Around the horn

June 1, 2003
This month, we want to focus on some questions that are commonly asked by participants at our "Real World Endo" courses.

Dennis Brave, DDS & Kenneth Koch, DMD

This month, we want to focus on some questions that are commonly asked by participants at our "Real World Endo" courses.

The first is, "Can I one-step a "hot tooth" that comes into the office on an emergency visit?" The answer is a definite yes — if the "hot tooth" is vital and the diagnosis is an acute pulpitis. The discomfort in these cases is principally related to inflammation; they normally will do very well with a one-visit procedure. Pain medication generally will be NSAIDS, but don't forget to relieve the occlusion. If the tooth is necrotic, it may require two visits, depending upon the experience of the clinician. Therefore, the key in one-stepping a "hot tooth" is the status of the pulp.

The second question we want to address is, "When can I do a .06 taper preparation and when should I do a .04 taper preparation?" This is a good question as it gets to the heart of endodontic preparation. As readers of this column know, we are strong proponents of a fully tapered .06 preparation. This technique has multiple advantages. However, there are certain instances where you cannot use this approach. Generally, MB-2 canals of maxillary molars are difficult to prepare with a .06 taper file, and a significant number of MB canals in lower molars will likewise require a .04 preparation. The rule regarding when to use which technique is simple: Never force a rotary file. If you enter a canal with a .06 taper rotary file and the resistance is extreme, we suggest that you shape that canal to a fully tapered .04 preparation. With experience, you can complete about 70 percent of root canal preparations with a .06 taper file; however, 30 percent will need a .04 taper. Remember — never force a file!

A third question is the very often asked, "How many times can I use a rotary file?" We used to say, "seven canals." However, the real answer is, "It is not how many times you have used a file, but how the file was used." For example, S-shape canals stress a file far more than straight canal shapes. A particularly difficult tooth can generate enough cyclic fatigue that the file needs to be replaced. Since cyclic fatigue cannot be seen, it is the clinician's responsibility to discard that file. An awareness of cyclic fatigue will greatly help the clinician reduce the possibility of separation.

Another question frequently asked is, "How can I stop the bleeding in a weeping tooth?" If you still have some bleeding after instrumenting a canal, it is usually a result of remaining tissue tags in the apical 2-3 mm. Make it a point to fully instrument the apical portion of the canal to the proper size. You may even have to use hand instruments to accomplish this task. The combination of complete instrumentation and proper irrigation will usually stop the bleeding.

A weeping canal can also be the result of over-instrumentation. If the canal is over-instrumented, place calcium hydroxide in the canal and re-appoint the patient in a week. Over-instrumented canals can be a source of postoperative pain, so please relieve the occlusion and supply some NSAIDS.

The final question we always get is, "Do you have a textbook or a video tape that you can recommend?" We actually do have a text entitled, The Fat-Free Endodontic Cookbook. This book is not for sale, but we do give a copy to every attendee of a Real World Endo Institute course. We also offer an educational DVD, The .06 Taper Preparation, which is available by calling (866) 793-3636, or online at

Endodontics continues to be exciting and we welcome all comments and questions. Hopefully, the answers to these common questions will help you in your practice. As always, we will continue to give you "Just the Facts, Nothing but the Facts."

Dr. Dennis Brave is a diplomate of the American Board of Endodontics and was the senior managing partner of a group specialty practice for 27 years. Dr. Kenneth Koch is the founder and past director of the new program in postdoctoral endodontics at the Harvard School of Dental Medicine. Drs. Koch and Brave together are Real World Endo, an endodontic education company. They can be reached at (866) RWE-ENDO, or visit their Web site at

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