by Barry Lee Musikant, DMD
For more on this topic, go to www.dentaleconomics.com and search using the following key words: instrument separation, endodontics, rotary NiTi instruments, procedural fear, K files, increasing limited usage, Dr. Barry Lee Musikant.
In a previous article on the improved economics derived from using a far less expensive endodontic system, the emphasis was on the financial consequences and the obvious positive ramifications for one's practice. However, the beneficial financial impact goes way beyond the less expensive costs. Other things to consider when evaluating the economic consequences include the implications of using a system that is far less vulnerable to breakage. These include:
Less procedural fear quickly translates into a willingness to tackle more challenging cases. In the past, the decision to do a procedure or send it out to a specialist was based on, among other things, the chances of separating an instrument. While some popular authors state that this is really not a problem and can be quickly resolved by some common sense cooperation between the endodontist and the dentist who fractured the instrument, the reality is that it is a chilling experience for the dentist.
It makes him or her vulnerable to the potential anger of the patient, casts a negative effect on the practice, can lead to a potential lawsuit, and takes a physical toll on the dentist. All of these things often make a dentist decide that he or she will err on the side of caution and make a referral.
The doctor's decision to refer is entirely rational considering the problems he or she could encounter. The practical outcome is that the doctor keeps less work in the office.
Dentists are likely to use the rotary NiTi instruments only once because of the same concern that made them refer out endodontic procedures in the first place — namely, separation anxiety. As a result, these doctors are doing less work while spending an exorbitant amount of money on a system that is underutilized.
The realistic psychological state of mind that equates rotary NiTi with extreme caution is a needless price that dentists pay when using rotary NiTi. On the other hand, using a relieved reamer–based reciprocating system produces an entirely different state of mind. This state of mind begins with the fact that because use is limited to a tight watch–winding motion or a 30º reciprocating handpiece, they are virtually invulnerable to separation.
What we are advocating can separate, but it would only occur through gross misuse, namely, locking the instrument in apically and continuing full rotations coronally. Any instrument would break in such circumstances.
Given the elimination of separation for all practical purposes, dentists no longer have to equate a significantly curved canal as a potential invitation to disaster. Once separation is eliminated as a cause for concern, negotiating curved canals without distortion is a very learnable procedure. Cases that doctors would have sent out when using rotary NiTi can now remain in the office.
Unlike the rotary NiTi learning curve where greater selectivity — otherwise known as an increasing limited usage — occurs, there are no limitations on the use of relieved reamers in a 30º reciprocating handpiece. The direct consequences of a system that does not fracture is increased usage, the development of greater skills, and a state of mind that welcomes curved canals as a challenge rather than something to be dreaded.
Not only do dentists feel better, but their practices retain more work and experience a financial upswing. The concept of single usage for rotary NiTi has evolved with the increasing undertanding that the forces that cause separation are not really under the control of the dentist. It has been clearly stated in the literature that most of the rotary NiTi instruments can be used several times, but unfortunately, the ones that cannot be used several times are not decipherable by the dentist.
As a result, it is better to use the instruments just once. In fact, from the manufacturer's standpoint, if that concept is acceptable to the dentists, it is a virtual gold mine. The only reason such a concept would be acceptable to doctors is because what they previously used — generally k–files from start to finish — are totally inadequate, yet dentists are unaware of any viable alternative. They are still reminded of this inadequacy even as they use rotary NiTi because of the need to create a glide path with the recommended use of K files.
Interestingly, the concept of the single usage of rotary NiTi instruments is opposite from the historical protocol employed for endodontic instruments prior to the introduction of rotary NiTi. They call for the instruments to be autoclaved and reused several times, and that is still the norm for all sorts of instruments used in surgeries that are exposed to far more blood than anything encountered in endodontics.
Common sense says that single usage is a rationalization to compensate for the weaknesses of rotary NiTi. By creating a standard that states that all endodontic instruments may only be used once, the singular vulnerability of rotary NiTi is muted and buffered, and from the manufacturer's point of view, hopefully obscured.
The obvious point is that dentists are spending a lot of money on rotary NiTi with the self–imposed limitations on the work they are doing. By going to another system, they can accomplish two immediate goals:
- Significantly reduce overhead for endodontic instruments by about 90% to 95% on a per use basis, and
- Retain far more work in the office.
There is no compensating price to pay for these two positive achievements. Secondarily, the quality of the work will be at least comparable, separation anxiety will no longer exist, and the doctor's skills will grow with time and experience in a virtuous cycle where greater skills help retain more work in the office.
The ability to change the endodontic environment rests on some incredibly simple precepts — instruments that do not separate, allow the safer preparation of canals to a greater diameter, and cost far less primarily because they can be used six to seven times before replacement.
What we present may sound radical to some — especially those who have invested in rotary NiTi — but we offer an introductory, free, two–to–three hour, one–on–one course for anyone curious enough to test the legitimacy of our approach.
To participate, call (212) 582–8161 for more information about the free workshop. For those who wish to ask questions and participate in a fully open dental forum, please join endomailmessageboard.com. It is free, open, informative, and incredibly good natured.
Dr. Barry Lee Musikant is a partner in the largest endodontic practice in Manhattan. Contact him at firstname.lastname@example.org. To view examples of complex anatomy shaped in a nondistorted manner, safely and effectively, with the SafeSiders instruments used in the EndoExpress reciprocating handpiece, visit www.edsdental.com/xrays.