root canal or wait?

[sheck33]

i have had several rootcanals so far, every time i have gone diving 1 or 2 days later, never had any problems. Even with a temporary filling or crown i have gone diving the next day.
just my experience.

 

[Laurence Stein DDS]

sheck33,

Actually, that's not unusual. There is no hard and fast rule that a root canal needing tooth is gonna hurt on a dive.

The problem is logistical and ethical.

If you don't want a problem with a tooth needing a root canal during your dive trip then get it done before you leave. If you don't want a problem with the tooth imploding during a dive following a root canal then ask the dentist to eliminate any air spaces under the temporary. If you don't want the possibility of aspirating a temporary crown (which, by the way is impossible to see on x-ray) if it is fabricated of plastic, then don't dive with a temporary crown on.

That being said, and with all due respect, knock yourself out.

Ethically, a professional must recommend the safest course of action and the most appropriate treatment.

Most root canal procedures do not hurt before, during or after treatment. Most temporaries don't come out or cause the tooth to emplode and most temporaries stay on UNTIL you are boarding the plane on your way to you dream dive. It's a Murphy's Law Corollary, as is the farther you traveled into the Third World, the more likely you are to need some medical help. Which witch doctor would you prefer?

Considering the total number of untreated root canal teeth in this world and the number of marginally treated root canals already done, I'd say the likelihood of you needing that root canal or temporary is extremely rare.

If you're asking my opinion, (and you didn't) the single most dangerous part of this whole venture is diving with a temporary crown (not the permanent crown). Many foods and snacks (gum, caramels, dried fruit, milk duds, licorice, ice, nuts and even bread) stick to the surface of temporaries and lift them off when you chew. This isn't so terrible if you happen to swallow them but if that sucker gets into your lungs....especially at depth, you could be a permanent statistic.

If you survive, then you're gonna call your dentist on the weekend or perhaps 3AM and he's going to have to make a new temporary or do a little surgery to remove the skin that grew in around the prepared tooth OR the new permanent crown won't fit because the surrounding teeth moved "just a little".

If it's an HMO...no problem he just grind on the crown and fit it with elbow grease, trapping the excess tissue under the now crummy fitting crown. Hey, so what if the margin leaks because there was a wad of dead skin cemented under the crown and it rotted away. You just get to make another a year or two later...unless you became that statistic I was talking about.

Of course, no self respecting HMO dentist will come in on the weekend!

Please excuse the "rag". I mean you no ill will or disrespect. I wish I had a nickle for every person who has called me about their temporary falling off while eating candy and they were out of town. Yes, these are the same people who call me at 3 AM asking what to do and they are 3000 miles away.

You're post simply brought a wry smile to my face and somewhere there's going to be an "I told you so" coming.

Enjoy the rest of your diving weekend.

All in good fun,

Laurence Stein,
:doctor:

 

[sheck33]

yea i agree, of course i am pushing it, but i just wanted to share that, i guess, most dentists do a good job
yea maybe one day i will not be lucky and swallow a temp crown, i hope i dont choke on it

 

[Laurence Stein DDS]

sheck33

You're a good sport...just be careful out there.

Larry Stein

 

[BigJetDriver]

Laurence Stein DDS once bubbled...


Speaking about assuming stuff.

I always ASSUME that when the plane is landing, that there is a runway in front of us. I also assume that you guys never pee cause I never see you walking around.
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(Jet69 Response) Actually, we make the same assumption about the runway when landing at Gatwick in the dense fog at 0800 GMT. Fortunately, given all of our instrumentation, that assumption works out to be true!

As for your assumption about pilots not peeing, you see that's just another of those "failed assumptions"! We do have to pee, but since 9-11 they won't let us out of our box very much. What do you think those foam cups they keep passing up to us are for?
-------------------------------------------------------------------------

(The Doc) I also assume that when we take off or land that there is enough runway...that was not always the case at Grand Cayman Island. I can remember taking off to go home years ago and the pilot gunned the engines in a plane that had every seat filled and then some. He accelerated onto the gravel runout and made a hard left turn.

He continued to gun the plane. I heard the wheels return to their perpendicular position at about the same time as we crossed the opposite runout and ajacent water.

I think I'm gonna stop making these assumptions too.
----------------------------------------------------------------------
(Jet69 Response) Since receiving the mighty Cessna Caravan, with its huge prop and extremely powerful turbine engine our friends, "The Pilots of the Caribbean", have redefined the theories of lift versus drag and weight, and performance versus air density. As far as I can tell, the belief is now that: "If it will fit inside the cubic confines of the machine, it WILL fly!" Fortunately, given the engineering assumptions of the aircraft designers, that one seems to work most of the time!
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(The Doc) Oh yeah...That stupid GPS moves much too slow on the seat back in the 777 when flying from Miami to Heathrow. I assume your's works better.
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(Jet69 Response) Hey, if you want to see a GPS plot moving WAAAY too slowly, you should watch it creep across the map on the Newark to Hong Kong Non-stop run! It gives rise to the saying: "When you are ready to scream and throw yourself out the window, you know you're halfway there!"
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Just a few light-hearted thoughts to amuse you all for the weekend! Happy no-bubbles diving (or bubbling, if that's your preference) to all!!!!

 

[Laurence Stein DDS]

That brought a big grin to my face!!!

Larry Stein:teeth:

 

[GreatInca]

I haven't had any problems diving after dental work. My dentists main concern was getting my wisdom teeth out becuase 3 of my second molars were being hollwed out from cavities between by 2nd/3rd mollars and my lower left one barely had anything left between cavity and root and narrowly avoided a root canal. He said I had a wonderful immune system . But no problems diving though (acutally I snorkeled at the time but did go below 30 feet).

 

[Laurence Stein DDS]

Hi
GreatInca,

Wisdom teeth are not usually a barotrauma problem. However, if they are erupted, they can become decayed just like any other tooth. In fact, when partially impacted, these teeth can decay while still covered with skin. Then they are subject to all the same problems your other teeth could have.

The problem you discribe is quite common...especially in horizontally impacted situations. The crown of the wisdom which is made of enamel--the hardest substance in the body can make contact with the cementum and dentin of the second molar directly in front of it.

As you chew, the erupted second molar is able to move just slightly up and down. The enamel of the impacted 3rd molar (wisdom tooth) may be in contact with the root of the 2nd molar ahead of it. During jaw function, the enamel rubs through the cementum of the moving second molar...damaging the second molar. It creates an erosion.

If there is a partial eruption of the wisdom tooth into the mouth, then food particles, germs and assorted types of crud gets shoved between the wisdom tooth and the damaged surface of the second molar.

The net result is the loss of BOTH teeth. Generally, it is not possible to repair the defect worn into the second molar. It is too far under the gum to get to successfully. Even a root canal makes no difference because the tooth cannot be restored...so why bother with the root canal treatment? It sounds like you were lucky and got the erosive lesion/cavity at a level that was still restorable. We sometimes see these erosions 1/2 to 2/3 the way down the root and there is no way to fill or cap them.

There is another short term problem that could result from the extraction of wisdom teeth. There are cases on record of jaw fracture during the extraction of wisdom teeth. It is very rare but should be discussed.

A scuba problem results by diving too soon following wisdom tooth extractions (especially difficult extractions or small jaws).
The pressure applied to the mouthpiece of the regulator theoretically could result in a fracture if you go back to diving too soon following these extractions.

The greatest stress applied to the jaw is at the angle of the lower jaw where the wisdom teeth are located. You have a mechanical advantage over this bone created by lever action and the force is multiplied over the distance in front of the extraction site...torque. If your jaw is weak enough, you can break it.

You should explain your hobby to the oral surgeon or dentist who does the extractions for a time line before diving again.

There is no hard and fast rule about how long to wait. The farther back an extraction is, the greater the amount of bone sacrifice to free the tooth, the larger the diameter of the tooth, the difficulty of the extraction, etc., all come into play when making the recommendation on how long to wait. Even with good advice, people heal differently and a problem could occur even if you follow all instructions.

Finally, there is one barotrauma problem that can occur with partially erupted wisdom teeth...especially if the skin around them is swollen, infected or sore (percoronitis). If the infection disects downward along the inside portion of the lower jaw, it can open a "potential space" between layers of muscles. If this occurs, and you inhale a stream of air that just happens to blow into this opening, the result could be a cervical (neck) or mediastinal (chest) air emphysema--air can be forced into the neck or chest and the infected material along with it. This doesn't sound like a good idea to me.:wacko:

Anyway, be careful with wisdom teeth. Ignoring them when they are sore or putting off an extraction that has been recommended can create some long term problems.

I won't even get into permanent numb lips or tongues because patients have waited too long to extract and the root are near or wrapped around the main nerve to the lower jaw and lips.

Whew! I'm so glad I got that off my chest. I hope I made your day

Regards,

Laurence Stein, DDS
:doctor:

Disclaimer
(No representations are made that in any way offer a diagnosis, treatment or cure for any illness or condition, either discussed or implied. Answers to questions are offered as information only and should always be used in conjunction with advice from your personal diving physician/dentist. I take no responsibility for any conceivable consequence, which might be related to any visit to this site.)

 

[GreatInca]

I've already gotten my wisdom teeth extracted. Procedure was worse than rumors (Insurance wouldn't pay for twilight -- not sure if I would've wanted it -- still feel everything) but the post procedure went great, which was where most of the nightmare rumors were. Bottom wisdom teeth were mostly erupted but were still considered partial bony impaction on the insurance co-pay. All four had cavities with the upper right having decay to the root (what made be go get them pulled). No impaction on top wisdom teeth but 2nd molar still had decay from in-between (not nearly as bad as lowers though). Post procedure went great. Rapid healing, minimal pain, and no infection. Felt flu-like energy depletion (mental and phsyical) for about 24hours after the procedure. Bleeding at scapal site lasted about 8 hours. Got prescriibed tylenol codiene and amoxicillan and only needed 2 of the codienes because the socket pain was an issue for less than 24 hours. Gum soreness lasted about 3-4 days and codienes didn't treat that at all but worked perfect on the sockets, but gum sorness was quite tolerable.

Losing connection with scuba but I seem to have a problem with only getting partial anethesia when getting fillings and especially the wisdom tooth extractions. Waiting longer doesn't help at all. Anyway to get around that? Didn't feel the scapel on that lower right but that grinder thingy really was agaonizing - he squirted local (marcane i think but thought morphine under the Nitrous oxide) right into the socket and it made it much better (still felt it though but managable).

 

[Laurence Stein DDS]

GreatInca,

Your story is very familiar to me —both professionally and personally.

When I had my lower wisdom teeth extracted as a 15 year old, my regular dentist did it...one at a time. Neither one got numb and I got the worst “dry sockets”. Each one hurt for two weeks...I was miserable! I also learned a great lesson--do all the extractions on the same day and if you are nervous, the newer sedative medications are great. Versed, creates amnesia so you don't have to be so heavily sedated.

In the days of sodium pentothal, (which is still used successfully) nausea was a bigger problem. You didn't remember anything but you could have been sick to your stomach. Pentothal requires you to be more deeply sedated--not quite surgical anesthesia but you are out of it and, on occasion, you might have to be assisted with respiration if you were to get too deep.

No matter what was used for sedation, local anesthetic is also used for pain control.

Really bad impactions requiring hospitalization was more common then, and when done this way, general anesthesia rather than local anesthesia and sedation was more likely to be used. An overnight hospital stay was necessary.

My wisdom teeth extractions hurt so bad that I put off having my upper wisdom teeth extracted until I was a resident in a hospital. Finally, the Chief of Oral Surgery took out my upper wisdom teeth using local anesthetic and IV sedation. I was on call that night (following the extractions) and needed no medication. What a difference!

To this day, on the rare occasions that I’ve had to replace old fillings on my lower teeth, they won’t get numb...until my ex-partner used a different technique for anesthesia for the lower teeth. It worked perfectly and I use it to this day--mostly with great success. There are a few other “tricks” I use when even this doesn't work.

First, let me explain how local anesthetic works and how we us it in the mouth.

Local anesthetic works by preventing the electrical impulse generated at the nerve endings from passing along the length of the nerve. The impulse is created by a series of depolarizations along the nerve fibers. Wherever the depolarization occurs, the signal is stopped and your brain fails to get the pain signal.

Within the mouth, there are several ways to make nerves numb. Upper teeth are in softer, more porous bone and the nerves that go to the teeth enter the bone from under the cheeks. So to numb an upper tooth, just depositing anesthetic under the skin over the tooth to be treated is usually sufficient and rarely do upper teeth fail to numb. This technique is called an infiltration.

The lower teeth are a different story. The lower jaw is harder, denser bone on the outside and the nerve to the teeth enters a canal that is located about half way back between the vertical portions of the mandible. To numb the lower teeth you have to do a technique called a mandibular block...you must “short circuit” the nerve as it enters the jaw bone.

This canal is on the inside of the jawbone next to the tongue. There is a bony projection in this area called the lingula and if it is large, it can deflect the needle so you may miss the position you are aiming for. In most people, the opening for this nerve is at a predictable spot and with proper technique, you get the person numb.

Unfortunately, not everybody is built the same. This is called normal variations. These variations, however, can cause big problems getting people numb on the lower jaw.
Some of the variations are: A bifid nerve...rather than one nerve to the lower jaw on each side, one or both sides may have two openings and a divided nerve. Sometimes this is visible on a panoramic x-ray and sometimes not. Regular, small x-rays don’t go far enough back to even give us a hint.

With this variation, part of the nerve is numbed but not the other. If we know it’s there, sometimes we can angle a second injection to the ASSUMED position of the second branch—that position is so variable though that it still may be missed. If all the branches fail to be blocked, you may feel numb on your lip but your teeth still hurt during procedures.

A second variation is a second sensory nerve that is not coming from the main mandibular nerve (inferior alveolar nerve). In this case it is usually a small nerve that enters the bone on the tongue side of the lower jaw next to the tooth you are trying to work on. The way you try to achieve anesthesia in this case is to deposit anesthetic between the tongue and the bone in the floor of the mouth--sometimes a little bit of anesthetic in front and then in back of the tooth you are trying to work on. THIS IS THE TECHNIQUE THAT GETS ME NUMB
and this is the technique I try first. It usually succeeds.

For reasons I don’t quite understand, the molar teeth are the hardest to numb. With the same anesthetic injection I might be able to work on a bicuspid but not the molar. The failure rate increases the farther back you have to work—this makes the wisdom teeth the hardest to numb.

Sometimes waiting is the best treatment. I have one patient that I numb and send shopping. If she waits in the chair nothing seems to happen. If she gets out of the office she gets numb in the car...go figure. Another way to wait is to sit the patient up...for some reason, some people get numb easier upright than laying down.

A third technique is to deposit some anesthetic into the cheek next to the tooth. This is called a “long buccal” injection and sometimes if works when everything else has failed.

There is an opening in the lower jaw on the OUTSIDE of the lower jaw in the bicuspid area called the Mental Foramen. The nerve that entered the jaw farther back, exits here and supplies feeling to the lip. Depositing anesthetic near or into this opening can achieve anesthesia of the teeth that are opposite this opening and forward of it. Occasionally, if you can feel the opening, you can put you finger over the needle inserted into this opening, inject slowly and force anesthetic backward within the canal...sometimes getting one tooth behind the opening numb. There is a risk of causing paresthesia—long lasting anesthesia due to trauma. Fortunately, this is usually reversible.

For really miserable to numb teeth, there is a special anesthetic device. It is capable of creating more pressure. You slip the needle into the space between the tooth and bone called the periodontal ligament and inject slowly in several places around the tooth. This will work but the duration is short because so little anesthetic get into this space. The tooth may also be sore for a few days.

In the last 10 years or so a new technique has been developed. It sound gross but in reality it is fairly gentle. Intraosseous injection. First you numb the gums with topical anesthetic, then you inject about 2 drops of anesthetic into the gum directly between the teeth—you try, when possible, to inject behind the tooth you intend to work on. Next there is a special tip you put on the drill that makes a hole through the skin an bone, into the marrow space. Finally, and this is the hard part, you slip the needle into this small channel and VERY SLOWLY inject anesthetic into the bone surrounding the roots of the tooth.

If you think about it, this is not different than the hole you leave following an extraction—only much smaller. Since the anesthetic is injected into the marrow space, and this is actually part of the vascular system, this technique is actually an IV injection. The anesthetic will be cleared in 10 to 60 minutes (60 minutes is really pushing it). Most anesthetics have a vaso- constrictor like epinephrine in it to reduce blood flow—it’s also a heart stimulant so I warn the patient that they may feel a rapid heartbeat which will pass. If you have hypertension or heart problems this is not a good technique! Most patients who I give this too will actually ask for it again in the future.

It cannot be used in really dense bone or near the sinuses and since it has a short duration, only short procedures are appropriate OR if you immediately remove the nerve (ie. root canal) and the maximum safe dose is no more than about two cartridges of anesthetic.

OK, I’m not done yet!

There are several other reasons that people don’t get numb and these are related to pathology.

Infection of a tooth, sinus, skin causes the tissue pH to go down...the tissue becomes more acidic. Anesthetics are formulated to work at normal tissue pH which is close to neutral (about 7 on a scale of 1-14). Infected teeth are sometimes impossible to numb and this is the reason root canals have a bad reputation. The ONLY way you are going to get a really infected tooth numb is to bite the bullet, let the dentist make an opening into the nerve and then inject directly into the nerve canal. This is called pupal anesthesia. It can be anywhere from a quick zip to totally miserable—it even hurts the dentist! Did you ever hear the joke about the woman needing dental work and she turns to the dentist and grabs....never mind. The punch line is “We won’t hurt each other will we!?

A patient with a cold, sinusitis or even active allergies can cause problems getting upper molar and bicuspid teeth numb because they are near the infected or inflamed sinus. If you have a cold DON’T GO TO THE DENTIST! Even with all the protective stuff we wear now, the drill make an aerosol of the virus laden saliva and it can float through the air, into the eyes and down the tear duct. A few days later we get sick, really. Besides you’re probable uncomfortable with a sore throat, post nasal drip, etc., can barely breathe and then we fill up your mouth with water. I may waste the appointment but I don’t want your cold. If you call me, I’m more than happy to reschedule a sick patient. Reschedule if you have an active fever blister or cold sore too...this can be transmitted to the eyes, and skin of the other people in the room and even left on the front desk counter when you touch your face and then touch the desk.

There’s a little more.

Fractured teeth occasionally are sensitive as the drill passes directly over the crack zone. The whole tooth is numb except one little spot. You have a localized area of inflammation within the tooth nerve and that part won’t numb.

If you have all the symptoms of anesthesia and I’ve used all my techniques and the tooth still fails to numb, I get very suspicious that the nerve is dead or dying and a root canal is going to be necessary.

The last variation for difficult anesthesia is the rare patient that simply doesn’t get numb. I don’t know the reason. I have had three patients like this in 29 years. The easiest tooth to numb still hurts no matter what. I suspect that their body chemistry is just a little different than the anesthetic is adjust for...I’m just guessing.

Sometimes a patient who is really nervous or has been in traffic and is late and is stressed fails to numb or may take an hour. Again I suspect the stress has changed the body chemistry.

Patients with a severe under bite are very difficult to numb. Remember that “normal variation”? It turns out that when the jaw grows like this, the opening to the jaw is usually higher up and may be missed during the injection. If these people have had braces and their bite corrected, that opening may still be in the “wrong” place. The dentist has to recognize this possibility and try to compensate by positioning the needle differently. Even then, the canal is so variable and can have multiple openings as earlier discussed, that anesthesia is difficult.

OK! There is some GOOD NEWS! There is a relatively new anesthetic that is FDA approved. It is called Articaine (Septocaine). It has been used in Europe for years and been in the US for just a few years. It’s amazing! There is usually rapid, profound anesthesia with it. It can last an hour but I have one patient that reported nearly 24 hours before all the anesthesia went away. This stuff is more soluble and can penetrate bone so well that on upper teeth, even the palate may get numb from just putting on the cheek side of the tooth.

I had heard about this stuff but nobody likes changes. Finally, I tried some and I think it is the best so far.

One last trick. A double injection of Lidocaine and Prilocaine (Xylocaine and Citanest--generic names) may work better than each alone. The same combination is used as a topical anesthetic called EMLA. It is wiped onto the skin and left for an hour--then a skin graft can be harvested WITHOUT the use of an injection. It is one of the few topical anesthetics that can penetrate the keratin on the skin.

In the mouth, you don’t wait an hour because the mixture is injected. I don’t know why the mixture works, I just know it does.

Congratulations, you have made it to the end of chapter 1. If you don’t want to see chapter 2, don’t call back!!!

You might want to talk to your dentist about some of these tricks. I know some tricks and other dentists know some other tricks. We learn from each other. It doesn’t make me better or another dentist better.

I GOT BLISTERS ON MY FINGERS!!!!!

Regards,

Laurence Stein, DDS
:doctor:

Disclaimer
(No representations are made that in any way offer a diagnosis, treatment or cure for any illness or condition, either discussed or implied. Answers to questions are offered as information only and should always be used in conjunction with advice from your personal diving physician/dentist. I take no responsibility for any conceivable consequence, which might be related to any visit to this site.)