Written by Richard Mounce, DDS Saturday, 30 April 2005 19:00
It has been said that, "the devil is in the details of just about anything. So it is with achieving endodontic excellence for our patients." Often, the issues that bedevil clinicians have little to do with theory, the literature, clinical controversies, or the academic issues related to the procedure. Many times, little things make the difference between a platform where the procedure can be smoothly completed to a high standard and a situation that more resembles a rodeo and produces a less-than-desirable outcome for all parties involved. In other words, it is most often the little things that determine whether we as clinicians are slippin' and slidin' or just sloggin' down the root canal system.
For example, the most talented of clinicians cannot achieve the results of which they are capable if their operatories are not laid out properly, the staff is not trained, needed files and supplies are not within reach, etc. With the goal of promoting efficiency and a higher level of patient and doctor satisfaction, the following suggestions are offered for consideration (in no particular order of importance).
TIPS FOR EFFICIENT ENDODONTICS
(1) Always use a rubber dam. It is the legal standard of care and the only real platform for maintaining extended moisture and microbial control from salivary contamination. Morbidity without its use cannot be justified. Sealing off the bottom of the rubber dam with a material such as OraSeal (Ultradent Products) can avoid irrigant accidentally slipping below the rubber dam. In addition, in a tooth that is missing a wall after access, irrigation can be hampered because a reservoir of irrigant is not possible due to the missing tooth structure. After caries removal, placement of a composite buildup to replace the missing wall and create an irrigant reservoir can improve the level of irrigation efficacy by providing a constant pool of irrigant coronally (if replenished); also, the chance of irrigant spilling under the rubber dam is reduced. Use an ultrathin rubber dam; there is no reason to use a heavier dam. Always tie a piece of floss on the rubber dam clamp in the unlikely event of aspiration.
(2) Always use the same color coding for labeling various irrigants and use the same size and type of syringe for any given irrigant. Never change the color coding of the label on an irrigant syringe or interchange the syringe type between irrigants without clear communication to staff that the new color coding is a permanent fixture. For example, if the clinician is using SmearClear (SybronEndo) for smear layer removal in bonded obturation, it is ill-advised to ever use the premarked SmearClear syringes and needles for sodium hypochlorite and vice versa. The interchanging of label and syringes can easily lead to misuse of the solutions and possible morbidity for the patient. In the worst-case scenario, potentially catastrophic problems could occur if sodium hypochlorite was placed into an anesthetic cartridge and accidentally injected into a patient.
|Figure 1. The Stropko Irrigator.|
(3) Use the Stropko Irrigator (SybronEndo and Vista Dental Products) as much as possible for debris removal in the pulp chamber. The Stropko Irrigator (Figure 1) is an invaluable tool in clinical endodontics. While a discussion of all the uses of a Stropko Irrigator is beyond the scope of this paper, use of the Stropko concomitantly with the Blue Max tip (Ultradent Products) makes irrigation of the pulpal floor to remove debris much easier to accomplish. Use of various tips in combination with reduced air pressure and water pressure have myriad applications both in endodontic surgery and in advanced drying techniques for canals before obturation. It is important never to blow air directly into the tooth.
(4) Having an assistant irrigating canals is generally not a good idea. The chances for a hypochlorite accident rise exponentially, especially if the assistant is not using a surgical operating microscope, he or she lacks the training and expertise to carry out this simple yet vital function, and/or the quality of suction is compromised in any way.
(5) Always have the patient wear protective eyewear. There is no defense against not doing so, as it is cost-effective and offers valuable protection of the patients eyes. A malfunctioning sodium hypochlorite syringe is an especially powerful argument for the patient to wear glasses in case the liquid sprays into the patients eyes. Recently, the author had a hypochlorite syringe explode with irrigant landing everywhere, including the top of the patients glasses. It happens.
(6) Change the cartridge every time if using an Obtura II needle (Obtura Spartan) or a RealSeal cartridge (SybronEndo) that is placed into either an Obtura II gun or the Elements Obturation Unit (SybronEndo), respectively. Everything that delays the procedure diminishes profitability and, more importantly, makes achieving an excellent result more difficult to obtain. Having to get up and change a broken Obtura needle or having the assistant get up to retrieve more of any given material during the procedure is counterproductive.
(7) Use a new needle for every anesthetic injection. A new needle for every single injection is always sharp, less painful, causes less tissue trauma, and reduces the chance that the needle will break during a block injection. The cost of new anesthetic needles is negligible in relation to the benefits. The patients perception that they were treated more comfortably is priceless.
(8) Have all the rotary Ni-Ti files laid out on a sponge in the order that they will be used clinically. The assistant should have the color code of the given rotary file system memorized for ease of transfer.
(9) Have multiple K-files available in order to achieve and maintain apical patency and a glide path. For the vast majority of clinical endodontic cases, the author has the following on his sponge: 21-mm and 25-mm 6, 8, 10, 15, and 20 K-files. In addition, the sponge has 25-mm 0.02 and 0.04 K3 (SybronEndo) 15 and 20 tip sizes and 0.06 15 to 35 tip sizes. In addition, K3 shaper files (orifice openers) of tip size 25 and taper sizes 0.08, 0.10, and 0.12 are utilized. The author does not use 21-mm K3 files because the laser markings on the 25-mm length are more easily read under the surgical operating microscope, making the 21-mm K3 rotary files redundant.
(10) Use K-files once. Again, similar to anesthetic needles, the cost savings of using a K-file twice are not justified in relation to the lost cutting efficiency of a used K-file.
(11) Rotary files are a disposable item. While a discussion of how many times a rotary Ni-Ti file (RNT) can be used is well beyond the scope of this paper, skepticism should always be applied to the life span of any RNT file. In short, if the file shows any deformation or has been subjected to moderate-to-severe curvature, excessive torsion, or multiple canals (excessive rotations in any given curvature), the file is at risk for immediate fracture due to torsional failure and cyclic fatigue (the phenomenon that occurs when a metal is bent at the same location repeatedly and snaps without warn-ing). Such a file should be discarded immediately. All profitability and efficiency is immediately lost when such a case has to be referred to a specialist for removal of a separated file.
(12) Any visualization is better than the naked eye; a surgical operating microscope is ideal. Any less visualization is a compromise.
(13) Have your assistant understand the functions of the various irrigating solutions. Such an understanding can only enhance the efficiency of the process as well as bring the assistant more in tune with the clinical care being provided. Most certainly, perform dry runs of the procedure, walking the assistant through all the various stages, especially when the assistant is new and/or a change in the technique is contemplated.
(14) Place the buildup at the completion of treatment if at all possible to avoid iatrogenic issues as well as to promote coronal seal and avoid the patient returning months later with an open tooth that is contaminated from crown to apex. (If the clinician who places the buildup did not perform the root canal, the second clinician will not be as familiar with the internal anatomy of the tooth as was the one who performed the root canal.) Placing the buildup in a second appointment is neither cost-effective nor convenient for the patient. Recently, the author had a patient who went 10 years with Cavit in the access of his lower anterior teeth, which had to be re-treated even though the previous endodontic treatment had been of high quality.
(15) If the clinician is bonding the obturation with Resilon (Resilon Research) or RealSeal (SybronEndo), the best way that the author has found to place the self-etch primer is to make sure the chamber is clean and dry and to use a microbrush to place the primer into the canal orifices. Subsequently, supersaturate paper points to place the primer to the desired length.
(16) Always precurve your hand files before you place them in a canal, no matter how straight the canal appears radiographically. All canals, even in upper anterior teeth, have some degree of curvature, especially those that curve in a buccal to lingual direction, which is not radiographically evident.
(17) Have your rotary files turning as they enter the orifice of a canal; do not lock them into the canal by hand and then activate them. Placing the rotary file stationary into the canal risks locking the file tip apically before its engagement, resulting in torsional failure and file breakage.
Such a list of suggestions could probably stretch on indefinitely. However, having given a large number of courses around the world and observed many clinicians chairside, the author believes these are the issues that repeatedly confront and frustrate many and often make the difference between slippin' and slidin' (enjoyable, practical, and predictable endodontics) and just sloggin' down the root canal system.
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