I'm going to let you in on a little secret about why I became an endodontist. When I was in dental school, I quickly realized that many procedures have a subjective component to them.
For instance, where someone might finish a margin, what type of materials to use or even how far to chase caries. The beauty of endodontics is that it's very objective: Find canal, clean canal, fill canal. But this doesn't mean that there isn't some subjectivity involved. What size should I prep the canal to? What instruments or irrigants should I use? Maybe you are asking yourself if you should even do endo at all in your office.
The goal with developing Spear's new “Approachable Clinical Endodontics” course (2.5 CE credits) was to give you a predictable way to treat endodontics cases successfully in your office. Spear's endodontics curricula – which includes an online pathway of video courses and lessons – provides restorative dentists with a better understanding of endodontics basics like diagnosis, instrumentation, and treatment. The pathway features a total of four courses presented by Dr. Lou Berman and Dr. David Landwehr.
With my new course, starting with Lesson 1, my goal is to give you some tips that can lead to improved access preps. One of the major topics within the lesson is the placement of a rubber dam.
It never ceases to amaze me how much resistance there is to this crucial initial step. Remember that the goal is to remove bacteria from the canal, not introduce more. If there is any salivary leakage into the access prep, you're taking a step back every time you try to move forward —not to mention the difficulty in keeping irrigants retained within the chamber without giving your patient a mouthful of bleach.
Despite what you might think about how your patient might react if you don't typically use a dam, I've found that many patients have a very positive experience and ask me why their general dentist doesn't use that all the time. Especially with patients that have a gagging tendency. Keeping fluids and instruments from the back of their throats is greatly appreciated.
Developing a 'reproduceable glide path' for endodontic success
In Lesson 3 we discuss the concept of creating a glide path, something that is critical to endodontic success. Although many viewers will be familiar with the term, sometimes there is difficulty in translating that into clinical performance. This is really where the battle is won or lost.
Failure to create a reproduceable glide path early in the case, will lead to shortcomings later. As mentioned earlier, there is some subjectivity in selecting instruments. While most of us were taught to start with a 10 file, I would encourage all of you to try working with a 6 file. There can be very complicated anatomy in the apical third that even a 10 file cannot navigate. By getting in the habit of using a smaller file initially, you'll find yourself achieving patency quicker and easier.
Part of Lesson 4 brings up something of a controversial topic, which is single use of an endodontic file. Without even asking, I always know what the answer is to why this isn't done on a consistent basis: cost. While I am sympathetic to the need to keep costs down, there are many other ways that can be accomplished that don't involve one of the main aspects of your endodontic armamentarium.
We've all adapted to the new normal when it comes to PPE and re-use of an N-95 mask has become necessary due to shortages. However, if readily available, wouldn't we all want a fresh one each time? This is true for endodontic files, as well.
For those of you that have run into trouble with instrument separation, multiple use is one of the main causes. A file can appear to look normal after initial use, but build-up of fatigue may have pushed that file near the breaking point without altering the appearance.
If you've completed endodontic therapy in the last 30 years, there's a high probability that you've used an apex locator. We're all familiar with them, but are we using them the way they're intended?
In Lesson 5, we approach this topic to give objective criteria on how to achieve a working length that is appropriate and based on clinical data. I'm commonly asked by other clinicians why they have consistently short (or long) fills once completed. The concepts in Lesson 5 will help to clear up the confusion and get you on the right path.
I once knew a board-certified endodontist who used saline solution as his main irrigant, which is totally inappropriate. We're not putting a contact lens in the canal, we're killing bacteria! With all the different irrigants, both in the literature and available in the marketplace, it's not hard to see why there's confusion.
Then there's the problem of how much to use and in what order to use them. Again, objectivity comes to the rescue in this lesson. By providing a formula for what to use, at what strength and when to use it, irrigation becomes simplified.
Whereas glide path may be where early wins and losses take place, irrigation is where that concept is magnified. Appropriate and thorough irrigation can lead to healing in even the most challenging situation.
Obturation and restoration of endodontically treated tooth
The “Approachable Clinical Endodontics” finishes up with a two-part look at obturation and subsequent restoration of the endodontically treated tooth.
Subjectivity can create difficulty in selecting an obturation technique that is predictable, but objectively the goal is exactly the same. The lessons on obturation, as well as the clinical demo, will help to give you a better feel for how each of the contemporary obturation techniques work.
The lesson on restoring an endodontically treated tooth pays particular attention to the post versus no-post debate. By laying out specific criteria as to when each modality is preferred, some of that subjectivity is removed on the way to restoration.
Many other topics are covered along the way and my intent is not necessarily for you to exactly follow what I do. However, my intent in any lecture, course or paper that I have done is to give you clinical tips that can be immediately brought to the chair to help improve the quality of endodontic therapy that you're providing.
With as much as 80% of endodontic therapy in the U.S. completed by general dentists, we're all in the same fight together. I hope you find the course informative and enjoyable. See you at the apex!
Matthew Chesler, D.D.S., is a Spear Study Club member and practicing endodontist in Escondido, California.