Five tips for painless endodontics

Aug. 1, 2003
At Real World Endo, we truly believe you can perform endodontics painlessly. The key is to know which procedures and techniques will result in a pain-free endodontic experience.

By Dennis Brave and Kenneth Koch

At Real World Endo, we truly believe you can perform endodontics painlessly. The key is to know which procedures and techniques will result in a pain-free endodontic experience.

Here are five tips that will help you achieve that goal.

1) Profound anesthesia

Profound anesthesia goes hand-in-hand with a painless dental experience. We've mentioned the following technique in previous columns, but it bears repeating because it is a great way to achieve profound mandibular anesthesia.

Begin by using one carpule of 3 percent mepivacaine, without vasoconstrictor, for your initial block injection.

Follow this with one carpule of regular lidocaine, 1/100,000 epinephrine. You will be pleasantly surprised how you will be able to achieve predictable profound mandibular anesthesia with this technique.

2) Crown down method

How you instrument a root canal can affect the level of discomfort from the procedure. This is significant since dental pulp degenerates from top to bottom. The crown down method is preferable because it removes the diseased coronal section of the pulp first; consequently, it results in less potential apical extrusion of debris. The less debris extruded apically, the less likelihood there is for post-operative sensitivity.

3) Determine final working length after the second rotary file

We do not recommend taking any hand file to final length until two rotary files have been used to open (pre-flare) the coronal half of the canal. By opening up the coronal half of the root canal, these first two rotary files will, in fact, remove about 70 percent of the root canal contents. Consequently, when you now take a hand file to length, you have greatly reduced the possibility of inoculating the periapical tissue. The inoculation of periapical tissues with necrotic debris from the root canal system is one of the major causes of discomfort.

4) Use an apex locator

In our opinion, there is no reason not to have an apex locator to help you determine final working length. A common cause of post-operative sensitivity is when the clinician has been working "long" in the periodontal ligament.

The lack of length control is one of the most common errors we see in endodontic treatment. The third generation apex locators are extremely accurate in determining final working length. Two models that we like are the "Root ZX" by J. Morita and the "Elements Diagnostic" by SybronEndo.

5) .06 tapered preparation

Endodontics is all about cleaning and shaping. Your irrigation agent has the ability to work more effectively in a fully tapered .06 preparation than with an .02 or .04 preparation. Additionally, the .06 preparation allows the clinician to use an ultrasonic tip, such as a CT-4, to more effectively clean the root canal system. Finally, another benefit of the .06 taper preparation is the reduction in extruded debris. All of these factors contribute to a reduction in post-operative sensitivity.

These five tips will help make your endodontics "pain free." It is now your challenge to implement these techniques into your root canal therapy. In the next few columns, we will be introducing further improvements in the art and science of endodontics. As is our custom, we will continue to offer, "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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