One poke or two??


2TheApex:  Two inferior alveolar nerve blocks (IANB) are more effective than one in both symptomatic and asymptomatic patients.

A recent article published in the Journal of Endodontics showed that administering 2 carpules of local anesthetic was significantly more effective at achieving profound lip anesthesia.  3169 people participated in the study with failure rates of 7.7% with one carpule, and 2.3% with two carpules of 2% Lido with 1:100,000 epi.  Although this may seem like common sense, it is the first article to show that increasing volume will increase IANB success rates.  This study only examined anesthetic success in terms of lip numbness, not as a pain free procedure.  As we all know, pain can still be present during the procedure even with profound lip numbness. However, adequate anesthesia will almost never be achieved without first achieving lip numbness as a sign of a successful IANB first.

Which irrigating solution is the best?


2TheApex:  Sodium hypochlorite

An ideal endodontic irrigant disinfects the canal, act as a lubricant, removes debris, dissolves tissue, removes the smear layer, and is safe for the patient.  Although there is no perfect irrigating solution, one does stand head and shoulders above the rest: sodium hypchlorite (NaOCl).  In a review article of irrigating solutions, Haapasallo stated “It is difficult to imagine successful irrigation of the root canal without hypochlorite.”  Sodium hypochlorite cannot fill all the criteria by itself, and so a chelating such as EDTA is used to help facilitate smear layer removal, but no other irrigant fits the criteria of an ideal irrigating solution better.  There are risks to using sodium hypchlorite, and it must be used with caution to avoid extrusion into periapical tissues.  Other irrigating solutions have been shown to be potentially beneficial in some circumstances, but if possible they should be used as an adjunct and not as the only irrigant.  At this point in time, the research is clear that NaOCl is the best endodontic irrigating solution available.


What is that purple stuff in my access?


2TheApex: It’s PermaFlo Purple, a colored flowable composite.

Coronal seal has been shown to be critical in the long-term success of endodontic treatment.  (click on “Coronal Seal” for flagship research on this subject) PermaFlo Purple is a flowable composite that will provide an excellent seal and is easily identifiable for when the Cavit is removed after treatment for the final restoration or if retreatment should needed in the future.  It is useful in teeth that have deep caries or small crack making a coronal seal with Cavit questionable, or in patients that may have difficulty returning for a final restoration within the 30 days recommended following root canal treatment. It is bonded and placed as a thin layer, so does not need to be removed and can be bonded to just like any other composite restoration.


What is Gutta-Percha made of?;-paper-point-gp.jpg

2TheApex: 65% Zinc Oxide; 20% Gutta-Percha; 10% metal sulfites; 5% waxes and resins (Friedman)

It’s mostly Zinc Oxide.  We call it Gutta-Percha since that is what gives it unique properties we enjoy, like plasticity.  The material was used as an obturation material over 100 years ago.  It comes from the sap of a tree that grows in Malaysia.  It is also safe to use in patients that are allergic to latex.  (American Latex Allergy Association)  Gutta-percha has stood the test of time and it still the standard by which all obturation materials are judged.

How do I do an oral cancer screening?

2TheApex: Very Easily

Oral cancer still has a poor 5 year survival rate although it has improved in the last 10 years to 57 percent.  Early detection is key!  Taking the time to do a screening could save someone’s life.  Here is a video on how to perform a comprehensive screening.  It’s worth the 11 minutes for a refresher.

Early in my practice this patient was referred for treatment of tooth #15.  I found this tongue lesion upon exam.


The lesion was squamous cell carcinoma.  It was removed in total by an oral surgeon and the patient needed no further care.

April is Oral Cancer Awareness month.  Click here for info on how to promote it within your practice.

Can you call in a RX containing Hydrocodone?

2TheApex:  Not any more (as of today)

Effective today any medication containing Hydrocodone is Reclassified as Schedule II.  Yes, Hydrocodone combined with Tylenol is now Schedule II.  (Click here for the DEA ruling on this) This means you CANNOT give an oral order for Hydrocodone.  The pharmacy will need a physical prescription brought in to the pharmacy.  Back to writing (or printing) and signing paper again.  No more phoning it in unless it’s an “emergency.”  Click below for the rules in our area.

Wisconsin           Minnesota         Iowa

Weekend pain control after October 6, 2014.  First determine the patients pain level and how they are currently trying to control it.  Sometimes patients are inadvertently doing things to make the pain worse. (Like placing ice on an swelling caused by infection)  Be sure they are taking OTC pain medications properly.  Taking 800 mg Ibuprofen every six hours with an Extra Strength Tylenol (500 mg) staggered between the Ibuprofen can manage most pain we encounter.

Other options:  Call in for Schedule III (Tylenol III) or call Hydrocodone in as an “emergency” and most states will allow you 7 days to get them a physical prescription.

Another medication that works well for dental pain is Ultram (Tramadol) Schedule IV

If you think the pain source is primarily inflammatory a Medrol dose pack can be very effective.

When prescribing, the patient’s heath history is paramount as well as current medications and allergies.  A proper diagnosis is always critical to managing a patient’s pain.

What do you plan to prescribe for a patient, if needed, after hours?

Is diagnosis more challenging with a patient taking Ibuprofen?

2TheApex: Yes!

If a patient has been taking Ibuprofen symptoms can be masked.  Read found palpation to be masked up to 40% of the time.  Cold response was masked 25% of the time.  Be sure and ask patients if they have been taking any NSAIDs and at what dosage prior to pulpal testing.  The bite stick test is one test that seems to be least affected by taking NSAIDs.  We encourage patients to cease taking any pain medication at least 6 hours prior to the appointment if it sounds like the diagnosis might be challenging.

Can you take a tax deduction if you are producing crowns (CEREC or similar) in your office?

2TheApex:  YES!


Disclaimer: We are not a source for tax advice nor are we accounting professionals.  Please consult a CPA to be sure this applies to your office and makes financial sense.

Domestic Production Activity Deduction (DPAD) is the production or manufacturing of tangible property within the United States.  Milling crowns in the office is considered by the IRS to be a manufacturing process.  The deduction is 9% of the net income from the CAD/CAM process. This may be worth contacting your accountant if you think it could apply to your practice.  Is the deduction enough to justify the additional paperwork your accountant will need to claim the deduction?



What is successful root canal treatment?

2TheApex: A functional, asymptomatic tooth with no clinical signs of pathosis can be considered successful even without complete healing of the ligament.

Endodontic success has traditionally been defined as the prevention or elimination of periapical disease following root canal treatment, meaning both complete healing of the PDL radiographically and absence of symptoms clinically. However, utilizing CBCT to evaluate PDL healing Patel showed a 25% reduction in “success” compared to periapical radiographs. Many of these teeth are still in function, asymptomatic, free of active disease, and esthetic; yet fail to meet the above, very stringent, definition of endodontic success. Has treatment been unsuccessful in these cases? How do we measure success clinically? Does it really even matter what definition we use for “success”? Having a clear definition of success is important because treatment plans are be based largely on the prognosis of treatment options. Endodontic treatment and implant placement will frequently be compared, however most implant studies define success as simply survival of the implant. (Iqbal) Helping patients maintain their natural dentition is a primary goal of endodontics, and a definition of success that emphasizes survival more closely aligns with both patient goals and allows for the most accurate comparison of treatment options. Doyle addressed this discrepancy directly by analyzing both the success and survival of implant and endodontic treatment, which resulted in almost identical success and survival rates. A financial evaluation, however, shows that in most circumstances endodontic treatment is the most cost effective option. (Pennington)

preop #30

Pre-Op #31 Pulp Necrosis with                                 Chronic Apical Abscess

Post-Op #31

Post-Op #31

18 Mo. Recall.  Asymptomatic.

18 Mo. Recall. Asymptomatic. Case by Dr. Nordeen