by Richard Mounce, DDS
For more on this topic, go to www.dentaleconomics.com and search using the following key words: surgical operating microscope, irrigation regimen, case referral, coronal seal, rubber dam, RNT instruments.
While luck may come in handy at the casino or racetrack, luck is not a word to associate with endodontics. Performing root canal treatment should never depend on luck, as the treatment should be well planned and executed based on sound literature-based principles and strategies. The principles are:
1) Using the surgical operating microscope (SOM) (Global Surgical, St. Louis, Mo.). There is no substitute for the lighting, magnification, and visualization this instrument provides. An entry-level microscope costs approximately $12,000 to $13,000. The SOM can be used for all phases of dentistry and is not simply an endodontic instrument. Despite the advocacy of some for loupes, they are second best compared to an SOM.
2) Choosing the correct irrigation regimen for each case. Irrigation should be tailored to the clinical indication. Vital cases require sodium hypochlorite, retreatment cases require 2% chlorhexidine, and removal of the smear layer is performed with a liquid EDTA solution such as SmearClear (SybronEndo, Orange, Calif.). Necrotic teeth can be irrigated with sodium hypochlorite, 2% chlorhexidine, or both. In any event, irrigation is optimally heated and activated in some way, be it ultrasonically or through other means. Irrigants should be constantly refreshed and worked into the apical regions of the canal through the insertion of hand and rotary files, in addition to the activation described above.
3) Using RNT instruments with the correct tactile control and in the correct sequence. Despite their existence for almost two decades, the strategies for safe clinical use of RNT still confuse some clinicians. In the most general terms, these instruments are used with minimal apical pressure, after the creation of a glide path wherein the canal is enlarged to at least a number 15 hand file first, in the presence of copious irrigation and frequent recapitulation, and used crown down, from large tapers to small, or big instruments to small. In my hands, the state-of-the-art system for canal preparation is the Twisted File (SybronEndo, Orange, CA). This file has an unprecedented ability to prepare an entire canal in one to two instruments to tapers such as .10 and .08 along the entire length of the canal to the minor constriction of the apical foramen, a capability never before possible.
4) Placing an adequate postendodontic coronal seal. Endodontic literature conclusively correlates clinical success with the placement of both early and adequate coronal seal. The optimal time to place the coronal seal is at obturation under the SOM and the rubber dam. This is when the tooth is clean and dry and the patient is numb, and significant time can be saved if the coronal seal is placed without delay. Some other advantages of providing early coronal seal include fewer appointments and less chance of an iatrogenic event by eliminating the second access into the tooth.
5) Referring the case when necessary. If ever the clinician does not have the time, materials, equipment or training to create an excellent result, the case should be referred to a specialist. The best chance for an excellent result is the first access into the tooth, and it should be optimized. The attitude that a patient can be referred later if a case becomes unwieldy is counterproductive for all parties.
6) Planning enough time to create the desired result. Treatment based on speed over excellence will diminish the potential for excellent results. Recently I read a clinical article that espoused the virtues of 10-minute anterior root canals and 20-minute molar treatment. While such a recommendation can fill an entire article, it does not recommend the time needed to perform the treatment to the highest level. There are not multiple ethical or legal standards of care; there is one standard of care for endodontists and general practitioners. Arguing for lesser materials or methods in the interest of saving time, and viewing profitability as the sole objective of treatment, dishonors the patient and creates the potential for iatrogenic issues.
Creating excellent results is predictable. I recommend a surgical operating microscope, optimal irrigation, correct tactile control of RNT instruments, placement of an adequate and early postendodontic coronal seal, and early referral as needed.
Dr. Mounce offers intensive customized endodontic single-day training programs in his office for groups of one to two doctors. For information, contact Dennis at 360-891-9111 or write [email protected]. Dr. Mounce lectures globally and is widely published. He is in private practice in endodontics in Vancouver, Wash.