How to become a Rembrandt

Jan. 1, 2010
Knowing mechanically how to do a root canal is one thing. Feeling, conceptualizing, and experiencing what is happening inside the tooth to bring about the best possible result is quite another.

For more on this topic, go to www.dentaleconomics.com and search using the following key words: root canal, Twisted File, mental focus during endodontics, Dr. Richard Mounce.

Knowing mechanically how to do a root canal is one thing. Feeling, conceptualizing, and experiencing what is happening inside the tooth to bring about the best possible result is quite another.

Said a different way, there are endodontic house painters, and there are Rembrandts. For the housepainter, a root canal is a mechanical process that involves putting file A to level A, File B to level B, inserting a master cone to level C, etc. For the Rembrandts there is an appreciation of the anatomy before treatment, a visualization of the ideal final result, and a planned yet flexible series of steps to bring about what was envisioned. This clinician is working at a higher level, in harmony with the tooth.

Is it possible for the housepainter to become a Rembrandt? How can a clinician develop endodontic mastery? Here are a few suggested selections:

1 Slow down. The result is more important than how fast the tooth takes to treat. Profitable endodontics is excellent endodontics. Profit comes from doing it right, not from churning out poor results and hoping for clinical success based on success/failure averages. The patient always comes first. 2 Know your patient, know your tooth, know your procedure, and know your equipment. Be entirely confident in what you are doing. If you are not confident from the outset, refer the case. Confidence is developed through practice on extracted teeth, simple clinical cases that progressively become more difficult, observation of endodontists, training classes, regional and national meetings, studying the literature and video, and more. Think, eat, drink, and sleep endo.

For example, I use the Twisted File.* Knowing that the .08/25 TF can, when used correctly by itself, prepare the basic taper to the TWL in approximately 75% of the roots encountered in approximately three to four insertions, is empowering.

Knowing that the .06/30, .06/35, and .04/40 follow the .08/25 with a single insertion to the TWL without orifice openers, streamlines canal preparation to a degree never before possible. Contrast this to a clinician using multiple files from different manufacturers and Gates Glidden drills and you realize this is wasted motion and energy relative to Twisted File technology.

3 Mental focus is everything in endodontics. From the start of access, the clinician should have his or her attention totally focused on the tooth. Getting up in the middle of a root canal to see another patient is entirely contrary to the necessary focus. Focus is made infinitely easier with the surgical operating microscope (Global Surgical, St. Louis, Mo.). For example, if access is being made through a gold crown with calcified canals in a necrotic tooth, it is essential that the clinician realize the chamber may be very narrow vertically, if it is present at all, and that the risk of perforation is extreme. Also, upon chamber access, the clinician is not going to see hemorrhage. Making this simple mental mistake and anticipating hemorrhage can lead to iatrogenic errors and diminished success.4 Using small hand K files and assuring oneself of the apical curvature, patency, glide path creation, and position of the minor constriction is an essential feature of ideal canal preparation, and underpins the use of subsequent rotary nickel titanium (RNT) file use. Using an RNT as a path finder with too much force in the absence of a firm mental grasp on the file tip's location, and how much resistance the canal is giving the clinician during insertion, is a recipe for file breakage. Alternatively, if focused, the tactile feel of the RNT during insertion can provide invaluable information regarding curvature, calcification, the optimal final prepared taper, and more. This is not the place for “reamin' and dreamin.'” Rather, this is the moment to anticipate and appreciate what is actually happening in the canal while the RNT is cutting dentin, and sensing when the file should be removed. Said differently, during treatment the clinician should know where the tips of the files (hand and RNT) are, as well as where they expect to be in five minutes. 5 Finally, if something goes wrong during treatment, it is imperative that the clinician stop and solve the problem before going on to something else and coming back. To continue to shape or obturate a root canal system in the presence of a clinical challenge is a recipe for clinical disaster. For example, if a canal is blocked, the blockage should be definitively managed before moving forward.

Following these steps will make the Rembrandt and bend the curve toward the best possible clinical result. I welcome your feedback.

*SybronEndo, Orange, Calif.

Dr. Mounce is the author of the nonfiction book, Dead Stuck, “One man's stories of adventure, parenting, and marriage told without heaping platitudes of political correctness.” (DeadStuck.com) Dr. Mounce lectures globally and is widely published. He is in private practice in endodontics in Vancouver, Wash.

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