The materials used in performing root canal treatment are secondary to the principles that govern the process. In essence, if one adheres to the key principles, it is possible to do exceptional endodontics with almost any set of instruments. This said, it is my empirical bias that some systems (file systems, obturation materials and techniques, irrigation delivery systems, etc.) are much more user-friendly and efficient than others. Adding these latest techniques and materials onto a solid and principled foundation, only can serve to optimize the patient service delivered.
In the most general terms, the universal principles to create endodontic excellence are:
❶ To aquire an adequate assessment of the patient’s dental and medical history combined with a comprehensive evaluation of the chief endodontic complaint. Such a comprehensive determination of the chief complaint would include pulp testing and evaluation of percussion, palpation, mobility and probings of all teeth in the quadrant (and possibly the opposing arch), and evaluating multiple radiographs of the suspected offending tooth. All of these are designed to develop a diagnosis that is confirmed by reproducing the patient’s symptoms.
❷ To inform patients adequately of the nature of the procedure, giving them possible alternatives, explaining the risks of treatment, and answering their questions. In essence, obtaining their consent.
❸Obtaining adequate anesthesia is a cornerstone of providing excellent service. It is virtually impossible without it. Using the rubber dam and creating straight-line access, adequate irrigation, as well as recapitulation and maintenance of canal and apical patency are essential.
❹To keep the canal in its original position, the apical foramen in its original position and at its original size, and creating a tapering funnel with narrowing cross sectional diameters as one moves apically, all fulfill the basic requirements of endodontic instrumentation. Not fulfilling any of these goals compromises proper cleaning and shaping and increases the chances of treatment failure.
❺ To create a three-dimensional obturation that seals the entire canal space (and duplicates the net effect of extraction combined with instrumentation procedures) followed by a coronal seal to prevent postoperative coronal microleakage and restoration of the tooth, returning the tooth to function. Finally, adequate recall and follow-up assure the clinician that the patient has healed comprehensively.
These principles notwithstanding, it should be noted that products do emerge frequently that advance the specialty and make achieving various principles far more efficient - and to a greater degree possible - than was the case previously. Such is the advance that bonded obturation now offers to the clinician with RealSeal (SybronEndo, Orange, Calif.) and Resilon (Resilon Research, Madison, Conn.). Not only can we fill canals in three dimensions (as is possible with gutta percha), but we also have the ability to intimately bond our obturation material to canal walls in a manner that diminishes coronal microleakage. For more information, please visit www.oralhealthjournal.com/issues/ISarticle.asp?id=152890&story_id=23669151352.
While these principles might seem relatively straightforward and somewhat academic, I have observed - as a full-time endodontist whose practice is approximately 50 to 75 percent retreatment - that a large percentage of these referrals derive from some lack of adherence to the aforementioned goals. Excellent results are predictable if we follow the core principles.
Intuitively, the endodontic process can be seen as a number of steps that build upon one another. Performance of one step in proper order at a high standard sets the stage for the next step. This progression ultimately allows the clinician to arrive at the desired goal. For example, achievement of apical patency and creation of a glide path prior to introducing rotary nickel titanium (RNT) instruments into the apical third reduces the incidence of rotary separation. To explore the apical third with RNT files without hand instruments first is to court disaster with separation, transportation, and accumulation of dentin debris apically. All of these, to one degree or another, prevent the clinician from achieving the desired result.
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 c[email protected]. Visit his Web site at www.MounceEndo.com.