Clarence R. Feller Jr., DDS, FAGD, FAAID, PA
For many years, I have struggled to make endodontics enjoyable and, more importantly, for the benefit of this article, profitable. In fact, I believe the two should go hand-in-hand. In our profession, if we don't enjoy a procedure, there is no way to make it profitable. Any procedure that is a chore is a burden in our lives and a major source of frustration and stress. My first goal, then, was to learn to enjoy endodontics by doing it well and creating the proper conditions for healing.
However, we all know that it can't be that simple. There are too many forces at work and there is too much confusion in the marketplace. That's why I found my own way.
The success that I have found in endodontics has been centered in four areas: diagnosis, access, preparation, and restoration. The techniques I use have been adapted from the leading speakers on endodontics, gurus, journals, and dental publications.
The most important tests are:
1) Hot (use hot coffee, retains heat best)
2) Cold (refrigerant spray from local electronics store — 60 degrees F)
3) Percussion (mirror handle, light tapping)
4) Periodontal evaluation
5) Radiographic evaluation (size of canals, pulp stones, apical lesions)
The effect of outside forces cannot be underestimated. If I have any question about the viability of the tooth, I consider the following:
* Removal of restoration (amalgam or composite) to evaluate the depth of the restoration and involvement of pulp horns. Check on the possibility of cracks and fractures.
* Removal of the crown if I did not place the crown. Crowns hide everything. Too many times, the decay is too great to save the tooth, the fracture is too extensive to restore the tooth, and the remaining tooth structure is so minimal that long-term prognosis is questionable.
* Inform the patient of my intentions before I begin treatment. Have the patient read and sign the consent form. Fracture is discussed as the primary reason for failure to complete the case. If the case involves root structure, I stop therapy and remove the tooth. "Hero-dontics" always seems to come back on you. Remember, no good deed goes unpunished!
Pulp chambers are in the middle of teeth. I use a 245 carbide to begin my access, creating the classic shapes in the middle of the tooth. The bur is my depth gauge. Routine chambers are usually no deeper than the end of the taper of the bur shaft. Remove the entire pulpal roof. Stay off the pulpal floor. The floor has the road map to find the canals. Use loupes to locate the orifice with high quality K-files. K-file sizes 6, 7 ,8, 10, and 15 are used to locate the canals. Hedstrom 21 mm files size 15, 20, 25 are used with anticurvature filing (five swipes away from the center of the tooth) to open the orifice. Piezo reamers 1, 2, 3 are utilized to open and prep the coronal one-third of the canal. The Medidenta Sonic Air MM1500 ultrasonic with Rispisonic size 10 and 15 also is helpful. The final chamber contour is completed with a long, tapered high-speed diamond (Brasseler 859-8798).
I divide the canal into sections — coronal, apical, and midroot — to ensure that I clean the canals effectively. With the coronal aspect out of the way, I proceed to the apical area. Establishing working length is the goal. Apex locators such as the Medidenta Justwo, the J. Morita Root Zx, and the Dent Corp Bingo 1020 are necessary to find the proper length. Remember, the radiographic apex is different from the apical foramen.
All tapered instruments can clean the coronal and midroot of the canal to a certain extent. But the apex area belongs to the LightSpeed instrument. Numerous studies suggest that the proper apical seal is the goal. A nontapered instrument that can deliver the proper preparation size to this area is key. The lack of taper removes the interference and misinterpretation of shoulder-binding of standard tapered files. The cutting ability of the apical component of the Lightspeed instrument allows proper cleaning of the canal.
What does all this mean? Kerekes and Tronstad published reports in the March 1977 issue of the Journal of Endodontics of apical prep sizes larger than a 20 or a 35. That study has helped to change my approach to apical preparation.
Could apical preparation on MB roots of upper molars be as large as a size 65? Do you have a case where the tooth is asymptomatic with radiolucency on the MB root? Could it still be dirty? Could it be underprepared? I have found that LightSpeed delivers a predictable systematic preparation of the apical region. I don't have to think about how it is prepped, my focus is on accomplishing the desired result.
The midroot is prepared to accommodate the final apical size that is determined by the LightSpeed instruments. My goal is a gentle taper from the apical to the coronal area and to limit the removal of excessive amounts of dentin. I do not try to gut the internal aspect of the tooth in an effort to hopefully remove the necrotic tissue. I choose to have a step-by-step predictable plan that includes the LightSpeed instrument.
The final restoration
The apical area when properly prepared will accept the proper size gutta percha like a cork in a bottle. The SimpliFill system is the cork. It is a modification of a gutta percha point. I think of it as gutta percha on a stick! I choose the SimpliFill in the same size as the apical size. I place the proper sealer in the canal with a paper point, set the working length, and place the gutta percha. SimpliFill is 5 mm long; therefore, a proper seal is created. The canal is ready for post placement if necessary. The midroot and coronal aspect are filled using standard gutta percha (the same size as the apical size), with additional accessory gutta percha points using lateral condensation.
I take two radiographs during the procedure. The first X-ray is used to determine working length, and the second is taken to see the final restoration. That's it! No digital, no microscopes — just loupes! The access prep is closed with the restoration of choice — i.e., amalgam or composite. That will take care of the coronal seal problem until the final tooth restoration (a crown) is completed.
Establishing your fee
Setting fees affects many aspects of my practice. It allows me to adequately pay myself and my team, to purchase proper equipment and supplies, and to deliver current technology in an office space that is comfortable and efficient. It should also provide an atmosphere that reduces stress for patients, team, and doctor.
I base my fee structure to accomplish these goals. I have estimated what the office has to earn per day, based on the days worked per year. My production goal is then split up by five hours of production time each day. I work eight hours per day (five hours of production time and three hours of nonproduction time). Because I am an early riser, my production time is set at 8 a.m. to 1 p.m. So, if a root canal takes me one hour of production time, I set this as my guideline for my fee structure.
I am a graduate of Walter Hailey's Dental Boot Kamp and a member of the Crown Council. I learned a long time ago from Walter that without integrity, the best communication skills in the world will not help you. I strive to perform procedures for my patients with the highest integrity.
My formula for profitability is simple: Lightspeed root canal therapy that gives my patients the highest percentage of predictability and healing, plus clear and consistent communication skills, add up to a fee structure that helps my practice to profit and grow with happy, paying patients who come back for other services and refer their friends.
Editor's Note: For more information on some of the forms used by Dr. Feller in his San Antonio practice, please log on to www.dentale conomics.com and search for "Feller."