Dr. Dalin: Endodontics seems to have made some great strides in technology through the years. Let’s start by discussing some of the tools intended to make endodontic diagnoses easier. I am a huge fan of digital radiography. Does this technology make the endodontist’s job easier?
Dr. Speer: Absolutely. This is the endodontist’s answer to the intraoral camera. Digital radiography allows me to show a patient what the problem is, and what endodontics is all about. Also, don’t overlook the “wow factor.” Patients are impressed by high tech! I can show patients the anatomy of a tooth and more. When patients come to my office for a root canal, it’s amazing how many think that I am going to remove the roots of the tooth!
Dr. Dalin: Let’s discuss the specifics of diagnosis before treatment. Can you give me a quick and easy guide of questions to ask patients when evaluating the need for endodontic treatment?
Dr. Speer: Before I begin to examine a patient, I want to hear that person’s story. What is the problem? What causes the pain? Is there pain now? The two important questions I ask are “Do you have spontaneous pain?” and “Does the pain come on with no outside stimulus?” If the answer to both questions is yes, then there probably is a 100 percent need for endodontics. Many times, these questions are not asked, complicated restorative work is performed, and the tooth becomes acutely painful.
Dr. Dalin: Electronic apex locators seem to be getting better and better. Please talk about this tool.
Dr. Speer: I rarely take working length radiographs any more. The accuracy of the new apex locators is remarkable. This piece of equipment has made a huge difference in my patients’ postoperative symptoms. Because I am working within the actual root canal and not at an arbitrary length, I have fewer calls the day after treatment complaining of pericementitis.
Dr. Dalin: Let’s discuss some recent advances in hand instruments. Nickel-titanium seems to be the standard of the field in 2006. Why has this material proven to be superior to files of old?
Dr. Speer: I do not believe that NiTi hand files are the standard. Stainless steel is still the way to scout the anatomy and create a glide path. But only the small sizes are able to safely and predictably negotiate the curves. I think NiTi rotary files have taken the forefront as the way to effectively and efficiently clean the root canal system.
Dr. Dalin: Do you advocate using lubricants during the filing and preparation of canals?
Dr. Speer: Absolutely! I never want to have a file (hand or rotary) working in the canal without lubricant and irrigant (NaOCl) in combination.
Dr. Dalin: Are you a fan of rotary endodontics? What about some of the techniques currently being taught, such as crown-down preparation?
Dr. Speer: I am definitely a fan of rotary endodontics. I have been using rotaries since long before rotary instrumentation was “cool.” If you expect success with most rotary systems, it is essential to work the preparation in a “crown-down” fashion. I teach my students to approach first the coronal one-half to create a glide path, and then to work with rotary files in this portion of the canal. Next, I have them explore the apical half, obtain a working length, create a glide path, and then complete the apical portion of the preparation.
Dr. Dalin: What do you think is the most important tool that is used during endodontic therapy?
Dr. Speer: The rubber dam. Many practitioners skip this step. In my opinion, not using this tool is a big mistake. This omission results in a lack of patient protection from instruments and irrigants we use, contamination by saliva, and the creation of a septic environment. It also helps to keep the patient’s tongue out of the way.
Dr. Dalin: I remember seeing in a recent survey that rubber dam use was approximately 50 to 60 percent. That is quite a shock to me, considering what you just mentioned. Let’s change the subject to filling canals. We seem to have many options for filling materials ... from classic gutta percha, to heated gutta percha, to Resilon. What are the advantages and disadvantages of each?
Dr. Speer: Although I am a great fan of change and improvement, I am a serious biological scientist. I have not seen enough research to convince me to change to Resilon. But I look forward to that body of research when it becomes available. I am convinced that how we fill root canals today will not be the same method I will be using when I retire. Today, I think gutta percha remains the best studied and most proven biological choice. The body of research shows a biocompatible material that does an adequate job of sealing the root canal in the presence of sealer. I am concerned about Resilon and the use of free monomer in the apical region as a component of the sealing technique. But the material is good to work with, and its characteristics are the same as gutta percha. I use the filling without the sealer component as an alternative for latex-allergy patients. But no matter what material you choose, I think the most important aspect of endodontic therapy is thorough cleansing and shaping of canals. By removing all debris, we can allow a patient’s host defense to cure the problem that is occurring.
Dr. Dalin: Leigh, let’s discuss posts. To me, there is nothing more frustrating than having a patient call after a crown has come off. The patient brings the crown to the office, and it is not just a dislodged crown ... it is a dislodged crown with the post and core protruding from the bottom. What is your advice in restoring a tooth after a root canal has been performed on it?
Dr. Speer: Today, adhesive dentistry allows the restoration of teeth without the use of the traditional post and core. In fact, I believe a tooth restored without a post may be less susceptible to fracture. However, many teeth do need additional retention and strengthening. In these instances, posts are beneficial. I like the new fiber posts as well as the traditional, stainless steel types.
Dr. Dalin: Since we are talking about items from a restorative dentist’s point of view, what recommendations do you have for a tooth with extremely deep decay? Should we clean the area as close as we feel comfortable, and then place a bonded temporary filling to see how the tooth reacts?
Dr. Speer: I think that is the call of the dentist on the scene. There are too many variables to address. However, once again, if the patient is having spontaneous pain, endodontics is needed.
Dr. Dalin: What should we do if we have a small exposure? There have been studies that show if a glass ionomer base is placed over the exposure, then a well-sealed composite resin is placed over that, the tooth might be able to be left as is. What are your thoughts on this?
Dr. Speer: My 30 years of experience, coupled with that of my mentor, Frank Weine, say that - sooner or later - the tooth will need endo. If the exposure happens on a tooth that is scheduled for an involved restoration or bridge abutment, I think endo is needed before proceeding.
Dr. Dalin: Let’s end our discussion by talking about making endodontics fun as well as interesting for our readers. What are your recommendations about continuing education for improving skills in endodontics?
Dr. Speer: Besides a course that I offer, I admire the teaching skills of Steve Buchanan and Cliff Ruddle. Both offer courses that address all aspects of endodontics.
Dr. Leigh Speer attended dental school and graduate school at Loyola University in Chicago. His endodontic training was done under Dr. Frank Weine. He is the former Director of Endodontics at Washington University School of Dental Medicine in St. Louis, Mo. He has maintained a private practice of endodontics for 33 years, and lectures internationally. Dr. Speer is a Fellow of the American College of Dentists, and is a Diplomate of the American Board of Endodontics. He can be contacted via e-mail at [email protected].
Jeffrey B. Dalin, DDS, FACD, FAGD, FICD, practices general dentistry in St. Louis. He also is the editor of St. Louis Dentistry magazine, and spokesman and critical-issue-response-team chairman for the Greater St. Louis Dental Society. Contact him by e-mail at [email protected], by phone at (314) 567-5612, or by fax at (314) 567-9047.
