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Written by John West, DDS, MSD Thursday, 31 March 2011 15:05
I begin this paper with what I intend to be a controversial statement: "Most of the problems related to Glidepath implementation are not with the actual Glidepath implementation; they are with the dentist." Glidepath implementation is as much a mental game as a mechanical game. Most of us think of Glidepath implementation as: 1, 2, 3. I invite you to think of Glidepath implementation instead as 3, 2, 1. My strategy is a simple one: start with the answer, the result that you want to produce.1 I am writing this to remind you how starting with the answer works, and how it does time after time, Glidepath after Glidepath. This possibility is available to all dentists at all times.
My agenda is to first significantly increase your Glidepath implementation awareness. Second, you will discover you have new options. Third, these options will give you new choices about what to do when. Fourth, you will then have a newfound control of competent, consistent, confident Glidepath preparation. I really want to teach what matters the most in Glidepath implementation, and for the clinician this involves learning about awareness, options, choice, and control.
Now, I can teach a dentist how to "do" a Glidepath preparation, but this last Dentistry Today article in the series on Glidepath teaches dentists how to "implement" it. There is a big difference between learning how to do it in just a didactic, theoretical, or mechanical sense, and how to do it in your practice. I know dentists can learn Glidepath technical mechanics, but for dentists to do it and implement the endodontic Glidepath in their hometown, the practice has to have a culture that allows the time, energy, enjoyment, value, thought process, vision, and attitude that comes with how to truly own the Glidepath and make rotary shaping safe. Energy and enjoyment may be as important to Glidepath implementation as learning the technical mechanics.
PUTTING IT ALL INTO CONTEXT
Let's imagine for a moment that it is Monday morning. During the weekend, you have attended an endodontic seminar and you are ready to test-drive your new rotary system. At the same time, you are aware that rotary systems "come and go" quite often and you are hoping that the one you just traded your entire previous endodontic inventory for is not one of those systems that is also soon to "come and go." After all, you were getting comfortable with it even though you had your technical troubles. Mostly, you are hoping you have made the right choice.2 However, regardless of how efficient, safe, or simple your new system claims to be, it does you no good if you can't "get down the canal." "Getting to the apex" or, said more precisely, "slipping and sliding to the radiographic terminus (RT)," represents the single most limiting factor for all endodontics. It is here where success and satisfaction, or failure and disappointment are found. Glidepath implementation is the difference that makes the difference. It is the most important skill to remember to remember. And, if and when you "get down the canal," how do you maintain length and how do you maintain a patent, smooth pilot tunnel for safe rotary instrumentation? The prerequisite for successful endodontic rotary shaping mechanics is mastery and implementation of the endodontic Glidepath.
In the first part of our series on endodontic Glidepath (The Endodontic Glidepath: "Secret to Rotary Saftey," September, 2010; available at dentistrytoday.com), I defined the finishing checklist for Glidepath as a "reproducible smooth tunnel from endodontic access orifice to the RT."3 The size of the smooth tunnel is validated by easily increasing a No. 10 endodontic file's vertical amplitudes down and up the radicular Glidepath from, at first, less than 1.0 mm to longer amplitudes; including sliding down and up the canal from halfway up the canal to the RT. In this way, the operator has the confidence that a super loose No. 10 endodontic manual file can effortlessly follow down and up the tunnel. While many teachers and clinicians prefer a larger file, such as a No. 15 or No. 20, these files are fraught with danger since canals are easily ledged or blocked because No. 15 and No. 20 files have abruptly wider diameters than a No. 1 file. In summary, part 1 described how to competently, consistently, and confidently prepare a predictable endodontic Glidepath for safe rotary shaping.
In the second part of our series on endodontic Glidepath ("Manual Versus Mechanical Endodontic Glidepath," January 2011; available at dentistrytoday.com), I walked the reader through when and how to increase the size of the Glidepath tunnel safely and efficiently using both manual and mechanical techniques.4 (Author's suggestion: Before reading further, it is recommended that you read/review the first 2 articles in this series.)
Now back to Monday morning and it is Glidepath implementation showtime! It is time to find, follow, and finish the endodontic Glidepath, which are the first steps toward successful rotary shaping, active cleaning, and 3-dimensional (3-D) obturation. There is just one thing missing: you have to transfer the mechanical skills of preparing a Glidepath in a plastic block or extracted tooth from your weekend training into actual practice at the chair for your Monday morning endodontic patient. Now, everything has changed: time, oral and endodontic access, visibility and illumination, and operatory ergonomics are all factors. The quality, ownership, and skills of your dental assistant are also factors. Furthermore, the level of energy and the attitudes of all staff needed for the procedure (including your patient) become factors; and the list goes on and on. Implementation has to do with starting with the answer: "I am preparing a Glidepath no matter what." The difference between an occasional good endodontic result and consistently well finished endodontic results is clear intention: knowing where you are, where you want to go, and a plan to get there. Glidepath implementation requires this clear intention and yet you must be passive. And so the great endodontic clinician learns how to implement the skills of endodontic Glidepath, even in the face of pressure to do otherwise; and, there is no doubt that there will be pressure to do "otherwise." These distractions might include: time; money; need proper instruments and operatory design; poor access; wrong file; wrong file curvature; broken file; not enough or not the proper irrigant/irrigation method; dentin mud; dense collagen; long, small, curved, calcified canals; and blocks, ledges, and/or transportations, just to name a few! In order to overcome these obstacles, the dentist must be aware of the skills, recognize his or her options at the many decision points of Glidepath mechanics, make the right choices, and discover a control that was not thought possible in the endodontic experience.
The purpose of this Glidepath series has been to help the dentist make a plan to win at the game of endodontics through learning the skill and implementation of Glidepath preparation. What are those skills, and how and when do you use them? The question is, how do you design and develop a culture in the operatory and in the entire office that intentionally produces the Glidepath result that you want: from equipment to ergonomics; from having enough energy to finish the next step to being energized at the end of Glidepath preparation; and from changing a defeated attitude to the endodontic "gold medal mind." If Olympic athletes can access this "secret," then I would suggest that it is also available to all of us, all of the time.
This article is divided into 3 specific skills that, if understood and fostered, will make endodontics a part of your restorative day that you truly look forward to because you know you can either do it or decide in advance that this is a patient who needs your endodontic specialist. This is most often a visceral decision: you look at the radiograph and can feel in your gut that this case is not for you. That's how you decide. Or ask the question, "What would I do if it were my tooth?" The right decision will promptly appear in the theater of your mind. If there is some hesitation, maybe this is the time to employ the specialist, instead of compromising the endodontic anatomy and then referring the patient. If you make the right case, and you know that you know you can prepare and implement the Glidepath, endodontics will then be energizing and financially rewarding. Furthermore, you will have fun experiencing the joy and satisfaction of predictable outcomes that are biologically successful.
THREE GLIDEPATH SKILLS
Before beginning treatment of your next patient, review toothatlas.com for all the teeth that are similar to the one you will treat. Also, look at page 129 of Michael Cohen's popular interdisciplinary text which indicates the number and frequency of canals for the tooth you are planning to treat.5 Armed with these 2 pieces of information, you will be better prepared for the root canal system anatomy that Mother Nature has in store for you. This preparation is essential for beginners and seasoned masters alike because it is as if you had an endodontic GPS. All you have to do is follow Mother Nature's directions and rules.
Glidepath Implementation Skill No. 1—Glidepath Mechanics: "How Do I Produce Desired and Consistent Technical Outcomes?" (Figures 1a to 1e)
• Finishing Checklist
• Quality Control
• The Intentional Mind
Vision: Start with the Answer
1. Design and prepare a successful access cavity.6 In anterior teeth, triangle No. 1 (mostly comprised of enamel) and triangle No. 2 (mostly comprised of dentin) must be removed. In posterior teeth, internal dentinal triangles must be removed using Gates Glidden burs, X gates (DENTSPLY Tulsa Dental Specialities), or ultrasonics.
2. Magnification and illumination are essential. The microscope allows superior ability to see while maintaining good and healthy posture.7
3. Immediately after straight-line access, wash the chamber using water; preferably by using the Stropko Irrigator. Grade your access cavity for smooth walls finished with a tapered diamond and orifice that allow full freedom to "follow." There should be no impeding enamel or dentinal triangles. Straight-line access is the first step toward successful Glidepath preparation and subsequent successful cleaning, shaping, and obturation. Thoroughly flush chamber with sodium hypochlorite (or preferably with Chlor-XTRA [Vista Dental Products] which has 4 times the capacity to digest both necrotic and detached pulpal tissue) and agitate solutions using EndoActivator (DENTSPLY Tulsa Dental Specialties) for one to 5 minutes, depending on the amount of pulpal remnants in the access cavity. Be patient here, making certain that your access is finished before proceeding. Many dentists are already thinking about "getting the length of tooth." Many times, you never get it. You see you never know if it is the right time to "follow." It has to be discovered. You are setting the tone for "following" the canal to the RT. This is a time for exploration, discovery, inquiry, wonder, enjoying the moment, fascination, learning local knowledge and "booby traps," and expecting the unexpected.8 After all, Mother Nature does not make straight-lines and she does not make 2 the same.9,10 If you understand this, you will never be surprised. Instead, you will surrender to the needed passive, gentle, and time-does-not-matter skills. The only thing that matters is that you "follow" to the end of the canal. (If you did not do as suggested earlier, this is a good time to read/review "The Endodontic Glidepath: 'Secret to Rotary Safety,'" September, 2010; available at the Web site dentistrytoday.com.)
4. Imagine the final obturation. Remember to start with the answer: 3, 2, 1. Start with the end in mind. Then, imagine seeing the No. 10 endodontic file at the RT. Imagine seeing it "following" there.
5. You finally have designed an unimpeded access and you can look directly into the orifice (Figures 2a to 2t). You are ready to follow. I start with file that I think will follow easily, which is smaller than the one that may follow. It is better to error with a file that is too narrow than with one that is too wide; this is because if the wider file is approximately the same diameter as the file, it will plow attached, detached, or necrotic pulp and calcifications ahead of it and produce an early block. Again, this is the time to tap into your attitude and state of mind of slow down. If you don't, and you make a mistake, you may need all day. Irrigate with Chlor-XTRA or sodium hypochlorite. Smoothly curve the last 5 mms of the first file. Finesse the file tip into the orifice. Follow the file as far as it can easily go and absolutely slow down before maximum resistance and carve your way out using the envelope of motion in order to remove potential restrictive dentin. Repeat follow/envelope/follow/envelope until you reach the RT. If the envelope does not allow the file to progress, remove again before maximum resistance, recurve the file and/or go to the narrow file and repeat follow/envelope plan to RT. If the file easily follows to the RT, follow along for the ride. (The only exception would be if the canal had significant necrotic debris present, or if the tooth had been left open for drainage and the canal was full of bacteria and/or food.) If the file were to easily follow, that is exactly what you want. Then, do a smoothing motion (smoothies) until the No. 10 file is super loose. You are now ready for rotary. Sometimes a sufficient Glidepath for rotary already exists in the root canal. If the No. 10 file literally falls to the RT, then Mother Nature has done you a favor. She has given you a canal that is already large and smooth enough for safe rotary; and, generally speaking, the walls are also sufficiently smooth enough for rotary or reciprocation. However, if you prefer a wider Glidepath, then proceed with a No. 15 file using the balance motion or used better progressively sized Series 29 manual files Nos. 1 to 3 (DENTSPLY Tulsa Dental Specialties). As I described in the second Glidepath article in this series ("Manual Versus Mechanical Endodontic Glidepath," January 2011; available at dentistrytoday.com), mechanical techniques, such as PathFiles (DENTSPLY Tulsa Dental Specialties) are also useful when a wider Glidepath is preferred for rotary safety. A second technique is to navigate No. 10 file just short of maximum resistance and then "brush" away restrictive dentin with ProTaper Shaper (DENTSPLY Tulsa Dental Specialties) files S1 and S2 short of No. 10 file depth, "follow" again with No. 10 file and expect to "follow" deeper. Repeat as necessary.
6. Irrigate thoroughly. Again the "Glidepath Finishing Checklist" is simple but the critical distinction before rotary.
7. For me, the next step is to manually follow into the Glidepath with ProTaper S1 and manually turn and carve clockwise.11 My hands are acting as the handpiece. Typically, I will make 2 to 4 rotations, and because of the exceptional ProTaper efficiency, and the progressive taper, the S1 naturally follows and carves away restrictive dentin in preparation to the finishers whose sole job is to connect the preparation outline dots from RT to orifice. Once S1 is 2 rubber stoppers away from the RT, then I know I am safe and I can then mechanically, and in full; rotary float, follow, and brush with purple S1 safely, while staying in control of the shaping. While other rotary systems may require a wider Glidepath than a super loose No. 10 file, the thought process and technique of manual rotary followed by mechanical rotary holds true. It should be noted that a current and becoming highly popular Glidepath sequence is first a super loose No. 10 file followed by the 3 PathFiles. The width of the Glidepath is safer yet.
Finishing Checklist: "You don't get what you want in endodontics, you get what you measure"—Be sure to radiographically or digitally verify your "first instrument to the RT" before proceeding with Glidepath preparation (Figure 1d). Then and only then proceed by preparing a reproducible and verifiable Glidepath by making dozens of short vertical amplitude strokes at the RT position then increasing the stroke amplitude until a super loose No. 10 endodontic file can easily, effortlessly, and repeatedly make longer and longer smoothing strokes until the stroke's amplitude reaches mid root.
|Figures 1a to 1e. Glidepath Implementation Skill No. 1: Glidepath Mechanics. (a) Teaching how to "do" an endondontic Glidepath is not enough. You must learn to "implement" the endodontic Glidepath by creating an office culture that fosters the right equipment, team, training, time, and value to "do the Glidepath right." (b) Start with the answer. Study pretreatment image and imagine or picture a Glidepath, appropriate shape, and 3-dimensional (3-D) obturation. (c) Actual post-treatment image of imagined result. (d) Measure Quality Control by confirming No. 10 file at the radiographic terminus (RT) in your next 10 endodontic cases. (e) Place Glidepath cue card on digital monitor or near you at chairside as a frequent reminder to create new and sustained neural Glidepath network (arrow).|
Quality Control: "Measure your consistency"—For your first "homeplay" assignment, take the next 10 Glidepaths in a row and only proceed once you have a verifiable radiographic or digital image of the "first instrument to the RT (Figure 1d)." Then, only progress with rotary shaping on these same 10 canals after you have a verifiable Glidepath as previously defined.
The Intentional Mind: "See, feel, think, and hold memories of a desired future"—This is the mind of Olympic athletes and great endodonitic clinicians.12 The intentional mind is something you use every day and, if applied to endodontic Glidepath, may be the difference that makes the difference. You wake up, you see yourself in the office in the theater of your mind, you feel what you feel about being in the office, you think that you believe this will happen in an hour or so, and you often hold this thought for a few seconds. This is 21st century neuroscience where the mind is actually creating new neural synapses in order to create a "future memory" or more accurately described as "memory of the future." See, feel, think, and hold. See what you want: the No. 10 endodontic file at the RT, feel: in your gut that that feels good to arrive at the RT, think: I am a skilled endodontic clinician and take the time and use the restraint to predictably follow to the RT, hold: keep seeing the result, holding the feeling, and thinking your successful Glidepath thought for 10 seconds. Now proceed and notice your newfound competence, consistency, and confidence. Do these "memory of the future" exercises before you start your Glidepath using a 3 x 5 cue card by your monitor or at chairside. A second 3 x 5 cue card should be placed outside the operatory where the x-ray button is so that you are cued every time you take a film. Remember to remember this most important guideline. Remember to see, feel, think, and hold your Glidepath 3 x 5 first person, present tense thoughts many times. The more you do it, the sooner you will be masterful at Glidepath preparation. You can e-mail me in 4 months and tell me I am crazy, or you can e-mail me and tell me I have changed your Glidepath preparation skills forever.
|Figures 2a to 2t. Glidepath Implementation: Skill No. 1: Glidepath Mechanics, continued. (a) Preoperative image of maxillary right first molar. (b) Mesiobuccal canal showing internal dentinal triangle preventing straight-line access (arrow). (c) JW 17 microexplorer (CK Dental) used for identifying small canal orifice. (d) Internal dentin triangle removed, demonstrating unrestrictive path to follow down the root canal system. (e) Obturated MB canal orifice. (f) Perpendicular post-treatment image of maxillary right first molar. (g) Oblique post-treatment image revealing 4 canals and canal shape and the result of sufficient obturation hydraulics to seal multiple portals of exit. (h) Curving first "following" file with metal cotton pliers. (i) First "following" stroke is delicate, nimble, and passive though intentional in its outcome to follow to the RT. (j) Fingers glance off stroked advancing file handle. (k) "Following" file arrives at RT. (l) Small vertical amplitude strokes called "smoothies" are repeated until amplitude effortlessly increases. (m) Smoothies motion. (n) Smoothie amplitude increases. (o) As amplitude increases, smoothie motion is easily followed back to RT. (p) If follow motion does not initially follow to RT or if you wish to clean coronal portion of root canal system then "envelope" the file out by carving clockwise on the outstroke. Then follow again, this time deeper if restrictive dentin were the situation. Repeat until you reach RT. (q) Tail end of envelope motion. (r) "Balance" motion is used when Glidepath is prepared but larger diameter Glidepath is desired. Turn handle clockwise. (s) Turn handle counterclockwise with slight apical pressure. (t) Turn handle clockwise again and slowly withdraw, carrying away dentin carvings in the flutes of the file.|
Skill No. 2—Energy: "How Do I Manage Energy to Increase Efficiency?"
• Do more of what you are good at and enjoy.
• Schedule based on energy.
• The power of full engagement. Present moment.
Do more of what you are good at and enjoy—Learn to delegate what you do not enjoy and keep the rest. It is that simple. If you do not like to give anesthetic or it takes a lot of energy for you to painlessly and profoundly anesthetize the "hot pulp" for example, have your hygienist do it if you are in a state that allows hygiene anesthetic. If placing the rubber dam takes up some effort and energy, teach your dental assistant what you want and let him or her take pride in the perfect rubber dam that is placed properly and does not distract you by being crooked or restricts your straight-line access. Teach your dental assistant to safely irrigate the access chamber when you remove a file to set its length or curve and to take pre- and post-treatment images.
Schedule based on energy—When preparing the endodontic Glidepath, you should have no time restraints. If a patient asks, "How long will this take?" say, "I do not know, but what I do know is that it will be done right. That is my commitment to you. Time does not matter here; what matters is being successful." I have never had a patient ask this question twice. They know they are in the right place and that I have their health and well-being as my single guideline. You have all heard that a "patient does not care how much we know until they know how much we care." The promise and rewards of successful Glidepath skills are no exception. Also, schedule endodontics when you can minimize interruptions and when you are most energized so that you can concentrate and be fully present in the moment.
The power of full engagement—Being present in the moment is what is needed for consistently successful Glidepath preparation. This is not a time for mental distractions that take you into the past or future. The best example of this is what occurs when children are playing. They are truly living in the now.13 While they may be hungry, or it may be raining, or they may be cold, somehow none of that matters. So, what really matters the most? Being in and enjoying the moment that life has given to them.14 Life has given all of us moments to implement Glidepath. Have fun with it and you will perform with the greatest of ease!
Implementation Skill No. 3—Fun: How Do I Strengthen the Relationship of "Doing" Endodontics, and Having "Fun" Doing Endodontics?
• The relationship of fulfillment and performance.
• Start with the answer.
The relationship of fulfillment and performance—Most dental education, and most of the content of these 3 Glidepath articles, has had to do with performance: how to "do" a Glidepath. However, industry teaches us that if we increase fulfillment (how much we enjoy a task or skill), we also enhance and increase the level of our performance. And so, there are 2 ways to increase the level of our Glidepath performance. First, practice the skills described in this series of 3 Glidepath articles. Second, make a commitment to have fun when you are doing it. This is a perfect time to make a new 3 x 5 Glidepath cue card that might read something like, "I have fun preparing the Glidepath because I take skilled and proper actions that get me there, even in the face of pressure to do otherwise."
Start with the Answer (Figures 3a to 3q)—If the answer is to enjoy your endodontics, then start by choosing to have fun doing it and see, feel, think, and hold that thought of knowing you own the Glidepath because a super loose No. 10 file is your proof.
|Figures 3a to 3q. Glidepath Implementation: Skill No. 2, Energy, and Skill No. 3, Fun, enable Skill No. 1, Glidepath Mechanics. (a) Glidepath Skill No. 2 Energy requires 4-handed skills. If designed efficiently and effectively, something is always occurring in the access cavity. For example, when the dentist is curving files or setting rubber stops, the assistant is safely irrigating into the access chamber. The endodontic assistant not only offers another pair of educated eyes in and out of the microscope but gives supportive energy when the "chips are down" or whenever it is needed. The endodontic team includes one, and sometimes 2, technical assistants, perhaps also an anesthetist such as a hygienist, and administrative team that values the vision of excellence and represents exceptional endodontics and patient care. (b) All you have to do is look at your "dentist in the mirror." You are your answer to successful Glidepath mechanics! The strategy is a simple one: Starting with the answer of the successfully obturated root canal system, you can peer at the endodontic pretreatment film and "see, feel, think, and hold that thought for 10 seconds." Then just do it! Experience your Glidepath skills and you will be competent, energized, and having fun being lost in the moment. (c) Imagine the result that you want. This is the answer. Then retrace all the steps needed to predictably accomplish the answer from post-treatment film to pretreatment film. Imagine restrictive flow shapes that allow you to mold warmed gutta-percha and sealer apically and laterally. (d) Back pack instrument, such as Calamus Dual (arrow) (DENTSPLY Tulsa Dental Specialties). (e) Animation of warmed gutta-percha and sealer molded apically and laterally. (f) Extracted tooth's horizontal section of 3-D obturation 4 mm from apex. Note narrow gutta-percha/dentin interface that is filled with endodontic sealer. (g) Conefit. (h) Pack down instrument, such as Calamus Dual (arrow). (i) Fit obturation material and dry canals. (j) Final EndoActivator rinses (DENTSPLY Tulsa Dental Specialties) to remove remaining tissue remnants and, biofilm, smear layer using QMix (DENTSPLY Tulsa Dental Specialties), tissue remnants and biofilm with Chlor-XTRA (Vista Dental Products) and alcohol for drying the root canal system. (k) Shape the radicular canals with efficient rotary files such as ProTaper Universal or (l) WaveOne (DENTSPLY Tulsa Dental Specialties). (m) Apex locator (J. Morita USA) for accurate physiologic terminus determination. (n) Efficient strategy of "first instrument to RT" and conefitting in previously shaped canal in single image. (o) Curving first "following" file. (p) Endo Access kit (DENTSPLY Tulsa Dental Specialties). (q) Preoperative image of maxillary right first molar.|
GLIDEPATH IMPLEMENTATION TROUBLESHOOTING
Situation No. 1: File will not fit into canal.
Solution No. 1: Change to a smaller file and/or use Mueller bur (Brasseler USA) or ultrasonics to follow canal remnant deeper since canals calcify in a crown-down direction. Canal will be wider deeper since calcification occurs from the crown/down.
Situation No. 2: File will not reach the RT.
Solution No. 2: Remove file in envelope motion, follow again, and repeat until reaching RT.
Situation No. 3: You have followed and enveloped as in solution No. 2 but file does not progress apically.
Solution No. 3: Remove file using envelope motion, irrigate, recurve and nimbly follow until reaching RT. If RT cannot be reached, repeat envelope/follow sequence until reaching RT.
Situation No. 4: You have followed/enveloped as in solution No. 3 but file did not go deeper. You removed file, recurved and followed and/or followed/envelope/follow and file does not reach RT.
Solution No. 4: Remove file with envelope motion, irrigate, select narrower file, curve and follow to RT. If not reaching RT, repeat solution No. 3.
Situation No. 5: You are following with your smallest file as in solution No. 4 but cannot reach the RT. The canal seems blocked.
Solution No. 5: Do not panic. Irrigate and take a deep breath. See, feel, and think that you are at the RT by looking at the radiograph or digital image and imagine the file at the RT. Hold that thought for 10 seconds. Perhaps the canal is partially calcified or filled with dense collagen or a dentin mud plug, which has been described as the "fatal flaw" of Glidepath success. You do not know. First assume plug, place a rather severe and smooth apical curve on smallest file over last 2 mm of your narrowest file. The curved tip will locate and penetrate the plug of dentin mud. Patience is the watchword. Patience will always trump force any day. "How many things have to happen to you," Robert Frost wrote, "before something occurs to you?" Repeat removal, recurve at tip of file, irrigate, and touch top of assumed dentin mud plug. Be resilient here. Resilience is born by grounding yourself in your own patience, experiencing a clinical gentleness you thought was way out of your range. Repeat until file follows through the dentin plug and then easily make smooth motions at level of RT using one-mm vertical amplitude strokes to loosen and break up the dentin plug before withdrawing the instrument from the canal.
Situation No. 6: Same as solution No. 5 but file will not follow to RT.
Solution No. 6: Canal could be clogged with collagen plug and/or calcified. First, partially calcified canals can be followed successfully if they are treated at the outset as if they were packed with dentin mud. Second, situation could be collagen plug. Introduce a viscous chelator (such as ProLube [DENTSPLY Tulsa Dental Specialties]) that will emulsify the collagen plug and allow the file to follow through the collagen plug to the RT. With an abrupt and smooth apical curve, each searching probe motion gains distance toward the RT even though progress may not be immediately measurable or perceptible. The curved file is removed using the envelope motion. Fresh sodium hypochlorite and/or viscous chelator is deposited into the access chamber and is drawn deep into the canal where it digests or emulsifies collagen material along the path of the instrument insertion path. Patience, restraint, and passive are the watchwords here. Caution is made to prevent pushing calcific material apically or it could block the canal. Typically each followed searching probe with the intentionally deflected file tip gains another fraction of penetration into the canal. The file should be immediately withdrawn each time prior to maximum resistance. Irrigate the pulp chamber. The file is recleaned, recurved, and followed into the canal again. Sequence is repeated until the RT is reached and verified by radiograph, digital image, and apex locator. Do not withdraw the file until the radiographic image has been carefully examined. If the file has indeed reached the RT, then "withdraw and follow in and out" to RT or slightly beyond using short amplitude motions or strokes until the file feels super loose. The stroke amplitude can be first increased to several millimeters and finally and until the stoke amplitude smoothly and effortlessly increases halfway up and down the canal. Insufficient smoothing strokes with the first file to the RT rearranges the calcific debris and collagen fibers insufficiently and haphazardly which risks permanent blockage at the physiologic terminus if a wider file is chosen to increase Glidepath size or if rotary were to follow. This "progressive increase stroke amplitude" technique not only smoothes the Glidepath walls but spreads the previously obstructing calcifications against the canal walls and allows sufficient entry of sodium hypochlorite and/or chelating agent to safely proceed with Glidepath completion. Once long amplitude and reproducible stokes are achieved, you now have finished sufficient Glidepath for most rotary systems to begin. You have mastered the Glidepath. You own it, and rotary shaping and 3-D cleaning becomes fun.
The purpose of this article, in the 3-part series of articles published by Dentistry Today on Glidepath, was to increase the reader's awareness of the 3 skills of endodontic Glidepath implementation, to recognize that you have new options and a new cognizance; and that with options come choices. Some are easy, such as to irrigate more, while others such as slowing down, being gentle, demonstrating restraint, being positive and smiling, embracing the situation, using new instruments, training and delegating appropriate tasks to your dental assistant, purchasing the right equipment, and getting trained in such areas as using microscopes and implementing digital radiography will require a deeper commitment. Above all, it is my sincere wish that everyone who implements these philosophies, concepts, and techniques into their practice enjoys the "Glidepath moment" and has fun! And finally, when you make the choices essential to Glidepath implementation, you will control the experience and the outcome. You will have discovered the answer to the question: What matters the most?
- West JD. Finishing: the essence of exceptional endodontics. Dent Today. 2001;20:37-41.
- West JD. So many rotary systems, so little time: how do I choose? Endodontic Practice. 2009;12:22-28.
- West JD. The endodontic Glidepath: "Secret to rotary safety." Dent Today. 2010;29:86-93.
- West JD. Manual versus mechanical endodontic Glidepath. Dent Today. 2011;30:136-145.
- West JD. Endodontic predictability—"Restore or remove: how do I choose?" In Cohen M, ed. Interdisciplinary Treatment Planning: Principles, Design, Implementation. Chicago, IL: Quintessence Publishing; 2008:123-164.
- West JD. Endodontic update 2006. J Esthet Restor Dent. 2006;18:280-300.
- West JD. The role of the microscope in 21st century endodontics: visions of a new frontier. Dent Today. 2000;19:62-69.
- West JD. Perforations, blocks, ledges, and transportations: overcoming barriers to endodontic finishing. Dent Today. 2005;24:68-73.
- West JD. Rules of engagement: mastering the endodontic game, part 1. Dent Today. 2006;25:94-101.
- West JD. Rules of engagement: mastering the endodontic game, part 2. Dent Today. 2006;25:108-112.
- West JD. Progressive taper technology: rationale and clinical technique for the new ProTaper universal system. Dent Today. 2006;25:64-69.
- Loehr J, Schwartz T. The Power of Full Engagement. New York, NY: The Free Press; 2003.
- Csikszentmihalyi M. Flow: The Psychology of Optimal Experience. New York, NY: Harper & Row; 1990.
- Singer MA. The Untethered Soul: The Journey Beyond Yourself. Oakland, CA: New Harbinger Publications/Noetic Books; 2007.
Disclosure: Dr. West is co-inventor of ProTaper Universal, WaveOne, and Calamus technologies.
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