Richard Mounce, DDS
At lectures, I'm often approached by participants who tell me about their string of bad clinical results ranging from severe postoperative pain to recurring iatrogenic events. Often it's these results that have brought them to the course. Anyone in practice has, at different times, had less than desirable results. But if bad results happen too frequently, some fine-tuning is in order. In sports, flair entertains, but it's the basics that wins games. So it is with endodontics. Getting back to the basics helps practitioners avoid undesirable outcomes.
Prior to working on a tooth, we should ask ourselves if we have the skills, equipment, and time to tackle the situation properly. If not, the case should be referred. Knowing when to treat and when to refer goes a long way toward achieving better results as well as greater profitability. Duplicating the patient's chief complaint, using a rubber dam, and having a preoperative visualization of the final result that takes into account all the possible challenges are essential. Adequate sodium hypochlorite irrigation (5.25 percent, using a side-venting needle, 80 to 150 cc per average molar), achievement and maintenance of apical patency, and adequate visualization (loupes or, ideally, a surgical operating microscope) give the doctor every possible opportunity to obtain the best results. The old adage applies: If you can see it, you can probably do it, and do it better.
In addition, a coronal seal after treatment is vital. A good clinical result can fail when the operator does not seal off the gutta percha from the oral environment after treatment. Gutta percha exposed to salivary contamination for any appreciable period of time should be retreated, even in the absence of symptoms. Coronal seal (a bonded build-up) is vital. This seal should be placed — in the absence of such mitigating circumstances as swelling, percussion sensitivity, inadequate time, or lack of patient compliance — ideally, the same day endodontic treatment is completed.
Excess sealer that becomes extruded apically also can be the etiology of postoperative pain. Only the thinnest coating of sealer that extends the length of the canal is required. Filling a canal entirely with sealer via a lentulo prior to placement of the master cone is not necessary. Sealer mixed with an excess of one component (especially liquid) also can cause unnecessary apical inflammation.
Severe postoperative pain arises from a host of factors. The common denominator is debris (pulp tissue, caustic medicaments, irrigants, pastes, etc.) that is left within the canal system and subsequently percolates into the apical tissues. Debris that has been forced out of the apical foramen during treatment — an "endodontic worm" — also is a source of postoperative discomfort. Anyone who has done a root canal on an extracted tooth with irrigation has seen this phenomenon. Instrumentation performed inappropriately can piston debris from the root and exacerbate this iatrogenic event. In addition, irrigation can push debris into the apical tissues if performed inappropriately, and also can put the patient at risk for an accident. This underscores the need to have full control over the tip of the irrigation needle at all times. As mentioned, a side-venting irrigating needle is recommended to minimize the chance for apical extrusion of irrigants. Needle tips locked in the canal can extrude irrigant, which will cause apical inflammation even in the absence of a true hypochlorite accident.
In addition, crown-down instrumentation, correct use of rotary nickel titanium files, avoiding unnecessary caustic intracanal medicaments, and frequent recapitulation all will help increase endodontic success and diminish postoperative pain. All things being equal, post-op pain that requires narcotics and or progresses to swelling or bruising should be rare.
Such a re-evaluation of the "basics" can go far toward giving us winning, long-term results.
Dr. Richard Mounce is in private endodontic practice in Portland, Ore. He lectures worldwide and has published numerous articles in the Journal of Endodontics. Dr. Mounce also writes "Endo Made Easy," a bimonthly tips feature for Dentistry magazine, and a quarterly column for Endodontic Practice in the UK. Contact Dr. Mounce via email at linek [email protected]. Visit his Web site at www.mounceendo.com.
