Written by Arthur K. Weathers, DDS Tuesday, 31 August 2004 19:00
The first 2 articles in this series, Access to Success, focused on the access aspect of endodontic procedures. I've emphasized the importance of creating the ideal access opening as one of the most important things you can do to help ensure a successful endodontic procedure.
With this article, I'm going to focus a bit more on the success component of the series title, and I'm going to do it by discussing a type of endodontic procedure all general practitioners should be performing but many dentists do not. When you learn a few important basics and some tricks of the trade, this particular type of procedure can actually become the most productive service you perform in your practice.
I'm referring to root canals on anterior teeth. These procedures are often referred by general dentists to endodontic specialists. I can tell you, if you're a general dentist and you're not performing anterior root canals in your office, you're passing up one of the most productive procedures available in dentistry. In fact, we find that at the completion of their training, attendees of our Endodontic Root Camp seminars produce just under $800 per hour performing anterior root canals.
Plus, if you're not performing your own anterior endodontics, then you're causing your patients unnecessary shuffling from one office to another and disruption in their treatment. By doing root canals on anterior teeth, you avoid sending your patient to a specialist who has never treated your patient, and in most cases, patients prefer having their root canals done by the dentist they have known and trusted for many years. The fact is, using the right techniques, any dentist can readily learn how to diagnose and perform productive anterior endodontics.
THE IMPORTANCE OF HIGH-QUALITY, DIAGNOSTIC X-RAYS
You've no doubt heard the old carpenters axiom, measure twice, cut once. This is a cautionary saying that reminds the carpenter to make sure he's got the board measured properly before he actually goes to work with his saw. The endodontic equivalent for me is x-ray twice, open once. That translates to make sure you've got at least two good-quality radiographs from different angles before you make your access opening.
I cannot stress that enough. Take 2 or more x-rays of the tooth on which you're going to perform an endodontic procedure, and take them from different angles. This brings me to a second point: the best and most efficient technology to perform this is with digital radiography equipment. If you're still performing endodontic procedures but haven't converted to digital x-rays, let me encourage you to do so. The Dexis digital radiography equipment we have installed for use by the dentists who attend our seminars enables us to capture and display x-ray images within seconds on a large computer screen.
There are other advantages to using digital radiography in performing root canals: because the radiation exposure to the patient is as much as 90% less than that of film (depending on the type of film used), you can take as many digital x -rays as you need (within reason, of course) without worrying about harmful radiation exposure levels. It doesn't hurt to explain this to your patients either. They'll appreciate the fact that you've got their safety and well-being in mind as you develop and improve your practice with new technology.
Here are some of the things you're likely to find when treating anterior teeth:
Maxillary Anterior Teeth. These 6 teeth almost always present the simplest cases for endodontic procedures. They generally have only a single root with a single canal. These teeth are easily x-rayed because there's not a lot of anatomical obstruction. Nonetheless, cases of dual root canals and multiple roots do occur, and you shouldn't relax your concentration simply because performing root canals on upper anteriors is fairly straightforward. Also, don't forget that most anterior canals are elliptical, which emphasizes the need for off-angled x-rays.
Mandibular Anterior Teeth. The first thing you should be looking for here is a second canal because many lower anterior teeth have 2 canals. Clues you can look for in your x-ray images include a sudden fading of the canal or the appearance of a double periodontal ligament. You might also look at adjacent teeth because if any of the patient's lower anteriors have 2 canals, the others are likely to be similarly configured. The lingual canal is the more difficult to find in cases where 2 canals are present, and a second, off-angled x-ray will help you locate it.
Easy Anesthesia. This is another reason it's good to work on anterior teeth. While upper anteriors are typically the easiest teeth to anesthetize, you should be aware of techniques that will help ensure profound anesthesia. For maxillary anterior teeth, inject the anesthetic high above (or apical to) the ipsilateral canine prior to regular infiltration of the tooth in question. You may find this technique referred to as an anterior superior alveolar block. The exact location of this first injection is the fossa adjacent to the side of the nose. The important thing to remember is that this injection anesthetizes not only the tooth you are treating but adjacent teeth as well because the complex nerve configurations in teeth often overlap from one tooth to another.
REMIND YOUR PATIENT AND YOURSELF TO OPEN WIDE
I never get tired of talking about the need for the proper access opening in performing endodontic procedures. First, as I've said before, you need to at least begin your access opening before you install a rubber dam. Although is not an everyday occurrence, it has happened that a dentist will place the rubber dam, leaving the wrong tooth exposed. If you install the rubber dam before you make your access opening, you're unnecessarily increasing the odds that you'll open the wrong tooth.
Once the rubber dam is in place, remember that the shortest distance between 2 points is a straight line. Your access opening must be large enough that your files can slide straight into the upper half of the opening. You must be able to find the canal or canals easily, and your instruments should slide right in with no binding or bending.
TIPS FOR ANTERIOR TEETH
Speaking of instruments, you'll find that larger sizes are necessary for anterior teeth, but you will not need many different sizes. In fact, you can often quickly complete an anterior tooth using a couple of rotary reamers and a few hand reamers. That's right; I said reamers rather than files. My favorite hand instruments are SafeSider reamers (Essential Dental Systems), and virtually all rotary nickel titanium files are actually reamers.
The basic difference between reamers and files is the orientation of the flutes. The flutes on a file are almost perpendicular to the long axis of the instrument, while the flutes on a reamer are almost parallel. This means that files must be used with an in-out motion to be effective, whereas reamers work best when they are rotated. Look closely at the rotary file system you are using, and you will see that the instruments are actually rotary reamers. Rotary files would tend to pull in, get stuck, and break, while rotary reamers cut much more efficiently without screwing them-selves into the canal.
My basic technique for preparing anterior teeth includes the following steps:
|Figure 1. Single-dose capsules from EndoSolutions provide a convenient way to dispense solutions directly into the root canal. In addition to the Endodilator (EDTA) shown in this photo, EndoSolutions also packages the following: Singles, Slide (file lubricant), Slide SH (slide with sodium hypochlorite), Endo-Klein (2.5% sodium hypochlorite), chlorhexidine, and Lube (file lubricant).||Figure 2. Assorted Accessory File Set from EndoSolutions includes 0.02 tapered rotary nickel titaium rotary files in the following sizes: Nos. 45, 50, 55, 60, 70, and 80.|
|Figure 3. An example of an over-extended master cone in the distal canal of a lower molar. Because the EZ-Fill technique was used in this case, it's very easy to correct this error.||Figure 4. The master cone shown in Figure 3 was removed, trimmed to the proper length and re-cemented. The small amount of excess sealer remaining beyond the apex will be absorbed in a relatively short period of time.|
(1)Access-Create straight-line access and remove any undercuts that would prevent easy entry into all canals.
(2) Glide path's Insert a small hand file or reamer into each canal to ensure nothing is blocking entry into the coronal portion of the canal. This step takes only a few seconds, and you are not trying to go to working length at this point. Incidentally, you should lubricate all instru-ments that enter the canal, and I use KY Jelly (an inexpensive, water-soluble gel containing chlorhexidine gluconate to help kill bacteria), which is available at any pharmacy.
(3) Coronal shapingâ€š I like to prepare the coronal third of the canal with a No. 2 Peeso reamer. If the Peeso doesn't easily enter the canal, the access isn't wide enough. You can also use Gates-Glidden burs or larger tapered rotary instruments for enlarging the coronal access.
(4) Flaring and chemical cleaning. After measuring the apical length with my electronic apex locator, I flare the canals to at least a 0.06 taper. The canals are irrigated with sodium hypochlorite to dissolve organic tissue, followed by EDTA to remove the smear layer. You can also use the single-dose capsules of solutions for this purpose (Figure 1).
(5) Final sizing of the apical few millimeters-I like to take the apical few millimeters to at least a size 40 prior to obturation. The Accessory rotary instruments (Endo Solutions) are perfect for shaping larger canals (Figure 2). Total preparation time using the above technique is usually 3 to 7 minutes.
I then obturate with EZ-Fill (Essential Dental Systems) and a single, tapered master cone. By preparing the canal to at least a 0.06 taper, you can select gutta-percha with a taper of 0.04 or larger. The larger tapered master cones resist apical displacement so over-extension is rare.
DON'T BE AFRAID TO CHARGE FOR YOUR ENDODONTIC SERVICES
I'd be remiss if I didn't talk about one more thing regarding performing root canals on anterior teeth-money. When you perform an endodontic procedure for one of your regular patients, you're actually doing him or her a great service, and when you broaden the range of the treatments you provide, you should not hesitate to charge an appropriate fee. Take a look at the rates charged by endodontic specialists and bring yours in line with theirs. Your patients (and their insurance companies, I might add) will not balk at being charged the going rate for specialized procedures. And remember, your work will be held to the same standards as that of a specialist, so you should be remunerated at the same level.
Don't be afraid to charge a fair fee for an anterior root canal. Be aware that in most cases, the patient expects the fee to be that of a molar root canal. (To them, a root canal is a root canal.) Additionally, because you are legally required to provide the same quality treatment as that of an endodontist, you should be aware of what your endodontist is charging. Despite this, our surveys find that the typical general dentist only charges about 65% of what the endodontist charges.
The often-ignored anterior root canal is usually the highest dollar-per-hour endo-dontic procedure that our endodontic seminar attendees perform. With an average hourly production of just under $800 following training, the anterior root canal is absolutely one of the most productive dental procedures our Root Camp graduates perform in their offices. Using the correct tools and having an organized system for each case ensures low stress and high productivity when doing anterior root canals.
In the next article of this series, I will discuss using microscopes, sonics/ultrasonics, and SafeSider hand reamers in conjunction with rotary instrumentation for complete preparation of the more difficult cases.
Dr. Weathers lectures and publishes on technologies, products, and processes designed to simplify the practice of endodontics. He pioneered a simplified system of nickel titanium files to enhance patient comfort with a one-visit endodontic procedure. The Level I and Level II Hands-on Endodontic Root Camp seminar series, which Dr. Weathers hosts, offers multiday, hands-on training to improve dental techniques while explaining his theory of endonomics, the economics of endodontic case management. From his own multimedia learning center in Griffin, Ga, as well as from the Las Vegas Institute for Advanced Dental Studies, Dr. Weathers offers his academically grounded approach to endodontics. Editor of the DentalMagic! newsletter and author of numerous articles on innovations in endodontic treatment products and processes as well as intraosseous anesthesia delivery systems, Dr. Weathers has also introduced the C.E. Magic! edutainment interactive learning system to the field of continuing education in dentistry. He can be reached at (770) 227-3636 or ce-magic.com.
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