Accident analysis

Recently, I completed a cavern diving (scuba) course in Florida. Cavern level is one step on the path to diving in caves.

Recently, I completed a cavern diving (scuba) course in Florida. Cavern level is one step on the path to diving in caves. Suffice it to say, such diving is dangerous. It is interesting to evaluate the factors that kill cave divers as compared to the things that make endodontic procedures go poorly. Accident analysis in cave diving refers to the common factors causing fatalities. These factors have an acronym - TGADL. This acronym stands for “Thank (training) God (a guideline or safety line always needs to be placed) All (adequate air supplies and turnaround times need to be observed) Divers (the depth dived can be fatal if not managed properly) Live (for cave diving, the diver needs at least three lights).”

In endodontics, there are also common factors - not unlike those for cave diving - that can predict success and failure. To violate these rules or ignore these parameters is to significantly risk an untoward outcome. Using the acronym’s letters, here is a closer look at the similarities between cave diving and endondontics:

1T: Training - Simply put, there is never enough training possible in endodontics. It is unrealistic for clinicians to take weekend courses (especially the single-day type) and gained the needed familiarity with a new material or technique from just one exposure. In much the same way, it would not be possible for a novice diver, who is used to diving with one tank in warm waters, to instantly become comfortable with two tanks and flourish in cave training - especially if diving in cold waters. Stated differently, the path to becoming better is one marked by training, practice, mistakes, and breakthroughs. For many of us, this process has happened on a learning curve that is anything but instant despite the claims of some manufacturers. The best training, in my opinion, involves treating extracted teeth - perhaps by the dozens. There is no substitute for practice when it comes to gaining efficiency and speed, troubleshooting problems with any given new material or technique, getting the feel of negotiating canals, creating a glide path in tortuous canals, or using rotary instruments and new obturation materials. Going straight to a patient after a one-day course or seeing something at an exhibition can be recipes for disaster in the wrong hands and with incorrect treatment planning. When I teach K3 rotary files and RealSeal SystemB obturation in my courses with the Elements Obturation unit (SybronEndo, Orange, Calif.), I always encourage participants to practice extensively on extracted teeth.

2G: Guideline - The endodontic equivalent of a guideline is a rubber dam. Contemplating treatment without one is problematic, and below the minimum standard of care.

3A: Air - The equivalent of having enough air is having the proper equipment needed to finish the case. If a tooth is 28 mm long and the clinician only has 25 mm hand and rotary files, then reaching working length becomes a challenge - if not impossible. Also, having endodontic supplies scattered in a series of Tupperware bins that are taken out and sorted only before each treatment is not being organized adequately for all contingencies.

4D: Depth - In combination with having the needed equipment mentioned in Number 3, assessing a case properly before a handpiece is ever picked up pays handsome dividends. Skipping steps at any level of the process, such as the preoperative evaluation mentioned previously, can only serve to compromise the final result. Before a dive, cave divers conduct several “checks,” such as making sure their air supply is turned on, that regulators are working, and that there are no air leaks. Such a mental checklist before initiating any endodontic treatment can create safety and efficiency during the process.

5L: Inadequate lighting - There is no real substitute for a surgical microscope when it comes to the proper visualization of canals and the internal anatomy of teeth. With all due respect, anything else is second best. If it were you - or your mother - would you rather be treated with loupes, the naked eye, or via a surgical microscope?

While the risk of cave and cavern diving is on a different level as compared to a failed endodontic procedure, the mindset of a scuba cave diver applies to the clinical reality of being adequately prepared during endodontic treatment. I welcome your questions and feedback.

Dr. Richard Mounce 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 Web cast pay-per-view. He lectures worldwide and is a widely published author. For more information, contact Dr. Mounce via e-mail at Visit his Web site at

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