Tuesday, August 20, 2013
Clinicians need predictable strategies to manage real world endodontic challenges. This column was written with a goal of making endodontics safer, more efficient, and more predictable for general dentists as they face such challenges.
Basic Technology
As a starting place, it is axiomatic that the endodontic diagnosis must be correct, the tooth must be restorable and the patient must have given informed consent before proceeding with any treatment. As a practicing endodontist it is invaluable to have a cone beam 3D imaging system, digital radiography, and a surgical microscope to aid with evaluating restorability and reproducing the patient’s chief complaint in order to confirm the diagnosis and achieve the ends above.
Not every case needs a cone beam scan, but having technology such as that or the surgical microscope can make the difference between locating all the anatomy present and missing something critical.
Anesthesia
Very little else allays patient anxiety and fear like profound anesthesia. While a discussion of achieving profound anesthesia in endodontics is well beyond the scope of this column, I have found both Aseptico’s STA/Wand and DENTSPLY’s X-tip to be lifesavers when needed. The STA/Wand is especially valuable because there is no equivalent way to comfortably deliver local anesthetic than with such a device across block, infiltration and PDL injections. I use it every case, every tooth, every day.
Endodontic Files
After achieving straight-line access and removal of the cervical dentinal triangle in shaping the coronal third, the savvy clinician knows how to use hand files effectively. Whether using rotary nickel titanium (RNT) files or reciprocated NT files (ReNT) in the canal, these instruments can be perilous when used in a canal not previously negotiated by hand with nickel titanium (NT) or stainless steel hand files. Ideally, the canal is enlarged to the size of a #20 hand K file prior to bulk canal shaping with RNT or ReNT.
While some clinicians suggest glide path creation with nickel titanium files, I am not an advocate of this technique. Intimate knowledge of canal anatomy with hand files cannot be duplicated by mechanical means. However, use of the W&H WA 62A reciprocating hand piece can reduce hand fatigue and save time in preparation of the glide path because it reciprocates K files, safe ended K files or nickel titanium hand files.
In my hands, exploration of canals and subsequent preparation of the glide path via the reciprocation of the WA 62A is performed in open and negotiable canals with Mani K files, Mani safe ended K files (SEC O K files) up to a size #15 hand file. Final preparation of the glide path is performed with the Mani ni ti Flare hand files in sizes #15 and #20.
Alternatively, for calcified canals, initial negotiation is achieved with Mani D Finders in sizes #8-12 as needed. Mani D Finders are not generally reciprocated but used as pathfinders. They can withstand a great deal more vertical pressure during insertion than many other hand file types used in negotiation.
Irrigation and Obturation
It is essential to copiously irrigate canals and activate irrigation—via sonic, ultrasonic, or mechanical means—along with recapitulation after the use of each RNT or ReNT file. Such an irrigating action minimizes the chances of canal blockage, iatrogenic events and canal transportation.
Regardless of the means of shaping, the end goal is clear—the three dimensional cleaning, shaping and obturation of the canal space from the orifice to the minor constriction of the apical foramen (MC) to a taper and tip size that can be irrigated and obturated predictably. At the present moment there are a bewildering array of various systems, all of which can shape canals, and a similarly vast array of corresponding methods for filling.
Endodontic Rotary File Systems
At this moment in time, given the marketplace options available, it is my belief that shaping systems are a commodity rather than a technology where one system or another is vastly superior to another. It is the clinician, not the file that produces the clinical result. While this may be true, the marketplace guides which systems are most user friendly, safe and efficient. The astute clinician will master at least two of these systems and understand where it has application to the greatest clinical benefit relative to the other systems.
File systems such as ProTaper, MounceFiles, Wave One, TF Adaptive, EndoSequence and others are all user friendly, efficient and safe. Mastering the system and knowing its strengths and limitations is more important than the brand name on the box. With any system, practicing in extracted teeth is a great way to learn its strengths and limitations.
Finishing the Root Canal
Obturation must be protected with a coronal seal, ideally one placed under illuminated magnification from a surgical microscope. Microscopes have become ubiquitous among endodontists because they bring true magnification and visualization to the clinician, in every case. If you can see what needs to be done as the case progresses, you can probably do it. Clinically, I place at least a glass ionomer filling without a cotton pellet in every case and composite in many. All placed under the surgical microscope.
Chairside Manner
And finally, one issue, rarely discussed, is dealing with the phobic patient, especially those who have difficulty getting numb or present with a behavioral issue that makes treatment challenging. As an endodontist, these patients tend more to be the norm than the exception. There is a reason for referral. Either the tooth is challenging, the patient is challenging or both.
Much of the burnout we experience as clinicians involves dealing with these personalities. To be fair, many of these individuals have been traumatized by their past dental experiences. In any event, identifying these patients is relatively simple if we listen carefully and observe their body language.
These patients require the clinician to take the time to listen, examine them adequately, inform them of their clinical needs, and discuss the proposed treatment and its possibilities for success. For example, given the particular circumstances of the case, the patient must know that they will need a crown after the root canal, what the probabilities of vertical fracture are, and other pertinent details. There should be no surprises after a root canal. Informed consent should be comprehensive.
For the endodontist and general dentist alike, managing such patients with real sensitivity cannot be overstated in value to the health of one’s practice. Such sensitivity has its roots in four things: listening to the patient carefully and meaningfully; achieving profound anesthesia; referring when needed; and planning for and carrying out the treatment in the most efficient, safe and predictable, principle-driven manner given the clinical situation at hand. I welcome your feedback.