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Endodontic Trimix: Safety, Excellence, and Profitability

March 1, 2006
A blend of continuing education, case selection, and better manual technique can produce the ideal endodontic “trimix” for achieving excellent outcomes
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A blend of continuing education, case selection, and better manual technique can produce the ideal endodontic “trimix” for achieving excellent outcomes

Trimix is a blend of oxygen, helium, and nitrogen that is used in technical scuba diving. Helium is an inert gas that, when blended with the other gases, diminishes the diver’s intake of nitrogen and decreases the chances the diver will experience nitrogen narcosis. Nitrogen narcosis is a harmful side effect of staying down too long and too deep for a given dive profile which is not managed safely. In the endodontic context, making endodontics safer, of higher quality, and more profitable also is a blend of three components analogous to the value of trimix: continuing education (CE), case selection, and better manual technique.

• CE allows the clinician to be exposed to new concepts, materials, and techniques that can elevate the individual’s present standard.

• Case selection allows a clinician to know “when to say when” and stay out of the proverbial deep water which might prove fatal to the final result of the case.

• Excellent manual technique is the component of the process which makes the tangible process of doing a root canal a more enjoyable and fulfilling experience both for the clinician and, much more important, the patient.

Great case selection and cool high-tech equipment are worthless if the actual treatment is not carried out safely, efficiently, and comfortably. In different terms, talking about making a great dive (endodontic case selection) is one thing, but executing it well is another. Ultimately, it is in the doing where value is created for the patient. This article will address the blending of these issues with an eye toward giving the clinician tools that might immediately be taken into the operatory.

First, I recommend that clinicians, both generalists and specialists alike, take as much endodontic CE as possible, irrespective of the source. While some CE providers are much stronger than others, an open mind blended with a cautious degree of skepticism can often sort the wheat from the chaff. Beware of the speaker who dogmatically says that there is only one way to achieve a clinical goal. It is axiomatic that certain aspects to the procedure we know as a “root canal” are inviolate. For example, the goal of treatment is the three-dimensional cleaning, shaping, and obturation of the root canal space from the orifice level to the minor constriction of the apical foramen in combination with a coronal seal, which protects the endodontic result from contact with bacteria via saliva. Whether such a result is provided by K3 files (SybronEndo, Orange, Calif.), LightSpeed (LightSpeed USA, San Antonio, Texas), or others, or with half-strength bleach or full-strength bleach, etc., there are clinical controversies open to the literature, opinion, experience, and so forth. Hearing all sides of a given debate, for example, RealSeal bonded obturation (SybronEndo, Orange, Calif.) versus Thermafil with gutta percha (Dentsply Tulsa Dental, Tulsa, Okla.) can at least help the clinician to understand the various parameters of what makes each system unique. This stands in sharp contrast to simply and blindly accepting the word of a guru (any guru!) about what is the “best” way to proceed in cleansing, shaping, and obturating a root-canal system. Dogma in endodontics changes with time, research, and experience, and there is more than one way to reach clinically excellent results.

It also is important to know that there are not two levels of endodontic knowledge, i.e., there isn’t one class or body of knowledge for endodontists and another one for generalists. There is no magic repository of knowledge that we endodontists keep locked in a closet to only discuss at large national meetings. The information available to specialists is freely available to all, irrespective of where one practices in the world. As I have traveled the world speaking, I have been very impressed by the level of competency of clinicians in such diverse places as Korea, Mexico, and Poland, and many points in between. This excellence has been created by a hunger to learn and an open-mindedness to be exposed to new ideas and materials. Simply showing up at a single hands-on course and buying a kit of equipment promoted as “state-of-the-art” without really understanding the limitations, qualities, and philosophy driving the material is the least-productive educational outcome. Such an approach may produce a menu-driven cookbook for treatment that may not be clinically appropriate, irrelevant for the case at hand, or both.

My recommendation is to listen to speakers who treat live patients; those who make their primary living from practicing and who are not professional speakers. Especially as materials and methods change, I want my educators to explain how they actually use the products they speak of and how they perform with real patients, not how other people have told them the products behave in practice.

Case selection

When I speak about case selection in hands-on courses, I see some eyes glaze over. The source of frustration I see most often for general practitioners is a lack of understanding regarding which cases they should refer and which cases they might do. They are unsure of how a “go, no go” decision is reached and, once a “go” decision is reached, they’re unsure about what planning is incorporated into the case preoperatively. Said succinctly, it is important to realize that sometimes the most profitable case is the one never treated. Choosing cases wisely and planning the treatment appropriately is every bit as important for the clinician as it is for a diver who must make a dive plan to ensure that the mixture and volume of air is appropriate for the given depth and duration of dive. A miscalculation can kill a diver and, by analogy, cost the patient the tooth when an endodontic procedure is not properly planned.

Before any endodontic procedure is started, it is essential that -

1) A complete dental and medical patient evaluation has been made.

2) The patient’s chief complaint has been recorded, and the percussion, palpation, mobility, and probing of all teeth in the quadrant of the suspected tooth also have been recorded as well as a comprehensive evaluation of the periodontal and radiographic status of the tooth.

3) The tooth is deemed restorable and, if not restorable now, it can be made restorable through periodontal procedures. The tooth is strategic and functional as well.

4) A firm and conclusive diagnosis has been reached.

5) The patient has given consent to the procedure and fully understands what having the root canal means in terms of needed follow-up treatment (a build-up and crown; possibly crown lengthening), the risk of treatment (that the procedure is not guaranteed, that adverse events can occur such as infection, separated files, perforations, etc.), and that as a last resort it is possible that surgery (such as root resection and retrofill) may be needed to resolve any lack of healing.

6) Once a “go” decision is made for treatment, the procedure itself must be evaluated to plan for all the foreseeable clinical challenges possible during the process (curvature, long roots, short roots, calcification, etc.). If treating the tooth is beyond the skill level of the clinician or his or her equipment, or if there is a personal incompatibility between the clinician and patient, or if not enough time is available to achieve an excellent result, then refer the patient. This is because the best chance to get an excellent result from treatment is at the first attempt. Excellence in decision-making can go a long way toward creating excellence in endodontics.

Technical considerations

When we think of endodontics as clinicians - because we are treatment-oriented - we tend to immediately default to treatment strategies. We think about how to perform treatment faster and more efficiently, and mentally emphasize the technical aspects of it. After you decide that you’re the best clinician to treat the case, take a look at several devices available to increase your quality. Everything that achieves an excellent result and avoids complications creates profitability. The converse also is true. Those devices viewed purely in mechanical terms would include:

Improved visualization - The more one can see, the more one can do and do better. The world’s top clinicians all use surgical microscopes for virtually all aspects of treatment. Endodontic treatment performed without a surgical microscope is always second best (or worse) relative to that which can be done with a microscope. If speed, comfort, excellence, and safety are your primary concerns, there is no substitute for this essential instrument.

Rotary nickel titanium (RNT) instrumentation is the present as well as the foreseeable future; hand-file at your peril. The only people still hand-filing are those who either haven’t tried RNT products or perhaps might have tried a less-than-ideal brand and used them incorrectly. RNT systems vary widely in their resistance to fracture, their range of clinician application, tactile sense, and cutting ability. Having experienced all the rotary systems in North America, my chosen system for optimal performance characteristics is the K3 system by SybronEndo for its tactile sense, cutting ability, and fracture resistance.

Warm obturation is slowly replacing cold lateral condensation. Methods and materials for warm obturation have never been easier or more readily available. Blending hands-on courses that expose clinicians to as many warm-obturation techniques as possible has value to integrate this vital treatment modality into practice.

Irrigation, recapitulation, and scouting with hand files and glide-path creation are all essential, irrespective of the file system used. It is not possible to either irrigate or recapitulate too much. Also, there is no such thing as spending too much time with small hand files exploring and negotiating canal spaces to learn the diameter and three-dimensional curvatures present before using RNT files.

Blending these three elements - like trimix used safely in technical scuba diving - into a comprehensive approach to endodontics can provide an added margin of safety. Such blending will take time, a financial investment, an open mind, and a hunger to learn. Blending CE, proper case selection, and use of the best treatment strategies possible can only improve the standard of clinical care and, as a result, profitability as a by-product of excellence (not speed) can increase.

Richard Mounce, DDS, is in private endodontic practice in Portland, Ore. Dr. Mounce is the author of a comprehensive DVD on cleansing, shaping, and packing the root canal system for the general practitioner. The material also is available as audio CDs and a Webcast pay-per-view. He lectures worldwide, and is a widely published author. For more information, contact him via e-mail at [email protected]. Visit his Web site at

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