Richard E. Mounce, DDS
Any successful clinical procedure requires a large number of often simple, yet interrelated and successive, steps. The motto of the Boy Scouts applies, "Be Prepared." What comes before a handpiece is ever picked up generally has much more to do with the quality of the final result than what comes after. Buildings are built on paper before the first anchors are pounded into bedrock. So should it be with our endodontics. Achieving excellence in endodontics amounts to breaking the process down into a large number of small, yet well-planned and accomplished steps and much of this planning should happen prior to starting. This article describes many of these smaller steps that cumulatively promote endodontic excellence and enhance profitability.
Problem areas creating less than ideal outcomes include:
1) Complex diagnosis, especially with nonodontogenic facial pain issues 2)Poor case selection
3)Inadequate anesthesia
4)Lack of informed consent
5)Lack of familiarity with instruments and materials of all sorts, manifesting in iatrogenic events
6)Lack of visualization
7)Lack of coronal seal, post-endodontically
If not managed properly, these issues can easily snowball. Conversely, successful initial strategies like excellent access create a platform for future success. The silver lining is that all of the potential problems outlined above can be prevented.
The critical steps in endodontic therapy require careful consideration and include the following:
1)Knowing the end point of therapy. The goal of endodontic therapy is the three-dimensional cleansing, shaping, and obturation of the root canal system. In other words, root canal therapy should duplicate the net effect of extraction. If the offending tooth is extracted, the patient will heal because all of the pulp has been removed. Successful endodontic therapy has the same basis for its success.
2) Case assessment is performed preoperatively.
• Can and should this tooth be restored?
• Is this a patient who can emotionally, physically, and medically tolerate the treatment?• Is the diagnosis correct?
a. Has the correct tooth been identified and the chief complaint been duplicated?
3)Ideal access has been achieved.
• The entire pulp chamber has been unroofed
• Access into the canals is straight-line
• The cervical triangle of dentin has been removed from molar teeth
4)Crown-down instrumentation (coronal third first, middle third second, apical third last) is performed to promote debris removal and tactile control over all the instruments by removal of restrictive coronal dentin.
5)Adequate irrigation is performed, and achievement and maintenance of apical patency is meticulously observed.
6)Postoperative canal preparation resembles a tapered funnel.
7Obturation of the canal space is three-dimensional, with gutta percha compacted into all the ramifications of the canal space.
8)Coronal seal (a coronal restoration impervious to moisture) is placed postoperatively.
There can be a tendency to view endodontics as a mechanical process similar to a menu-driven cookbook procedure. It is much more complex than that! Preoperative preparation in the form of cognition, visualization, excellent case selection, patient evaluation, and operatory and equipment readiness — as well as giving ourselves enough time to do the procedures correctly — can pay handsome dividends as we move through these steps.
Cognition requires us to be fully present
Creating efficiencies requires a cognition that endodontics is a dynamic process which can change instantly. In a given case, an abrupt apical curve not realized can easily become an impassable ledge and short fill, leaving debris and risking the result. Recognizing and addressing this challenge requires an unconditional mental focus on the information at your disposal — radiographically, visually, and by your fingertips. In other words, as you move through the process, you should ask, "What is occurring in the tooth at the present moment, what needs to be done next, and where will the treatment process be in the next five minutes?" To achieve such an unconditional focus, it is axiomatic that your attention be fully focused on the tooth at hand. Working multiple chairs, etc., can only disetract from that focus. You need to be fully present mentally at the point of treatment.
Visualize the final result
Knowing the destination can help us get there. Seeing the excellent final result in your mind's eye before starting creates a better chance that it can be produced. To not do so would be the equivalent of getting in a plane and taking off without a destination. Top-level professional athletes do such mental visualization habitually. World-class footballers (soccer players) imagine the ball coming at them from different angles and then see themselves volleying into the back of the net. A mental picture of the final result also should guide each successive step of the process performed in the proper order. You should never move to Step C without first taking Steps A and B. Putting files into canals without adequate access would piston debris further apically into the canal, creating dentin mud and becoming an iatrogenic risk factor.
Case selection is paramount
Glancing at a single nondiagnostic radiograph from across the room, taking the patient's word for the offending tooth, or not probing each tooth periodontally are all problematic. Cursory examinations lead to risk factors being ignored. For example, caries often can be obscured by a crown and, once excavated, can render the tooth nonrestorable. Such risk factors, communicated preoperatively, can go a long way toward avoiding unwanted outcomes. Telling a patient before something happens that it might occur makes the doctor a prophet, but telling patients after the fact becomes an excuse that frequently results in a loss of the relationship, efficiency, and profitability. Careful evaluation of all the potential challenges that might exist prior to starting is essential. For example, challenges might include (amongst many factors) the presence of resorption, furcal bone loss, deep pockets which are not accompanied by apparent radiographic bone loss, abrupt apical curves, iatrogenic events, etc.
If you have never treated a resorption case, a trauma case, or a perforation, starting such a clinical entity without substantial extra training and study is ill-advised. It would be best to refer this type of case. Occasionally, the most successful and profitable endodontic procedure is the one not attempted. Wisdom lies in knowing our limits and capabilities and keeping the patient's best interest — not ours — in mind. The worst of all worlds is to begin a case with the thought that we can refer it later if we run into trouble. This is rarely satisfactory for doctor, patient, or endodontiscs, and rarely creates profitability. In such a cauldron, iatrogenic mistakes can be made that might have been otherwise avoidable.
Know thy patient
The old adage,"Doctor, know thy patient," applies here. Is the patient someone with whom you have established rapport? Before ever picking up a handpiece, mentally ask yourself, "Is this a patient I really want to treat and why?" If the only reason you want to treat the patient is to pay your overhead, then there is little incentive to create excellence. Ideally, the desire to treat the patient should flow from a love of your profession and that should provide your motivation. Profit flows freely from such a pure source of motivation. Doing the job correctly and taking the time you need always creates greater profit than doing it fast and cutting corners. It is what we would expect if we were the patient.
Too much informed consent is never enough. If the patient does not want to cooperate fully with the recommended treatment in any way, don't do the treatment! While this subject alone could be the topic for an entire article, no fee in the world is enough to compensate us for the liability and negativity of treating an unreasonable and uncooperative patient. Comprehensive, signed informational materials should be given to the patient both pre- and postoperatively. While such forms may have questionable legal significance in the event of a lawsuit, they do create a piece of physical evidence — along with excellent chart notes — that show what the patient was or was not told.
Are your endodontic skills, training, materials, and education up-to-date? Many excellent CE courses are available for advanced training in endodontics. Attend the lectures of a wide and varied group of speakers on endodontics and evaluate their claims. Despite some advertising, there is very little agreed-upon "endodontic truth." Even among endodontists, vibrant clinical controversies surround the most clinically-appropriate methods. Take little for granted, ask questions often, try as many systems as possible, and familiarize yourself with their strengths and weaknesses through hands-on courses and clinical trials. Much can be gained from being open-minded, given the wide diversity of opinions on endodontics.
Set aside enough time
It is almost axiomatic that there never seems to be enough time to do the job right the first time, but we can always find time to do it right the second! The difference between excellent and lesser-quality endodontic work is frequently not a matter of skill or the latest sexy technique, but centers on taking the time to achieve the best results — something we are all capable of doing. Efficiencies can be created by allowing enough time in the schedule to finish the tooth in one visit (when indicated) so the patient does not need to return.
Equipment and office preparation
Are your endodontic supplies spread out all over the office? Having needed equipment and supplies laid out in an ergonomic manner for use at a moment's notice diminishes the stress associated with performing an unexpected emergency procedure. Endodontic supplies, motors, equipment, instruments and files, etc., should be placed in the operatory in such a way that they can be employed immediately. In addition, intraosseous anesthesia supplies should be ready in the event that block anesthesia fails. That said, waiting long enough for anesthesia to fully take effect often is the missing link in excellent anesthesia. Preloaded syringes of irrigants also should be ready.
Are your files rusted, deformed, etc., or are they new? Using K files only once is an excellent idea. The pennies saved by reusing K files can cost dollars later when a dull or deformed K file cuts poorly or — worse still — separates. For an average molar (not a severely calcified one), I will use approximately three to 10 packs of K files to achieve and maintain apical patency. Calcified cases easily can require two to three times this number. All such files should be on a sponge, ready to go, before the tooth is ever accessed. Autoclaving used K files is not cost-effective due to the labor and time it takes to sort them out.
In addition, having every member of the clinical staff intimately familiar with your procedures by rehearsing builds patient trust. Patients can tell how much more confident you and your staff are about procedures you know well and are comfortable doing. Rehearsing the procedure on a regular basis will breed that confidence.This should also include teaching your assistant how to take excellent endodontic radiographs. Poor radiographs are a prime source of less-than-ideal outcomes.
The efficiency gained by using a surgical microscope is dramatic. At every step in the procedure, endodontics can be done to the highest standard possible through the use of a surgical microscope. There simply is no substitute for its capability to improve endodontic quality, efficiency, and, ultimately, profitability.
Utilize a rubber dam; medically and legally speaking, there is no excuse or alternative. If the dam can't be placed, the tooth should not be treated. Straight-line access is essential, as is unroofing the entire pulp chamber. More often than not, access openings are too small and leave significant overhangs which prevent straight-line access.
Crown-down instrumentation
It makes intuitive sense to remove the coronal third pulp first, the middle third second, and the apical third last.This is what we call the crown-down technique. Doing so prevents moving from a dirty space (for example, the coronal third) and advancing that debris apically, where it will be more challenging to remove. In addition, working in the apical third last allows restrictive dentin to be removed more coronally first, giving greater tactile control over the file, as well as enhanced irrigation. Adequate irrigation and apical patency (5.25 percent sodium hypochlorite, 90-150 cc per average molar) are essential at all stages of the procedure. Scout the canal with K files, especially in the apical third, until patency and a glide path (up to a 15 K file) have been created before taking rotary files into these canal spaces.
Know your instrumentation system and apex locator
Practice on multiple extracted teeth. I am a strong advocate of the K3 rotary NiTi system by SybronEndo (Orange, Calif.) because of its robust sense of tactile control, fracture-resistance, and cutting ability. To enhance productivity, the assistant can place the successive K3 files into your electric motor handpiece attachments, or you might consider having multiple attachments with the files already placed.
Recently, a new fourth-generation, state-of-the-art machine has been introduced into the marketplace (the Elements Diagnostic Unit, SybronEndo, Orange, Calif.). The unit measures the placement of the file tip in a manner that speeds the determination of the true working length with as much precision as possible.
This machine measures resistance and capacitance as the file moves down the canal, and references these values with an internal set of precomputed values. As a result, the machine can give the location of the file tip instantly, without all the calculations needed by previous generations. In my hands, the Elements unit is faster, more accurate, and more stable than any of the previous models I have used.
There are no shortcuts to excellence ... just a large number of small, but essential, steps. The standards of excellence that drive the dentist's hands have much more to do with treatment success and failure and profitability than the material used. Taking into account the techniques discussed in this article can help you create efficiencies in achieving the biologic objectives of excellent endodontics. As stated at the beginning of this article, the most important step is to be prepared.
