Transcribed by Mandy Weil 10 October 2014

[DOD] [45 and 46] [Introduction to Root and Pulp Anatomy] by [Laurie
Fleisher, D.M.D.]

[110] [Proper Access]
[Fleisher] Hi. Thanks for coming. Im going to get started in about a minute.
Please bear with me. I have a bad cold. So if there are any questions, if you dont
understandmy words are a little garbled. I apologize.Thank you for letting me
know that this was rescheduled cause I reallyIm starting off whereI started
going very quickly. And were gonna take a step back now, because we certainly
have the time to now that we went over the root and pulp morphology, I want to
talk about access cavities. And I want you to know something

[109] [Access Cavity]
[Fleisher] Your case will only be as good as your access cavity. The access cavity
is really your limiting factor. Its what really sets the stage for your endodontic
case. You wont be able to successfully clean and shape the root canal system, nor
will you be able to obturate correctly. Alright? Because youll be limited by not
having direct line access. Youll also, really, if youre not as conservative as
possible, really destroy the possibility for successful restorations.
Okay? So this is the definition of access cavity: The opening prepared in a tooth to
gain entrance to the root canal systemwhich I have here, abbreviated as RCS
for the purpose of cleaning shaping and obturating. And that is the standing
definition from the Association of Endodontists.

[110] [Proper Access]
[Fleisher] So, what is this all about? You have to know, you need to visualize the
location of the pulp chamber before you start anything. So in order to visualize, it
is not just the intraoral inspection and palpation of seeing where the roots are. Or
the inclination of the crown in relation to the roots. But its also what youre able
to tell on your radiographs. And I know we talking about the periapical (PA)
versus a bitewing. And really, you can glean different things from both. A
bitewing doesnt show you the roots or the root morphology. But, what a bitewing
does is show you the relationship of the crown to the bone. It shows you the
relationship of the caries inside the crown, to the relationship it has with the
bone, with the CEJ, with the root. With the furca. Better known as a furcation. Also,
what a bitewing (BW) tells you is where your pulp chamber lies in relationship to
the occlusal surface of the tooth. Its very distorted just trying to assess that from
a PA film. Because, depending on the angulation of your PA filmtheyre never
reproduced completely from one to another like a BW is. A BW is always taken at a
90 degree angle without any distortion. Thats why we use it for caries detection.
Whereas a PA filmtheres a little more play how you take the film. Sometimes
its a little more foreshortened or elongated. Its very hard to accurately
reproduce that film. So we reallyfor every posterior toothit is a rule, at least
in my world of endodontics, never to attempt an access cavity without a PA and
1
Transcribed by Mandy Weil 10 October 2014

BW. And when you come through urgent care, that will be the rule in urgent care
clinic. Alright?
So, you open into the pulp chamber without any unnecessary sacrifice of tooth
structure. What does that mean? Of course you have to remove tooth structure
that is carious in nature. You cant leave any unhealthy or infected tooth structure.
But, you cannot just extend your access without realizing where your pulp
chambers are beneath it. Or your pulpal orYour pulp chamber and your canal
orifices lie beneath it. That is why its so important by palpation, intraorally, in a
patient, many patients have malocclusions. Their teeth are not aligned like they
are in your typodont. Once a rubber dam is placed, you will have difficulty in
reorienting yourself to the proper angulation. So, its very important to be able to
feel in the bone where the root lies in relation to the crown. If theres a tip mesial,
distal, buccal, lingual, palatalall of these things are important.
Also, learning to deal with difficult access situations lends itself to also knowing
when to send to a specialist. And that is something that really reflects your
expertise. It doesnt make you less of a practitioner to sayyou know, I think this
should go to a specialist. It actually shows that you know when something is really
warranted in being treated by a specialist. And at the very beginning, a lot of new
practitioners are afraid to send anything out. Because they think its going to
reflect poorly that they dont have the skills. But it really is just the opposite. It
really lets people in the dental community know: Wow, this new dentist is really
sharp. They can see that x, y, z, would really be a potential problem for anyone but
a specialist to handle this case. So you shouldnt look at it that way. Okay?

[111] [Visualization]
[Fleisher] Visualization. I know I put this up on the screen last time. And if you
come into the Urgent Care clinic, you will see this is always ever-present. And
what it does, besides show you the individual access, it really gives you the access
in relation to the tooth medial and distal to it. And to see how theres a
progression within the dentition. And, as you can see, even in the molars, the
access becomes less of a broad triangle and almost more in a linear aspect. So its
important, even if youre not doing 2nd molars here at the school, to realize, when
youre excavating caries in these molars, where the pulp tissue lies. And, to expect
certain things by a how a case presents. Its important to tell a patient when
assessing their treatment plan: this is really a potential problemthis is most
likely. Only because, if youre working and just say: Oh! You need a root canal. If
it comes out of nowhere for a patient, they will, first of all be very upset without
any warning. But also, you havent adequately educated them, which is important.
Because when you educate your patient about what their dental needs arethere
used to be a commercial on TV. Sy Simsan educated consumer is our best
customer. That will give you the most loyal patients and the patients who trust
you the most. Cause patients really, their basis in fear, sitting in your chair is what
they are afraid of and what they dont know.Its fear of the unknown.
Once again, its written here: You want to study the anatomy before the rubber
dam placement. Thats a very important concept to remember. And you want a
2
Transcribed by Mandy Weil 10 October 2014

current PA and bitewing. Many times it wont happen in a general practice office.
But so many times in my practice somebody will come in with radiographs that
are sent by their referring dentist. If that should ever happen to you, you want a
radiograph, and plural radiographs, of how the patient is presenting to you now.
Just cause theyre holding the radiographs in front of you does not mean that
those are representative of what the status of their tooth looks like at that time.
Many times the referring dentist will send you their pre-operative film. Theyve
unsuccessfully tried to gain access. Then decide to pack up the case, close the case,
send it to the endodontist, and if you dont have an x-ray, really, a showing how
the patient is presenting to you, and you open up the case and see that theres a
perforation or its really another problemyou have to basis to prove your point.
Because, the dentist will say, well, I sent you the pre-op films. So its incumbent
on you to always, even in a trauma case, even if you saw the patient the week
before: Its how the patient is presenting at that time for an emergency. Its very
important, when we see patients, and I know Im using Urgent Care as an
exampleBecause I am in urgent careso many times patients will say: well,
here, my dentist just sent this to me or an emergency on the floor where the
student will say here, we just took x-rays 2 weeks ago. But its not how the
patient is presenting today. So thats something you should all remember.

[112] [High Speed Initial Entry]
[Fleisher] AlrightHigh spend initial entry. Very important. It minimizes
vibration. A lot of the teeth that need root canals are very badly broken down.
Also, it decreases any discomfort for the patient. Believe it or not, a lot of patients
are very thrown off by the vibration. They interpret that as pain. Theyre
expecting, once theyre numb, not to have any sensation at all. Theyre veryif
you extract a tooththeyre expecting not to feel pressure. You all know, because
youre studying anesthesia, unless youre sedated where youre unconscious, you
perceive pressure with local anesthetic. So you have to try to minimize all these
other things and all these other stimuli to make the patient more comfortable.You
want to also always think of the long axis of the tooth. And when you get into your
pulp chamber roof, you will feel a drop. You will feel a drop because youve now
gone through dentin, gone through the roof of the pulp chamber and gone into the
pulpal chamber space that isnt as dense because its not filled with dentin. Its
filled either with necrotic debris or irreversibly pulpitic pulp. Okay? So its gonna
be different.
Low speed: once youve gone through and gained access to the chamber, then
really the best way to approach it, is your long shank slow-speed round burr.
Because youre gonna lift up the chamber. Never touching the pulpal floor. And
some pulp chambers, which are very narrow from an occlusal-going-apical
direction, a north to south direction, its very easy to almost miss that drop. So you
have to be very conservative.

[113] [Proper Access]
3
Transcribed by Mandy Weil 10 October 2014

[Fleisher] Okay, Proper access leads to all three of these things (Slide has 3
arrows point to the words cleaning, shaping, and obturation.) Access is really
the key to your case. That doesnt mean that you can skimp on any of thosebut if
you start off with improper access, the rest is doomed.

[114] [3 Major Objectives]
[Fleisher] Three major objectives: This is a very important thing to make a
notation of. The three major objectives of access and proper access cavity
preparation is the attainment of straight line access, conservation of tooth
structure, and the unroofing of the chamber to expose the orifices and to remove
the pulp horns. This is especially important in anterior teeth. That, I know I
mentioned last time, is why, an upper central incisor is part of your board exam.
Cause they want to know that you know you have to remove the pulp horns,
mesial and distal, on these teeth.

[115] [Straight Line Access]
[Fleisher] You get improved instrument control. Less chance of apical
transportation. So many times when were working our way in a canal, especially if
we feel some resistance, and tend to aggressively move the instrument, if youre
leaning against an access cavity that doesnt give you direct access, what happens
is the file will be deflected into a direction that is not coincident with the canal.
And the file is very sharp and can cut through dentin and make its own passage.
You can create your own canal. Alright? It improves your obturation. You get
better introduction of the spreader and youre able to get a better condensation,
which is critical for the apical seal. And, it also allows for less chance of procedural
errors. Without a doubt, doing the access, most of the time, takes me, I would
say1/3 of the timeWell I dont want to generalize, Because some teeth are not
that way, but a very complicated access: a tooth with a very calcified chamber,
thats tipped in a certain direction, I really, I never rush through a difficult access.
Not if I want a chance to be successful with that case.

[116] [Tooth structure removed]
[Fleisher] So, you have to remember, no unsupported tooth structure is to be
left. Now that also means any dentinal or lingual shelf. Or palatal. Anything in that
direction. The enamel from the incisal surface: Theres a triangle thats formed in
anterior teeth.
Once you makeand I think theres a picture coming uponce you make your
approach with the burr, at a 45 degree angle, on the lingual surface of anterior
teeth, youre leaving material incisal to where that burr was introduced. That can
disrupt your path of insertion of the file. So, you have to remove that to make sure
that when you place your file, or your endo explorer in, its not impingement on
that incisal surface. Okay?

[117] [Conservation of Tooth Structure]
4
Transcribed by Mandy Weil 10 October 2014

[Fleisher] Conservation. I know I keep saying and saying it. But its very
important. Because so many times, what happens, a patient comes back, the week
before the tooth is ready to be obturated and its broken off at the gum line.
Alright? So, not only do you have to know to reduce the occlusion of the teeth that
youre doing endodontic treatment on, you have to try to have those marginal
ridges, medial and distal, left in tact for support. Of course, that doesnt apply if
theyre compromised by caries. But just to include them for the sake of having a
bigger access hole, which we thing will make things easier, actually doesnt make
things easier. It makes things more confusing. Because youre looking at a vast
space and then when you look in, the orifices are somewhere really far removed
from the cavosurface margin line of the outline form of your access cavity. Alright?
You have to remove all unsupported tooth structure. Very important. A lot of
people thing that by leaving an enamel shelf and putting an IRM in, whats gonna
happen? The patient is going to bite down and fracture off that area. And what will
happen when they fracture off that area, the fracture will include another part of
the tooth, unfortunately, that now will make it unrestorable.
Occlusal reduction is important. Why? A lot of times these teeth are
super-erupted. Super-erupted, because pathogens and bacterial by-products find
their way into the PDL space. Two things cant occupy the same space at once. It
super-erupts the tooth. You want the patient to feel must more comfortable after
your appointment. Also, you want to reduce the occlusion to minimize any, any
chance of fracture. There are times when you will not be able to reduce the
occlusion. If youre working through crown or a bridge, by reducing the occlusion,
youll destroy the crown. And, in those cases, I let all my patients know: please
dont be alarmed when the anesthetic wears off. This is going to be tender for a
couple of days until things settle down. Because once you start reducing the
porcelain off of a crown, you didnt fabricate that, or you really dont know how
much porcelain there is: youll either crack through the porcelain. Or youll
destroy the occlusion that, once the patient is finished, the patient cant bite on it
because its no long in occlusion. And having a tooth thats no longer in occlusion
causes it to super-erupt. I wont go into scenarios, but teeth that, especially in
patients with high furcationsonce they super-erupt, you have perio problems.
And you have furcation involvement. Im giving you all extremes, but Im really
trying to hit the point home, that you have to thing with every case, if this
concept applies.

[118] [Extend Access to Include Pulp Horns]
[Fleisher] Alrgiht, Pulp horns contain debris.
Anterior teeth. A lot of times they dont need full coverage restoration. So you
want esthetic considerations kept into account. So, you wanna know that youre
not over-sizing your access, but that youre also including it in that triangular
shape to get those pulp horns out.

[119] [Picture]
5
Transcribed by Mandy Weil 10 October 2014

[Fleisher] Okay, once again, and I will get this lecture to youI am somewhat
saddened to hear you still dont have it. I will make sure this is emailed tonight.
Again.
And.. The diagrams that are at the end of this lecture, cause actually, after this,
were gonna go into Treatment Planning. So this is actually almost at the end of
this lecture, which is almost a 2 hour lecture. It really shows you both in a sagittal
plane, going mesiodistal and bucccolingualhow the pulp actually lies within the
teeth. Excuse me one second. I want you to see that the pulp tissueIm gonna
just turn this off for a secondhold on(coughsmic is off)Alright, I want you
to see that the pulp: when you look at it from a side viewthe pulp and its horn
actually really moves very much more incisally than the rest of the pulp chamber.
A lot of times, when you look at the toothIm sorry, my light is no longer
functioningWhen you look at the tooth, from this aspect, and you look at your
ideal access cavity and you dont realize that the tooth is tipping in a certain
direction, which is, in this case, in this case, this is tipping buccally. In this case,
this is tipping palatally. You cannot appreciate the three dimensionality unless
you really study these types of pictures. Because youre so used to looking at
radiographs, which are in 2-dimension, that you lose perspective of working in
three dimension, which is key in endodontics.

[120] [Picture]
[Fleisher] Helpful hintsand i know I mentioned it last timeALWAYS mark
the tooth that you are working on. I use a little Thompson stick, which is used in
Ortho. We now use it for sight verification when we do extractions. Because when
you put your rubber dam on, it is really very very easy to misidentify
whichthey all look so similar, the lower anteriors. And you can accidentally drill
into the wrong tooth.
[Skips to the next slide, then reverses back]
Alright I just want to go back here where Im talking about lower anteriors. A
two canaled lower anterior is really not that uncommon. So if you find your canal
seems very, very much toward the buccal, rather than in the center of where
youve gone, and made your triangle access, that you feel your endo explorer is
coming up at this end right here, look carefully more towards the CEJ. Towards
the lingual side, there may be 2nd canal, that follows, if you notice the outline of
the lingual side, it follows down, and will be at the most apical end of your access
cavity.

[121] [Picture]
[Fleisher] A lot of times you can really discern these things from really having
diagnostic radiographs. Dont cut yourselfdont put yourself in a very tough
position by going with a film that is not diagnostic.Take the extra minute and
get another film. Because otherwise, if you dont know how many roots are in a
tooth for examplefor, heres a perfect example: An upper first premolar or an
upper second premolar. If you dont realize that the upper 2nd premolar has two
roots, and is really following the same morphology as an upper first premolar,
6
Transcribed by Mandy Weil 10 October 2014

youre gonna go drilling in the center and find you come out the furcation. So its
really important, because if you have bifurcated tooth, youre gonna make your
access more oval. And youre gonna really be looking more buccal and lingual for
your canals.

[122] [Picture--difficult tooth is in upper right corner]
[Fleisher] This is just different types of scenariosOf course these two are very,
very challenging. And maybe at another time in another lecture, I actually have a
picture of another case like this, which was very, very hard. Anyone who wants to
see the picture can email me.
It was very hard because what, because what you have to do in a case like that is
actually rely on the increased width of the coronal and middle thirds. And then be
able to curve your instrument in two directions. And then when you place your
gutta percha, you have to place them side by side. So to have enough space here,
without weakening the root, to be able to seat them apically as it branches off at
that apical third.

[123] [Picture]
[Fleisher] [referring to image on upper left] My favorite teethUpper first
molars. Why you may ask? Because when theyre filled, theyre really beautiful.
Theyre flowing. They have a poetry I know it sounds strange.
Endodontistswell, all dentists are strange sometimesBut it just has a
beautiful flow. A real beautiful flow. And when you look, for example, here, this is a
beautiful example access cavity. Youre not impinging on the marginal ridge.
Youre not coming too far buccal. And I want you to see that your distobuccal canal
does not lie on the same plane horizontally as your mesiobuccal. But look at
something else. If you look at the profile of the tooth, along the buccal, it actually
is mimicking that. Do you see that? It mimics the diagonal. So, when you go in and
do your access, you have to realize: this groove heremost of the time this
distobuccal is right under the groove horizontally across the transverse ridge. So
you go in the groove, across the transverse ridge. Into the central groove of the
tooth. Most of the time, your distobuccal lies right in this area. Then, you go up to
the mid incline plane of the mesiobuccal root, and thats where your mesiobuccal
lies. I dont worry about my MB2 right now. What I do is then take from my
MB1your mesiobuccal, and I go down to the mid-inclined plane of this palatal. A
lot of you, when you get ready to do your boards later on, youll see theres a tape
or something where I say dont go to Florida. Take that bottom to Texas. Well,
when I was teaching the NERB review, I would always identify this lower left
corner as San Diego. Here the middle of the palatal size as Texas. And over at the
far right, Florida. Because so many of the students were taking and making their
triangle going so far to the mesial on the palatal that their triangle came in this
direction. So always remember that your palatal orientation is to the center. The
middle of the incline plane of your palatal cusp.
[referring to image on upper right] Heres a second molar. You can see how much
narrower and how really more compact and tight that access cavity is. Because as
7
Transcribed by Mandy Weil 10 October 2014

the teeth move distally in the mouth, the roots become more convergent. And the
teeth reallythe pulp chambers come closer together.

[124] [Picture]
[Fleisher] Here we see a mandibular first molar. The distal canal is not very
distal at all. The distal is really right in the center. the Distal orifice. And, your
mesiobuccal lies reallythis should even be more exaggerated. You see how it
pulls? Its not exactly an equilateral triangle. It pulls mesially. The mesiolingual
lies lingual, but not as far as you would think. And why is that? Because the way
the teeth are inclined, your access is always gonna be towards the buccal of the
tooth.

[125] [Remember]
[Fleisher] Remember: straight line access. Straight line access doesnt mean that
you look down and you can see all your canals at once. That is almost a
decrownization. Removing of the whole crown. What you want to be able to do, is,
for example, use your access endo explorer and make sure that you have straight
line access into every orifice without hitting any of the dentinal walls. It doesnt
mean you have to just open the tooth and visually be able to see everything all at
once. And really also, whats important at this step is really is really the long
shank slow speed.

[126] [Troubleshooting]
[Fleisher] Troubleshooting: remember to verify the long access of the tooth. You
want to verify it before the rubber dam is on. You would have no idea, looking at
this tooth, which now has a rubber dam in place, which way to go unless you
examined it beforehand, to know that you have to go in a more lingual approach.

[127] [Picture]
[Fleisher] Some common mistakes; really, I stop multiple times and use my
explorer to see where I am because its really easy to just overshoot the canal and
end up finding yourself on the facial aspect of a tooth. Okay. Always look at the
incline plane. Look at the angle of the crown in relation to the long axis of the
tooth.

[128] [Remember]
[Fleisher] Remember but be aware that a tooth with dens in dente (spells it out)
will really be a tooth that is actually a nightmare to try to do endodontically.
Because whats happening is you find yourself in this almost like maze of pulpal
and dentin structure. Because its dentin and the pulp almost all convoluted
inside. Its a very difficult, difficult, difficult case to do. Also know that
teethknow your anatomythat teeth that tip very much roots toward the
palatal, its very easy to come out towards the facial. (coughs) Yes?

Student Question: Can you diagnose dens in dente from a radiograph?
8
Transcribed by Mandy Weil 10 October 2014


[Fleisher] You can, sometimes. What happens is, it almost looks, when you look at
the film, it almost looks like gray and whitelike a swirl sometimes. But also, if
you look at the lingual aspect of the tooth: a lot of times it has Its not like a
lingual groove, but it has a little anomalous type of structure on the lingual
surface.
Also this last is the common mistake of just keeping going. And where some of
you will have your pitfall is if you are in a sea of water, that youre doing your
access with, you wont be really able I do all my accesses.access cavities
without water. And then I rinse off. Because its really hard, unless you have an
assistant standing there, to really be able to visualize, while youre in a slurry of
blood, dentin and pulp. You cant see. And so, a lot of times, a lot of students keep
going and going and going waiting to feel that drop. And the drop they feel is
really coming through the furcation. Into the osseous. Into the bone.

[129] [Enjoy Endodontics]
[Fleisher] Okay This is the end of this first slide, this first section Now Im
going to switch to the other one.

[Endodontic Treatment Planning]

[2] [Sequence of Events]
[Fleisher] Endodontic Treatment Planning
Okay. Theres always a sequence of events when you see a patient. The first always
starts off with a medical history. Especially if its a patient in an Urgent Care
setting. Alright? But even if its a patient thats already in recordthe status of
their medical history can always change. Medications change. Blood pressure
status changes. Always medical history. Okay? And thats before any treatment is
given.
A subjective history. A subjective history is a nice big word for what is the
patients chief complaint? What are they telling you? What are they saying when
they come into your office? That is their interpretation of whats happening. Its in
their own words.
Objective diagnostic testing. Those are things that you use to be able to definitely
diagnose what is happening. Its things like an electric pulp tester. Cold test.
Radiographs. Percussion. Palpation. Transillumination. Everything that when you
do them in sequence, really, youre able to tease out the answer.
Analysis.Your analysis is your diagnosis. Youve figured out whats happening.
And your plan of action. Thats your treatment. You have to understand, after your
diagnostic testing, you should come up with about 3-4 things thats a possibility.
And as you move on with your objective diagnostic testing, youre beginning to
prove what the symptoms are a reflection of and what they are not. Alright?

[3] [Medical History]
9
Transcribed by Mandy Weil 10 October 2014

[Fleisher] Medical history. Of course, everything is pretty obvious. Medical
conditions, hospitalizations. Medications. Any alcohol, tobacco, or drugs. But the
last thing hereany noticeable signs and symptoms that may indicate an
undiagnosed health problem. Youd be amazed how being in the dentists chair can
actually be the first avenue of determining a lot of disease. Sjogrens syndrome,
diabetes. A lot of things that are not necessarily picked up because the patient
doesnt go to a physician.

[4] [Subjective History]
[Fleisher] So what is the subjective history? The patient will tell you where the
location is. Youll say, where is it hurting you? The intensity. How much is it
hurting you? Has it been constant since it started or do you find its really worse
in the morning when you wake up? Or is it something that really increases during
the day? What is the duration? Does is last all day, do you get any relief?Does it
come or go according to any thermal, hot or cold, foods that you eat? What spurs it
on? Is it chewing? Is it laying down? and What brings relief? Patients who have an
irreversible pulpits in the first stagethey will have extreme sensitivity to cold.
That so many of them will say, Oh, it feels much better when I put my tongue on
it, or have something warm. The second stage of irreversible pulpitsthe patient
may come to you with ice cubes in their mouth because a hot cup of coffee in the
morning set off such a horrible, horrible pain that the only way they can get it to
diminish is by applying cold. And, is it something thats just spontaneous. Okay?
These all give rise to a tentative diagnosis. This is where youre going to really try
to get your differential diagnosis. Youve got to confirm. Youve got to confirm by
objective diagnostic testing.

[5] [Objective Diagnostic Testing]
[Fleisher] Heres your list. Most of the things I mentioned. Youre gonna visually
examine the patient. That means youre going to stand in front of that patient to
look at them full face forward. So many times, the operators are so small that we
really say hello and greet our patients standing on the side of them. You only see
half their face. Its important to know: is there swelling? is there a droopy eyelid?
Did the patient wake up really thinking it was a tooth problem where theyre
having a TIAa transient ischemic attack. Where they have a mini-stroke, and you
see the whole side of their face is drooping. So a lot of things are really first
assessed by your visual assessment of that patient.
Radiographs. PA and bitewing. Dont underestimate good diagnostic films.
Percussion. What does percussion tell you? Ouch. My PDL hurts. Thats all it tells
you .It doesnt tell you more than that. Percussion sensitivity can come from
occlusal trauma. It can come from a necrotic tooth. It can come from the end stage
of irreversible pulpitis thats causing a large inflammatory reaction by the release
of inflammatory mediators. So dont be fooled just cause theres a radiolucency and
its percussion sensitive. Or if its percussion sensitive it designates endodontics.
It does not.
10
Transcribed by Mandy Weil 10 October 2014

Palpation: you want to also feel along the outline of the bucccal and palatal or
buccal and lingual areas where the roots lie. And you want to feel the adjacent
areas and the contralateral side. You want to get a baseline to really determine
what the patients symptoms are and if theyre really, if they have the same
problem all throughout their mouth. Because then its not something just
identifiable with this one tooth.
Alright, you want to see mobility. Is this a perio problem? I mean everybody
really likes to jump and say Oh! Its always endo. Most of the time it is not endo.
Electric pump test. I always say EPT in front of a patient. Anything. But the word
electric makes them very nervous. You have to realize though, that when you do
your electric pulp test and when you do your Endo Ice, its very, very important to
have complete isolation of the gingiva with cotton rolls. Otherwise the electricity
is conducted through the saliva and the endo ice wicks to the gingiva. So youll get
a gingival response. Youll get a non-diagnostic response. Also in very calcified
teeth, you will not get a very viable diagnostic response with endo ice. The
tubules are too calcified. The pulp may be too receded. If I get a negative response
from endo ice in a case where I can see the pulpal chamber is very calcified and
receded, I always diagnostically check with an electric pulp tester.
Alright. Periodontal probingvery important. Theres always a perio probe on my
examination tray. Thats why its in yellow. The things in yellow. PA and BW
radiographs, periodontal probingyou wanna rule out any etiology that may be
contributory. Is it perio? Is it perio-endo? Alright?
A test cavity. Well, when would you use a test cavity? When you dont have the
access to have any ability to do any diagnostic test on tooth structure. Also realize,
the diagnostic test on the tooth structure cannot be on any restoration. You cannot
but endo ice on a composite or an amalgam or a crown. You cant put an electric
pulp tester on a composite, or an amalgam, or a crown. It has to be and really
mid buccal is ideal.
Transillumination, thats really very helpful in detecting fractures. It cant detect a
root fracture because you cant transilluminate through the osseous. But, it will
help detect fractures on the pulpal floor and through the coronal tooth structure.
Where, your job is to trace out that fracture line and make sure that it doesnt
continue down to a point where that tooth is now non-restorable.
And, ocllusion. Occlusion, occlusion, occlusion. Occlusion Is usually the thing thats
overlooked. Its the simplest to correct and so many cases are just occlusal trauma.
A patient gets a new crown or a new filling, their bite is completely different.
Also, your occlusion is dynamic. Its fluid. Its always changing according to how
much you grind your teeth, how much you clench your teeth. What kind of diet
you haveAnd I think I used this as an example. Its getting your car tires aligned
and then going over a pot hole. You need an alignment again. So always check
occlusion. And check occlusion in centric relation and centric occlusion. The
patients occlusion isnt the same when theyre laying down versus sitting up.

[6] [Analysis of Data Collected]
[Fleisher] You take all this data and what do you doyou make your diagnosis.
11
Transcribed by Mandy Weil 10 October 2014


[7] [Predictable Endodontic Therapy]
[Fleisher] Okay so we have a medical history, pulpal diagnosis, perio. Is it
restorable? Will there be a feral effect? Will a crown crush this tooth? What is the
crown to root ratio? And all of that you have to weigh againstis this predictable
endo? Is this predictable endo? In a day and age where everyone is so quick to say:
Im gonna pull out this tooth. Its gonna be more predictable to put an implant
in. Dont go there. Because implants fail too. And then you have no place to go.
But, you cant go through all of this if its not a predictable result. You have to
really, really ensure that what you do is in the most predictable fashion for the
patient.

[8] [SBE Prophylaxis]
[Fleisher] SBE prophylaxiswe keep up to date on that. Alright? If theres any
question, never hesitate to get in touch with the physician.

[9] [2 g Amox...]
[Fleisher] And most of the time, I do get in touch with the physician. Because I
like to document personally that physician insists on pre-medication. Even if the
regimen says it isnt needed by my dental association. I will then write insisted
on by the physician. and I do that with pregnant patients too. In my book:
physician is the bottom line for any medical clearance. And, it also protects you in
your chart. Because they say, Well you never asked my doctor and he always
wanted me to take this. Okay? So Im never shy about double checking.

[10] [Diabetes]
[Fleisher] Diabetes. We dont see it often, because most diabetics are now
controlled. But we cannot treat endodontically an uncontrolled diabetic. Actually, I
dont think in the clinic, you should do very much on the patient at all. Thats a
very severe health status and the patient should have a medical consult. If you do
have diabetics: Schedule them first thing in the morning. And have a sugar source
available. A lot of dentists offices have some juice. Orange juice gets very readily
in the blood stream. And, you want to make sure, I check with the patient: Did
you have your insulin this morning, and did you eat? Dont be afraid. Dont think
theyre silly questions. A lot of patients say, Oh, I didnt want to eat because I was
coming to the dentistI didnt know if I would, you know, feel too full. It is
amazing. Just ask. Just ask.

[11] [Pregnancy]
[Fleisher] Avoid treatment in pregnant patients in the first and third trimester.
But also know I am never shy to ask the OB/GYN second trimester. Because
youre relying on the patient to tell you their dates. I mean, lets face it, you know,
then theyll say Well, I really wasnt sure of my date. I dont know which
trimester I check. I really check. Okay? Of course, you know, you keep
radiographic exposure to a minimum. And, if theres an emergency and you have
12
Transcribed by Mandy Weil 10 October 2014

to treat the patient, once again, you always call the physician. You get their
clearance. And I like to have it on a fax machine. Not a verbal okay. I like something
that I can put in the chart.

[12] [Dialysis]
[Fleisher] Dialysis patient. A lot of these patients will come with very
voluminous medical histories. but you have to make sure that what theyre
bringing you is current. A lot of these patients are not compliant with their
doctors who have some of these health conditions. So you have to make sure that
the paperwork theyre bringing you is valid and current. Okay? Everything thats
elective, we postpone until the day after dialysis. Elective means the patient is
symptom free. Theyre in between appointments. They dont have pain. Theyre
not in pain. Its not a painful urgent care emergency. Alright? Also know, dialysis
removes certain drugs from the circulation and can shorten the effect or the
half-life of some medications. You want to avoid aspirin or acetaminophen. Or you
want to lengthen the interval between doses. Okay? Because they stay longer in
the bloodstream. PenVK, cephalexin and tetracycline. Require increase doses
because theyre cleared out much quicker. And Erythromycin stays the same.
There is no change.

[13] [Latex Allergy]
[Fleisher] Latex allergies. This school is now latex-free. We have non-latex
rubber dams and latex-free gloves. In my office, I personally use latex gloves
unless my patent has, um, tells me they are latex allergic. Why? Because you have
much better feel in the tips of your fingers with a thin latex glove. It was quite a
transition when this school went to the purple gloves. All of us, who really rely on
our fingertips to feel so much, it took a lot, first of all, I was trained when we
didnt even use rubber gloves. It was just before the AIDS epidemic. And so, going
from that to wearing rubber gloves was quite a jump. And I thought I could never
get used to that. But now I find usingand I use a powdered globe because i
change my gloves so frequently that it really allows them to go on nice and
smoothly. But its going to depend on what you can tolerate and whats the most
comfortable for you.

[14] [Psychiatric and Behavioral Considerations]
[Fleisher] Psychiatric and behavioral considerations. Now stress is a very
important component when it relates to dental treatment. About 1 in 5 people
avoid the dentist altogether because they cite fear as the reason. So, you have to
be sensitive. And Im not even talking people who may have bipolar disorder or
other behavioral issuesThe average person is frightened to death to really sit it
your chair. I had a dental student this morning who wanted me to check a tooth
that was bothering her. It ended up being occlusal trauma. But I wanted to do endo
ice. And she goes no, no, no! And this is a dental student. So, imagine how you are
sitting in the chair. ItsA lot of patients really need your reassurance. Need you
to talk with them. Just speaking with them reduces their anxiety. Explaining what,
13
Transcribed by Mandy Weil 10 October 2014

taking that extra moment. They have found, in studies, and I dont know if its one
of my slidesbut in Urgent Care, I always talk about a study that was done in
England in the 60s, where, just talking to the patient before an operation. This
was a medical study with physicians, reduced the need or a morphine drip by
50%. I mean this was actually able to be calculated. The patients actually came out
of the procedure calmer, with less anxiety. Its really important. That is one of the
main, main underlying techniques in pain management.
Okay. Now, lets also check for drug interactions and side-effects. We have to hope
patients are honest with us about their medical history. Many are not. Some not
because theyre trying to be dishonest. But theyve actually told me: Well, youre
a dentist. I didnt think you needed to know that. So when you go over the
medical history, really make sure you underscore to them. ITs really important.
Anything. Even over the counter medications.St. Johns Wort? Is that what its
called? Yes. It has tremendous effects. And its all natural. Alright? (inaudible
student question) Consult with the physician. Consult with the physician.

[15] [Systemic Contraindications]
[Fleisher] OkaySystemic contraindications for elective. Now, when Im talking
elective, that means the patient needs a prosthetically indicated root canal. We
dont like to call them prophylactic endo. If I said to you: Im taking out your
appendix prophylacticallyyoud run away from me. Youd say: theres nothing
wrong with my appendix. But, if you need to have a root canal in order to make
the restoration work, then it is indicated. Youre not doing it for a prophylactic
measure. Youre doing it cause you cant get retention with your post or your
crown. Your restorative end will fail. So, its prosthetically indicated. Thats
something that would be an elective procedure. Okay.
An MI, a myocardial infarction within the past 6 monthswithout medical
clearance, I dont touch a patient. Unless it is an urgent care need with medical
clearanceand then I get medical clearance. Alright. And of course an
uncontrolled diabetic. And I dont know if you want to call that a systemic
contraindication, but first trimester of pregnancy.

[16] [Radiographs]
[Fleisher] Radiographs. Always take your own Pre-op radiographs. This is a
recurrent theme that I put in my slides. Never make a diagnosis based on
radiographic evidence alone. It is another one of your objective diagnostic tests.

[17] [Periodontal Status]
[Fleisher] What is the Perio status? You cant build a house on quicksand. So
here you have a tooth, but its mobile, its probing 10 mmand its below the CEJ.
I could do endo on anything. But if its not retainable, theres no reason to.
Alright? Perio is king. I always say perio is the king. Because if perio is not good,
nothing will last, nothing can stand on it. Alright. Perio probing. The first thing I
do before I do an endo case, I record the perio probings. Cause I also wanna know,
if there is a problem in the middle of my case, has the probing depths changed?
14
Transcribed by Mandy Weil 10 October 2014

Alright. A significant pocket with the absence of perio disease means the whole
mouth is, ({?} cannot discern one word at 1:00:20 left in podcast) of any perio
disease.
So youre probing, a tight probe, 2 mm, 2mm, 2 mm, you drop down to 9. You come
up. 2mm, 2mm, 2mm. That may indicate a vertical root fracture. Cause what
happens is, the PDL detaches along that line of the fracture.
Alright, and poor perio prognosis of course it makes sense now is a
contraindication to endo therapy. And an ethical endodontist will not do that. And
a really good practitioner will know not to send the case to the endodontist.

[18] [Vital tooth]
[Fleisher] Okay, a vital tooth with a perio lesion. Now let me talk about perio
lesions. If you see an area, a radiolucency, around a tooth, if the tooth tests vital,
the etiology of that radiolucency cannot, cannot be from the pulp! Because the
tooth is healthy. So what is that radiolucency from? Its either gonna be from
something very bad thats going to require a biopsy. Or, perio in nature.
OkayWhen I first came here There wasActually Im gonna turn this off:
((She tells a story about working at U. Michigan and a dental student who wanted
to do unnecessary endo))
Mic on:
So, when you have a radiolucency that cannot have its etiology due to the pulp,
that means the pulp test vital, and youve done the vitality test the correct way.
You have to then look for its true etiology. Now, when you come to something like
this, and you say Is it perio or is it endo? Well, you test the vitality. And if a
tooth tests vital, you know that the pulp is not contributing to that bone loss. So
you have say to yourself Wow. This is a perio lesion. This tooth has no chance.
Its lost. Thats why periodontists have patients for life. Because the perio doesnt
go away. You can only maintain perio disease. And keep it under control. There is
no cure for it. So if the tooth is vital, and theres bone loss, and you see a
radiolucency.you have to look elsewhere. Now by the same token: If this tooth
was necroticthen you say: Well, you give the patient the option. Because if
youre probing straight through, you have to realize, once the band of attachment
is gone at the CEJ, youre never gonna get reattachment again. Youll get a long
epithelial junction, but youre not gonna get sharpeys fibers going back in that
tooth. Youre not gonna get a real attachment apparatus going in that tooth. So,
what we hope for is the bone thats lost from the endo etiology will regenerate
and will fill back in. But what was lost to the perio component will not.

[19] [Vital tooth]
[Fleisher] So, thats a case by case decision. And Im really sorry, cause this was
in my office when we didnt have digital films. And trying to reproduce this was
hard. This is a vital tooth. This is a pure perio lesion. Pure perio. Now someone
would say: well, look at how calcified this is. This is a virgin tooth. This is a
virgin tooth. Look how calcified this canal is. This is pure perio.

15
Transcribed by Mandy Weil 10 October 2014

[20] [Perio Status and Restorability]
[Fleisher] Perio Status and Restorability. Its very important, and I know its
hard to hear an endodontist really harp on the perio. The perioBut really, my
work, I will not let someone say the endo has failed, when its perio. So I wont go
into a case that I know is doomed for failure. Also, I couldnt ethically think along
those terms. But aside from that, I want you to be educated, to know to look for
these things. Also, root caries. This is a non restorable entity. Periodontal probing.
You have to make sure youre going in the long access of the tooth.

[22] [Analysis]
[Fleisher] So: analysis. Here we are. Were gonna analyze everything. So we have
our history, our examination, our diagnostic testing. Now, we arrive at a clinical
diagnosis. We arrive at a pulpal diagnosis. And a periapical diagnosis.

[23] [Treatment planning]
[Fleisher] Treatment planning. All of our decisions are based on everything we
talked about. The medical history. The pulpal diagnosis. The periapical diagnosis.
The restorability. The periodontal considerations and the financial considerations
of this patient. Maybe an indirect pulp cap in a patient that you know if you tell
them that youre in the pulp and youre gonna have toI mean, a direct pulp cap
is not as predictable, if you want to use the word predictable for an indirect pulp
cap. But youve boxed the patient in with less of a chance to save that tooth. So im
very, very aware if a patients finances cannot yield optimal treatment. Thaton
many outreaches where we go, Id rather do an indirect pulp cap than do a root
canal and know that next year when we go visit them on the outreach, the tooth is
fractured cause theres no crown on it. So, you have to also work with the patients
and be compassionate to their needs. Okay?

[24] [Successful Endodontics]
[Fleisher] So, how do we get successful Endontics? Everything funnels in
together. Are we able to restore it? What is the perio status? And really, what is
the medical history?

[25] [Is root canal therapy indicated?]
[Fleisher] Is root canal therapy even indicated? Should I carry this out myself or
send it to a specialist? Its gonna depend. If you have a dilacerated root, that has a
90 degree bend, I dont even want to see that in my office. So its gonna depend on
what the root morphology is, the apical morphology, the diagnosis and the pulpal
space and also the malposition of the dentition. Some teeth are very hard to get
access. When you have lower anteriors that are all crowded and overlapped, its
very hard to get a rubber dam and its very hard to get access because the toot
adjacent to it is actually sitting against that lingual aspect of the tooth.


[26] [Other considerations]
16
Transcribed by Mandy Weil 10 October 2014

[Fleisher] Other considerations. What is the existing restoration? Have you even
suspected a fracture? Is there resorption? Is there internal resorption? External
resorption? Is there a history of trauma? is this a retreatment case? Are there
perforations? And when is an implant perhaps really the best option?

[27] [Treatment planning]
[Fleisher] So your treatment planning takes all of that into account. And, you
have to understand, root canal is indicated when the pulp cant recover. The pulp
cant recover when its in an irreversibly pulpitic state or its necrosed. And I am
revisiting what prosthetic needs are indicated. And thats an elective
prosthetically indicated root canal.

[28] [Following Endodontic Treatment]
[Fleisher] Okay, following endo treatment, I cannot think of any exception where
all posterior teeth must be restored with full coverage. The teeth become dry,
brittle, you have to realize that the dentin becomes dehydrated and the tooth is
very susceptible to fracture. A post may be required if theres insufficient
structure to retain the core. And, anterior teeth may not require full coverage at
all. Thats why you should be conservative.

[29] [Enjoy Endodontics]
[Fleisher] And more than anything, I see were ending early I want you to
enjoy endo. If there are any questions, Ill be glad to take them.

Note: Slides 21-27 on the NYUClasses powerpoint were not in the lecture. Refer to
title of slide.
17