- NOTES ON ASPIRATION STRATEGY - USING IRRIGATION OR ENDODONTIC NEEDLE AND SYRINGE

FUNCTION - Irrigation needles serve two main purposes. The most important one is to flush out debris. The second purpose is to deliver "magical elixars" as I like to call them, because their actual effects are typically more imaginary than real. Reason is the gums are constantly flushing themselves out with gum juice, inter-whatever fluid, which is similar to blood plasma. So any imaginations that some short-term irrigation is going to have some special effect is misinformed or delusional.


Which is not to say they will have no effect at all. Just not much. So what can be done to overcome this issue? First is the fact that the periodontal pocket is going to contain some volume. So maybe the gums don't flush themselves out so fast, eh? True rabbit. Second is the possibility to irrigate over a period of time. Let us say to put the flow into the gums for say 20 minutes or longer to increase the exposure time. Yes. Also if you are getting any successful flushing, especially from a deep periodontal abscess, then it is likely you will continue the process for awhile. Hence yielding your exposure time.


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HOW I RIDE - 02-28-14 - Right now I am into the fat 16 guage Luer-lock open-ended irrigation needle, combined with the 3cc syringe. Mostly I use it to drive thick hyaluronic acid into the deep pockets. Also to drive the 3Mix Triple Antibiotic Paste down low. Reason is the thicker gel-like fluid disperses slower. Plus my subgingivals are mostly running fairly clean after numerous debridement after debridement.


I probably have the 18 guage too. And am still a big fan of the 20 guage open-ended needles for moderately thick hyaluronic acid. Plus still like the 23 guage needles for general fluid driving, like povidone iodine.


I used to be a fan of the 5cc syringes. But largely prefer the 3cc syringes now because can draw better vacuum and drive more pressure. On account of the smaller radius plunger. Also I am not so much into the aspiration anymore. Reason being that I would get these small fluid draws and get all exited I was liberating infection. Then it turned out all I got was the tip of the iceberg and it was completely filthy down below. Disenchanting me from aspiration. Though obviously it has its merits. Especially if there is some deep pool of crud that you can bust into with the needle. In fact right now (02-28-14) I suspect a deep abscess on my maxillary sinus. And one good strategy is to target it with the needle.


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SPECIAL NOTE - Can also use DuoDerm as a hydrocolloid gel bandage, which is thick enough to lay in place. DuoDerm can help autolyctic debridement. So it is good stuff.


PRIMARY SUPPLIER - Vista Dental - catalogue - Idea is to just act cool and not claim to be anybody who you aren't. It is perfectly legal to purchase irrigation needles. Also keep in mind that some dental suppliers only sell to dentists. So they have their controlled stuff mixed in with their uncontrolled stuff and you won't even be able to purchase a tongue depresser from them.


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PRIMARY SYRINGES - Obviously all syringes should have a "Luer Lock" - which is the standard modern fitting for syringes.


5mm syringe - workhorse - I bought a box of 100 veterinary syringes for like $20. Once the syringe starts to stick can just throw away. But don't have to be too quick as long as you rinse the syringe out well. Good thing is it can deliver a lot of fluid. It expecially works out well with the 23 guage irrigation needle. The main problem is that when you get deep into the periodontal pockets sometimes the fluid just does not want to come out. Essentially you are trapped inside the pocket. For that you need a smaller diameter syringe to deliver more pressure.


3mm syringe - delivers more pressure - especially good where you are using a thicker fluid, like DuoDerm or less quantity or need to overcome back-pressure from the periodontal pocket.


SPECIAL NOTE - Obviously it is a bad idea to force fluid into periodontal pockets under extreme pressure. But can back off the needle and the fluid can track in it's wake. Likewise can insert the needle and create a well of fluid in front of the needle to push it in deeper. This is known as "pumping the needle." So major issue is correct combination of needle guage and appropriate syringe size.


SPECIAL NOTE - Also keep in mind that if the pocket is filthy that most of the benefits you might imagine that irrigation are going to deliver are in fact going to largely be illusionary.  With some exceptions, like delivery of Povodine Iodine, which is dangerous and not for the foolish. Especially since you could kill a nerve that way. Or poison yourself. Or could try your luck with the Hyaluronic Acid and see if it does actually "frack." Which I decided it doesn't since there is not enough water in calculus for it to expand and break. SUMMARY - most of the imaginary functions you might imagine irrigation delivering are just not going to happen. The only thing that is going to deliver the results is the curette, as unpleasant, difficult and futile as that process might seem


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PRIMARY NEEDLES - I wouldn't bother with the rounded nose irrigation tips with the holes in the side. The half-moon 23 guage 1.25" endodontic needles work fine in spite of the two sharp corners. Turns out largely don't really need the extra 1/4 inche over the 1 inch needles most of the time.


23 guage needle (skinny) - endodontic (half-moon) 1.25 inches - OR - blunt-tip 1 inch - The key attribute of this needle is it is skinny. And able to slip into fissures into fairly deep pockets. It only works with fairly fluid not so thick fluids. Can dilute to suit. Such as Honey or Hyaluronic Acid. Likewise works well with Urea-Papain. This is a workhorse. Works well with the 4mm syringe. Can also be used as an aspiration needle.


20 guage needle (fatter) - 1 inch blunt tip - This needle works great with the thicker Hyaluronic Acid or thicker Honey. Won't slip in as easily as the 23 guage needle. I use it with the 5mm syringe. Could work with slightly diluted DuoDerm.


18 guage needle (fatter) - 1 inch blunt tip - I have this needle but haven't tried it out. Could possible work with DuoDerm


16 guage needle (fatter) - 1 inch blunt tip - 3mm syringe - DuoDerm hydrocolloid bandage. Idea is to lay this stuff up into the pocket for autolyctic debridement and to protect healing tissue. Has lots and lots of potential. Especially in final stages of debridement, like after months and months of primary and secondary debridement, with still some softening left to go.


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UPDATE - Think aspiration has its merits. But it is very easy to end up thinking you are getting somewhere with the aspiration when the real problem is calculus instead. In which case the answer is the curette, not the needle. But the needle is still good for finishing an area that really really is otherwise clean. And doesn't have calculus lurking somewhere.


LIKEWISE FOR ABSCESSES - Aspiration may end up relieving the symptoms temporarily by relieving the pressure. But the abscess is still there and possibly growing too. So while the aspiration might be useful it doesn't really address the underlying issue. And the small amounts of blood and debris may not add up to much when compared against the actual abscess.


KICKING THE CAN DOWN THE ROAD - Aspiration is likely to make people feel they accomplished something while getting some blood and debris for their efforts. Realityland is the problem is likely much deeper and much more serious. So aspiration can easily become a FOOLS PARADISE. Like what happened to me. Otherwise referred to as BATTLING THE TAIL OF THE DRAGON - So you really showed them. Meanwhile the disaster just gets bigger and bigger and you are putting on band aids that don't do anything and relieving symptoms, not cause. WHAT TO REPLACE WITH? Think hyaluronic acid irrigation has its merits. But ultimately curettage is the only solution that actually words. JUST HAVE TO DIG.


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Aspiration strategy -- idea is to use an endodontic needle and syringe to suck up the bacterial colonists and associated xenomorph infrastructure out from underneath the gum line. Like a vacuum cleaner. Why not an irrigation needle? Which has a blunt tip instead of the square corner half-moon tip of the endonontic needle. Which could potentially cause damage.

Good question. Could use an irrigation needle instead. But the endodontic needle seems to work just fine. There are some laceration issues because of the sharp upper corners of the half-moon shaped end of the endodontic needle. But the open hole of the endodontic needle is capable of sucking up large xenomorphs. Which I think makes it superior. Additionally have successfully "walked the dog," i.e. the edge of the needle, along quite sensitive gum margins. Albeit with some trauma, but still very reasonable.


NOTE - In a nutshell, aspiration cannot remove calculus ledges. Its forte is removing non-attached blobs. Especially in narrow spaces where it is like a weasel.
NOTE - If irrigation hits the jackpot bingo ie an abscess then expect lots and lots of crud to come out. But this does not mean that irrigation is superior to aspiration.
NOTE - OK OK - In a perfect world irrigation would be better than aspiration. But irrigation is very very difficult to control. With aspiration can use thumb to lock-in vacuum and do detail work in much greater detail than with irrigation.


SUMMARY - MIX OF IRRIGATION AND ASPIRATION IS BEST - USE EACH FOR THEIR STRONG POINTS AND DON'T PUSH YOUR LUCK WITH IRRIGATION. ASPIRATION IS SAFER.


Syringes -- purchased a box of 100 cheap 6ml veterinary syringes for around $20 plus shipping.

Aspiration needle -- I use a Kendall 23 gauge x 1.25 inch needle. (32 mm). With Luer tip The length is long enough to reach around the teeth into my deepest pockets. I bought a box of 25 needles for roughly $12 plus shipping. 


NEEDLES - STANDARD NEEDLE - KENDAL 23G - 1.25 INCHES HALF MOON ENDODONTIC - this needle is a compromise between narrow access and draw.

NEEDLES - THIN NEEDLE - KENDAL 27G - 1.25 INCHES - this needle is only practical for very narrow areas. It has very little draw.
NEEDLES - FAT NEEDLE - KENDAS 20G - 1.0 INCHES - this needle is indeed FAT - It does not fit well into narrow spaces. It has very good draw.


Ideas for setup. Five needles appear to be the minimum reasonable setup. Each needle is attached

-- Straight needle -- very practical any time there is no need to bend the needle. Can also be bent when needed.

-- 45 bend needle -- very practical as an alternative to the straight needle.

-- 90 bend needle -- largely I have that these needles as close to the base as possible. To get maximum reach. Alternately it might be practical to bend angles closer to the tip.

-- Right-hand corkscrew -- which is not really a corkscrew. Rather it is a double-bend needle angling the right.

-- Left-hand corkscrew -- mirror image of the right-hand corkscrew.

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WHAT IS AN ASPIRATION-IRRIGATION NEEDLE?

Basic premise is to use a whole metal irrigation needle to remove crud and debris and loose periodontal infection out from underneath the gum line.

Aspiration uses vacuum pressure to suck out the crud into the syringe. Irrigation uses water pressure to dislodge the crud.

In addition the mechanical action of either irrigation or aspiration can dislodge the crud and stimulate the body to release fairly large quanties of bloody plasma and what is called sinovial fluid. Which flushes the crud out from under the gums without any need for irrigation. This is what happens in the dentist's office.

To see for yourself how this process works check out the scaling and root planing videos on YouTube. Google - diy perio

Or wonder why the stuff that gets scraped off at the dentist's office flushes itself away rather than stay under the gums. What happens is that largely once a piece of crud gets dislodged it will tend to flush itself out on its own accord. Aided by the release of bloody plasma and sinovial fluid. 

The mechanical action can also dislodge the crud so it comes out on its own accord. Flushed out by the body. Which releases bloody plasma for the express purpose of washing out the crud. This is why the calculus and debris will naturally flush itself out from underneath the gum line at the dentist's office. For this reason irrigation is not strictly needed for the body to be able to flush out the crud all on its own once the biofilm infrastructure is successfully mechanically disrupted.

But largely the needle has to be applied directly into the actual physical structure of the particular periodontal pocket underneath the gum line. And realistically the hard calculus structures will tend to remain mostly unaffected by the needle. So the needle can only get out portions of the crud. The rest will only come out under instrumentation with curettes or ultrasonic.

It is also hard to figure out where the pockets of infection are located. In the area around the opening at the gum line there may be multiple series of periodontal pockets that resemble tunnels in different directions. Likewise the gum tissue will tend to swell in the vicinity around an active periodontal infection.

In addition there can be fairly large ledges of calculus that don't even get touched in a regular cleaning and that can even get overlooked in a deep cleaning. Especially if the periodontist or hygienist was just not quite thorough enough within the allotted cleaning time to be able to identify and remove the tenacious difficult to remove calculus ledges.

So, in effect, deep infections can remain well hidden. Protected by nearby swelling from nearby infections. Indeed the infected areas can be highly unyielding. What this ends up meaning is that a periodontal pocket can be much much deeper than it appears.

Only when the areas of relatively shallow infections are disrupted will the deeper infections reveal themselves. What this means is that the process of using aspiration and irrigation is progressive. Which can very easily require multiple treatments over a period of weeks or even months to get to the bottom of the infection.

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MY OPINION ON THE NEEDLE - I had several great success stories. The primary advantage of the needle is it is so thin it can creep up narrow passageways, spelunking so to speak, since the subterranean redoubts and passageways can be very narrow.

 

1) Used the needle to suck out a deep crater between my upper right bicuspid and first molar. Maxillary. This is part of what I term as my "triple deck." Which is particularly nasty and terminal. Piling bad upon bad.

 

The shallowest deck is the normal gumline, combined with collapsed bone. But the bone did not completely collapse. Below that is apparently the general level of the nerve. So the nerve is literally dangling in mid-air. Once the eventual certainty happens that nerve gets compromised the tooth is basically a goner. Since it is not worth a root canal or other heroic efforts to save a dead tooth. And once the tooth goes it will most certainly create a large hole into the maxillary sinus.

 

The deepest deck is the sinus itself. Otherwise termed as "skull." Hence representing a "clear and present danger." But what to do? What to do?

 

DIYs position is that the dental profession can offer surgery in this situation. But that the situation is oftentimes explained as long-past any reasonable dental professional answers involving Scaling & Root Planing (SRP). But alternate position in the dental profession is for continued SRP. Which is the same as DIY Perio's postion.

 

SO WHAT HAPPENED? - After hours and hours of DIY SRP when things got to looking somewhat clean went in with the needle. 22 guage Kendell half-moon tip endodontic needle. With artful bends. Primary use was sweeping up the fringes of the periodontal pockets. Where each attempt might yield a small amount of blood & crud.

 

But other primary use was going in deeper. Issue of going in deep in so-called Nerve & Skull Territory is that the diseased tissue has been largely turned into mush.

 

WHAT IS MUSH? So-called "MUSH" is diseased tissue where it is very difficult to determine what is what. Life blends with death. And both living and dead blend with disease and infection. What is what? The only one who knows is God. So the role of man is to give the dead and diseased the opportunity to leave without destroying the opportunity for the living to gain back its life. Which also includes so-called - ZOMBIE BONE - which is bone that has died that does indeed have the opportunity to become the scaffolding for future living bone. But which also may be a chimera or product of wishful imagination. And what is the means? At its simplest level it is - COMMUNICATION - or contact of diseased tissue with the outside world. Allowing the diseased material to exit or be flushed out by release from the body of blood and plasma to flush out the infection. Which a natural body response.

 

HUH? - (PER LIVING BODY vs NON-LIVING BODY) - Don't carelessly go in too deep with the needle or you might just punch a hole into your sinus. Or foolishly spread a dangerous infection even further. That is what this all means. So what to do instead? Basic answer is to be respectful of disease. Try to remove as much infection as possible without disturbing what might in fact be living body.  Go as far as you can go with a 100% confidence level.

 

Then what happens is the living tissue, which then becomes less burdened by disease, will tend to recover. But if there is too much disease left over then the recovery won't be very good. Perhaps just enough to keep the pain to a moderate level if you go back in again say three days or two weeks or so later.

 

BUT ISN'T THIS HOW ALL THE BAD AREAS START OUT? - YES - Yes, in general all the bad areas will start out feeling like mush. But you forge ahead anyway and remove as much crud as you can without making the problem even worse. Then after awhile, even if the area is still hugely filled with disease, the trauma will tend to go down and the area will tend to recover. WHAT TO DO THEN? WHACK IT AGAIN.

 

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NOTE -  OR could even very very carefully blow air under the gumline. OR if you have access to pure oxygen can try that -  BUT ISN'T THIS DANGEROUS? YES IT IS. SINCE YOU COULD CAUSE AN AIR EMBOLISM AND DIE OR HURT A LOT - ESPECIALLY IF THE POCKETS ARE DEEP AND YOU BREAK THROUGH INTO DEEPER STRUCTURES - BUT FOR SHALLOW POCKETS IT IS PROBABLY NOT VERY DANGEROUS - Which would be true in very deep pockets. BUT... I have done some irrigation with air into super-deep pockets and abscesses. But mostly to drive the needle plasma-missile style. Issue being that many deep pockets do not accept any type of irrigation in a friendly manner. Meaning it would be very easy to force the fluid or air into nominally healthy areas and damage them or cause air embolism. But again if person accepts the danger and tries to be careful and is not foolish even a mild mistake is not likely to prove fatal.

www.diyperio.com

tom@diyperio.com

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