regularly.
Getting proper sleep is necessary to overcome the stress so this is another aspect to be looked into and to overcome insomnia, once again stress management is the option. As far as diet is concerned, people who have the habit of grinding their teeth are asked to avoid foods needing hard chewing and drink plenty of water everyday.

Internal Resorption – Pink tooth of Mummery

Internal resorption is a condition where the slow or fast resorption of the dentin of the pulp, and the internal walls of the root canals occurs. It is named as Pink tooth of Mummery after the anatomist – James Howard Mummery.

Cause and symptoms

The cause of this condition is not clearly known, except of few patients complaining about trauma to the teeth. Also, persistant chronic pulpitis may sometimes cause the internal resorption. This is another asymptomatic condition, and a type of Chronic irreversible pulpitis (other types include Pulp Polyp).
The crown of the tooth clearly shows a reddish spot, called as Pink Spot which represents the granulation tissue, showing the resorbed area of the tooth. The resorption can be confined to just the crown or the root, or sometimes both. The duration can also vary, with slow progression for 1-2 years or rapid progression within a few months. There is pain seen if there is severe resorption, leading to perforation of the crown.

Diagnosis

Radiographic changes -

• Radiolucent enlargement of pulp canal
• Original root canal outline is distorted
• Changes in the bone not usually seen, but visible only when the root perforation occurs

Pulp vitality tests are usually positive, because although the coronal pulp is not responsive, the apical pulp is still vital.

Treatment

The internal resorption can be stopped by Pulp extirpation procedure. In some, the condition still progresses to finally perforate the root, where calcium hydroxide paste is sealed to repair that area and form a calcific barrier. After this is done, plasticized gutta-percha is used for obturating the open canals.

Oral Piercing Types Complications Infections

Different types of body piercing have become famous among a large number of young people now days. One may see a lot of people who have undergone oral piercing. Different types of oral piercing are done by the piercers. Oral piercing can be done in tongue, lips and cheeks. The jewelry which is inserted in the piercing comes in different materials, designs and sizes. People who want to get oral piercing done should understand that there may be different complications and side effects of oral piercing.
Oral piercing may cause different types of complication in the people. It puts a risk to the dental health of the people. Once oral piercing is done, the chances of infection also increase in the area which is pierced. Different kinds of bacteria always remain present in the mouth. When blood vessels present in the tongue are damaged due to piercing, they may bleed in excessive amounts. This may cause excessive loss of blood. Swelling usually occurs after oral piercing is done. It becomes difficult to heal the effects of piercing because tongue is used a lot for different functions. In some cases, swelling may cause hindrance to the breathing process. The risk of different blood borne disease like hepatitis C, B, D, G and tetanus also increases after oral piercing.

When people have barbells fitted in to their tongue they tend to tap it again and again on teeth and gums. This may lead to broken teeth and gum diseases. A large number of people who have oral piercing usually come up with some kind of infection in their gums. The infection which may be caused to the blood vessels which are connected to brain and other crucial parts of body, may even take one’s life. If you search the internet you can get to know about such cases. In case unsterile instruments are used for piercing the tongue, cheek or lips, it may cause HIV or AIDS. If you have to get oral piercing done then visiting a reputable clinic will be the best option.

Dental care during pregnancy

Pregnancy is one of the most crucial times to take care of woman’s health, where most of the care and health is dedicated to the developing fetus. Accd. to American Dental Association, this is the period when women don’t take proper care of their teeth and gums, which can lead to a lot of problems to the dental health, which complicates the general health and pregnancy too. Here are a few tips, facts and things to remember during pregnancy.

Dental Treatments

Most of the dental treatments that include extractions, fillings, root canal treatments or placement of crowns etc. are to be carried out during the 2nd trimester of pregnancy (i.e. the 4th-6th month), and only if they can’t be avoided. If the 3rd trimester is entered, then its best to delay any treatment procedure till the birth of the child, and get it done later. Sitting on your back for long time is not possible during the 3rd trimester of pregnancy, so any treatment procedure has to be canceled. Also, the stress sometimes due to bigger treatment procedures can affect pregnancy a lot.
Maximum try is to reduce the exposure of the child to any treatment motions, and any medication that may cross the placental barrier. One of the examples is tetracycline drugs. If these drugs are taken during the pregnancy period, it affects the child’s teeth by forming tetracycline stains.

Taking X-Rays

Taking X-rays during pregnancy, should be avoided as much as possible. The radiations are not only dangerous for the mother, but also the developing child in the 1st trimester. Although sometimes X-rays are needed compulsorily, to come to a proper diagnosis of the problem, care should be taken to reduce the exposure of the developing child to the radiations.

Effect of Pregnancy in mouths

During pregnancy, the blood flow increases by about 30-50% and the hormonal production is also high. The condition of Pregnancy Gingivitis is common and half of the total pregnant women experience it. In this, the gums appear glowing pink/red because of the higher circulation of blood, which can provide good nutrition and house for bacterial growth, and although good oral hygiene is tried to maintain, bleeding while brushing the teeth is common. Its also because of higher levels of estrogen and progesterone, that leads to sensitivity of gums.
The gingivitis that occurs in the gums, sometimes develop into mass or lump in the gum called as pyogenic granulomas, or “pregnancy tumors”, although its not any cancer/tumor. This also occurs sometimes, but regresses as child birth occurs.

Oral hygiene measures to be taken

Although your gums might bleed, although you might not be finding less time to take care of your teeth, you should be trying to brush twice daily and floss the teeth. Use a soft toothbrush, to avoid pressure on the gums, and don’t worry if your gums are bleeding. Give a scheduled visit to the dentist during the 2nd trimester of pregnancy to get your teeth cleaned professionally, by scaling procedures. Use a good ADA-approved toothpaste to brush your teeth, which contains fluorides so that adequate amount of fluorides are supplied to the child.
Flossing would help in keeping the gums healthy, and the areas between the teeth where plaque accumulation can lead to tooth decay.

While at the dental office

When you visit a dentist during your pregnancy phase, you should let them know what drugs you have been using since the start of your pregnancy period, so that the appropriate medication is given, if required, after any simple dental treatment procedure.
You feeling comfortable would reduce the stress on the developing baby. And when the anesthesia is given for any treatment, the lesser would be better to keep you comfortable. Higher amounts of anesthesia should be given only if required.
Antibiotic drugs like Penicillin, amoxicillin, and clindamycin are safer drugs to be taken during pregnancy, if any infections occur. Avoid taking tetracycline, as already said they would cause stains to child’s baby teeth as well as the permanent teeth.
Avoiding a dental visit only because you are pregnant is not a good choice. Just oral problems can lead to many complications.

Women get pregnant usually at an age of around 20-24 and this is when the wisdom tooth eruption occurs, in a normal or abnormal position. So if there is a problem, then delaying the removal of the wisdom tooth should be best postponed to after the child birth.

Clinical Clues for Identifying Cracked/Fracture Roots

Accurate diagnosis of a cracked/fractured root is a difficult task. It is important to get it right, because the treatment for a cracked root is usually extraction. I explain to patients that there are some clinical signs that would indicate a cracked root, but they are not 100% conclusive all the time. These same clinical signs can occur in other situations as well.

The typical signs associated with a cracked/fracture root that we have previously reported:

1. J-shaped lesion or large lateral lesion

2. Deep, narrow periodontal pocket

A couple new clinical signs that I have not previously reported include:

3. Swelling in the in the marginal gingival, adjacent to the fracture

4. Failure of a swelling to resolve despite a course of antibiotics

The more of these clinical signs I see in one patient, the more confident I am that the root is cracked/fractured.

I explain to patients that the only way to know with certainty is to visualize the crack. This is most effectively done with magnification. This can either be done through an endodontic access, or through a small periodontal flap to examine the root surface. I expect that with time, CBCT will be better able to help us in the diagnosis of cracked/fractured roots. At this time, the CBCT does not appear pick up on a cracked/fractured root until the pieces of the root begin to separate.

Here is an example of a case in which several of the described clinical signs were present indicating a cracked/fractured root. Access and visualization confirmed the diagnosis of cracked root.

Pt presents with a swelling in the marginal gingiva adjacent to distal root of #19. The radiograph shows a large, lateral lesion on mesial of distal root. Patient had been taking Penicillin for several days, without resolution of the swelling. Antibiotic was changed to clindamycin to see if swelling would resolve.

Swelling did not resolve after taking clindamycin.

At this point, I am quite certain I will find a cracked root. If this were simply a perio issue or an endo issue, I would have expected it to clear up with the antibiotics.

Access into pulp chamber exposes a vertical crack/fracture on the MB root as well as the DB root.

The tooth is deemed non-restorable and extraction recommended.

If you are unsure if a tooth has a cracked/fractured root, contact your endodontist. Not all teeth can be saved, but endodontists are the specialists for saving teeth and can help you determine which ones to save.