4/2021 The Secrets of Predictably Successful Endodontics Part II Dr. Andre K. Mickel 1 4/2021 Andre’ K. Mickel DDS, MSD, MDiv 2 4/2021 LET EVERYTHING THAT HAS BREATH…Praise the Lord! 3 4/2021 God, Family…then Endodontics 4 4/2021 My Favorite Rotary System • Fast • Effective • Only need one file!! • Inexpensive • BUT… A BIT FRIGHTENING! 5 4/2021 YOU WANT TO KNOW ABOUT ROTARIES ?? OPEN UP, I CAN SHOW YOU BETTER THAN I CAN TELL YOU! The Secret to Success… • Seeing your work primarily as a service to others and not as a means of personal gain (video)? 6 4/2021 DO NO HARM 7 4/2021 Case Scenario ● 25 y.o. caucasian female ● Chief complaint: “Burning pain in my top front area; it burns to touch it” ● Medical history: noncontributory ● Dental history: 6 RCTs performed 6 months ago by general dentist ○ No pain prior - but constant pain ever since ○ Patient’s understanding of why tx was performed: “deep decay” ● Pain meds: NSAIDS - no relief Case Scenario ● Clinical and Radiographic Exam ○ Pertinent Findings: ■ Severe pain to touch teeth and soft tissues in the anterior area ■ Constant pain 10/10. Felt swollen, but not clinically detectable Case Scenario ● No treatment was done. Patient referred to Oral Medicine and Orofacial Pain clinic ● Diagnostic bilateral injections relieved the pain. Presumptive Diagnosis of Trigeminal neuropathic pain. Gabapentin 300mg t.i.d. ● Came back 3 weeks later with photophobia and nausea consistent with Migraine. Topiramate 25mg-100mg b.i.d. ● Came back for an emergency visit with severe pain and autonomic symptoms. Patient was placed on 10 liter/min oxygen for 20 minutes and immediate relief was noted. 8 4/2021 Case Scenario ● Final Diagnosis: Cluster Headache ● Brain MRI was made to rule out any CNS neoplasms ● Pain was completely relieved by 60mg Prednisone for 5 days ● Daily therapy of Verapamil t.i.d. Showed adequate symptom control DO NO HARM 9 4/2021 This Photo by Unknown Author is licensed under CC BY-NC-ND 10 4/2021 11 4/2021 12 4/2021 Holmes and Rahe Life Change Index Scale Holmes and Rahe Life Change Index Scale As clinicians, effective communication provides a baseline in the establishment of patient-provider trust when treating an anxious or fearful patient. Considering the apprehensiveness exhibited by patients recommended for Endodontic procedures, recognizing dental anxiety allows for a more timely and accurate diagnosis. Learning simple techniques to desensitize a patient’s unpleasant expectations will pave the way for more time efficient encounters. 13 4/2021 Other Nonpharmacological options for the management of dental anxiety pleasing scents Rapport building giving patients a sense of control Distraction- visual and/or aural Increased information on the experience cognitive behavioral therapy Systematic desensitization Computer-assisted relaxation learning Behavioral changes Hypnosis Relaxation therapy 14 4/2021 15 4/2021 16 4/2021 A root canal is just like: Baking cookies at grandma’s ! 17 4/2021 18 4/2021 Soft and Relaxing Music OR… …Frank Sinatra and RCT’s 19 4/2021 20 4/2021 21 4/2021 Yummmm…Can you smell them?? 22 4/2021 23 4/2021 24 4/2021 Patient Management CAUSES OF FAILURE 2. Lack of AMBITION to move past mediocrity COMMUNICATION: MUST “SOLERize” Patients 25 4/2021 Square on Open Posture Lean In Eye Contact Relax What is SOLER? SOLER is mainly focusing on your attending skills in a counseling session. Gerard Egan created this theory and acronym to assist new counselors in a therapeutic setting, understand how to put their clients at ease through their body language. What is S.O.L.E.R ? The Gerard Egan Soler Theory describes techniques for active listening . It can be valuable when helping another person as it will make them feel cared for, involved, respected and understood. S.O.L.E.R S= Square On O=Open L=Lean In E=Eye Contact R= Relaxed 26 4/2021 Solar theory 1: Square on The first important part is how you posture yourself in relationship to your client. Your face facing the clients face shows that you are engaging, interested and actively listening. You can have your shoulders turned a little away to dispel any feelings of intimidation, but your face should be square onto the clients face. Square on… Soler theory 2: Open This openness refers again to posture. Ensuring that arms and legs are not crossed will convey a sense of ease to your client. As mentioned above, this openness in body posture will stop feelings of intimidation from occurring. 27 4/2021 Open posture while listening Solar Theory 3: Lean in By leaning towards your client, a sense of care and genuine interest will be conveyed to the other party. Simply leaning forward will automatically make them feel that their concerns are being heard and understood and this will instill further ease and facilitate openness. 28 4/2021 No No No!! Lean in while listening… Soler theory 4: Eye contact This interest is further enhanced by eye contact. Maintaining eye contact shows interest and concern. However, it is important to vary the eye contact so that the other party does not feel threatened or intimidated. 29 4/2021 When they look you in the eyes…look back…and don’t blink! Solar theory 5: relax This is an obvious, but sometimes forgotten aspect. One must relax before your client. If you are fidgeting or showing any anxiety, this will be conveyed. They will either think you are not interested in them, or they will take on your tension, or possibly both! NO NO NO… 30 4/2021 COMMUNICATION: RELAXED!! “SOLERize” Patients Psychological aspects of endodontic pain Within the scope of Endodontics, pain management is a critical entity in securing patient trust. Emphasizing the importance of pain management, special care should be taken to enhance patient experience and reduce procedural chair time. S.O.L.E.R is used to connect psychologically with patients to aid in reducing anxiety and fear in regards to treatment plan acceptance, patient compliance and post-operative pain. Psychological aspects of endodontic pain . It’s been determined that the best predictors of post operative pain are pre-operative pain/swelling- Walton & Fouad. Best predictors: Level of pre-operative pain and anxiety- Torabinejad . Concluded that apprehension causes reduced pain threshold- Hargreaves & Keiser 31 4/2021 Psychological aspects of endodontic pain Patients who never received Endodontic treatment experienced high levels of dental anxiety and considered it to be more unpleasant than oral surgery (Wong 1991) 67% of patients reported moderate anxiety associated with endodontic treatment, while 17% experienced intense anxiety (Dou 2018) For patients with moderate levels of dental anxiety, providing more information about endodontic treatment and what they will experience can reduce dental anxiety and fear of pain (Newton 2012; van Himel2006) Anxiety Assessment and treatment Flowchart The triangle in the middle represents CBT's tenet that all humans' core beliefs can be summed up in three categories: self, others, future. 32 4/2021 Cognitive behavioral therapy Cognitive behavioral therapy is a psycho-social intervention that aims to improve mental health. CBT focuses on challenging and changing cognitive distortions and behaviors, improving emotional regulation, and the development of personal coping strategies that target solving current problems. Originally, it was designed to treat depression, but its uses have been expanded to include treatment of a number of mental health conditions, including anxiety. CBT includes a number of cognitive or behavior psychotherapies that treat defined psychopathologies using evidence-based techniques and strategies……………………………Blah Blah Blah… General Anesthesia IV Sedation Inhalation Sedation Psychological Techniques Good Pain Control Communication 33 4/2021 34 4/2021 …Frank Sinatra and RCT’s 35 4/2021 36 4/2021 Yummmm…Can you smell them?? 37 4/2021 38 4/2021 Ethics • Informed consent • Discussion of risks, benefits and alternatives • Best interest of the patient • Best evidence 39 4/2021 • Informed consent • Discussion of risks, benefits and alternatives • Best interest of the patient • Best evidence 40 4/2021 CAUSES OF FAILURE 2. Lack of AMBITION to move past mediocrity “C.I.B.” Endo Mother Litmus Test Nothing like Mommy! 41 4/2021 NOTHING LIKE MOMMY! Don’t talk about my Mama! Treat every patient like your Mommy! 42 4/2021 A root canal is just like: Baking cookies at grandma’s ! Yummmm…Can you smell them?? A root canal is just like: Baking cookies at grandma’s ! 43 4/2021 But…stuff does happen… Mishaps: Bleach Injury 44 4/2021 Irrigant NaOCL ERRORS AND TX • MAKE SURE CHAMBER NOT “LEAKING” • GOOD RUBBER DAM ISOLATION • DO NOT WEDGE NEEDLE • USE SIDE RELEASING NEEDLES • MOVE NEEDLE UP AND DOWN WHEN IRRIGATING TX OF NaOCL ERRORS • DILUTE- REANESTHETIZE • NSAIDS • TOPICAL CORTICOSTEROID OR CONSIDER MEDROL DOSE PACK • CALL OFTEN, CLOSE FOLLOW • WARN OF SEQUELA • SWELLING, SLOUGHING, DISCOLORATION, LONG TERM DISCOMFORT •TLC 45 4/2021 This Photo by Unknown Author is licensed under CC BY-SA This Photo by Unknown Author is licensed under CC BY-SA This Photo by Unknown Author is licensed under CC BY-ND 46 4/2021 Things go wrong!! • Too small • Missed canals • Visibility • Instrument access • Fatigue • Breakage of instrument • Inadequate Cleaning and shaping Things go wrong!! • Off center • Perforations • Restorability • Missed canals • Reduced prognosis • Inadequate cleaning Access in special conditions 47 4/2021 Things go wrong!! • Too shallow or too deep Law Regarding Perforation • Let patient know an accident occurred and was promptly repaired. (MTA, RRM Putty, matrix/geristore) • Prognosis better if repaired ASAP • Smaller is better • No communication with sulcus • Above bone better • SOM …Magnification + Illumination Mommy LOVE 48 4/2021 CAUSES OF FAILURE 3. A NEGATIVE mental attitude This Photo by Unknown Author is licensed under CC BY-SA This Photo by Unknown Author is licensed under CC BY-SA 49 4/2021 This Photo by Unknown Author is licensed under CC BY-SA This Photo by Unknown Author is licensed under CC BY-SA-NC This Photo by Unknown Author is licensed under CC BY-SA 50 4/2021 Don’t POUT! DON’T BE A GRUMPY OLD MAN! 51 4/2021 THERE IS ALWAYS SOMEONE WORSE OFF ! CAUSES OF FAILURE 3.