I once heard LANCE ARMSTRONG speak about maximizing every variable to produce success: lowest bike weight, optimal nutrition and fitness, and more. He examined every preparation variable to look for improvements that could enhance his performance. The concept is simple but powerful, and if it’s good enough for Lance, it’s good enough for me.
While a single instrument or technique can be significant, many variables add up to deliver the best possible result. Exceptional instrumentation with poor irrigation, or thermoplastic replication of prepared canal space with a poor shape in which to obturate, are two examples of working at cross purposes to the final goal. The goal is to three dimensionally clean, shape and obturate the canal from the canal orifice to the minor constriction of the apical foramen.
Root canal treatment should ideally be broken down into many components. Rather than viewing the entire process as one, it’s beneficial to visualize it as a series of small procedures that build on each other. For example, profound anesthesia is a prerequisite to a cooperative patient. Excellent access utilizing a surgical operating microscope (SOM) (Global Scopes, St. Louis, Mo.) makes instrumentation without iatrogenic events far more likely. Alternatively, a lack of straight-line access makes irrigation and ideal tactile control in the apical third problematic. How then to carry out each of these mini procedures for greatest efficiency and quality? One proven method is dedicated learning and practice, ideally with an open mind.
Much has been written on the technical aspects of endodontics, but there is an often unspoken ingredient that should be mentioned – an open mind. Over the past five years I have lectured extensively across the globe. I had a recent moment of clarity while answering questions during a course. People learn best, make breakthroughs, and integrate new ideas and technology when they are open to change. What I’m sure has challenged many a teacher since the beginning of time are the students who close their minds, who believe they already understand the subject, and want only to adapt part of a material or technique to fit into their existing concepts and treatment regimen.
Complicating matters are the cases where a student’s initial beliefs may be flawed or simply untrue. For example, someone told one of my recent course participants that in the apical third of roots there must be a viscous EDTA gel like File EZE (Ultradent, South Jordan, Utah) in canals for lubrication.
While a viscous EDTA gel is essential in the early stages of a vital case to hold the pulp in suspension in the apical third, it is generally not used or necessary as a lubricant apically. Misinformation such as this can evolve into dogma. Dogma becomes stasis and the clinician stays at a level of practice that does not reflect the possibilities of today’s technology and materials. Innovation can be stifled in this crucible of mythology, opinion, and unproven bias.
For obturation, I use the Elements Obturation Unit, RealSeal, and SystemB (SybronEndo, Orange, Calif.) under the Global Surgical Operating Microscope (SOM). The obturation is made into shapes with the K3 rotary nickel titanium file system. I have found this technique to be simple, efficient, predictable, and easily mastered. The myth that SystemB is technique sensitive and equipment intensive is simply not true. Interestingly, in my hands, obturation couldn’t be simpler or done more easily.
Another area where misinformation abounds is the vital importance of early coronal seal. A major avenue of endodontic failure is the lack of a coronal seal. It is intuitive to place this seal at the time of obturation under the SOM and rubber dam. To delay placement of the coronal seal for whatever reason defies logic, when often the endodontist is looking at the access under high power through the SOM and under the SOM.
This is the time to place the coronal build up and seal the tooth with finality and control. I use PermaFlo injected with the Skini syringe (Ultradent). Regardless of the material, to delay its placement and possibly place the build up without a rubber dam does not promote long-term success.
As evidenced by a winner like Lance Armstrong, every variable should be optimized in treatment. The importance of an open mind toward change and growth cannot be overstated in this process.
Dr. Richard Mounce offers intensive, customized endodontic single-day training programs in his office for small groups of one to two doctors. For information, contact Dennis at (360) 891-9111 or e-mail [email protected]. Dr. Mounce lectures globally and is widely published. He is in private practice in Vancouver, Wash.
