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Endodontic Predictability: “Are You Making the Right Decisions?”
INTRODUCTION
The key to endodontic predictability is knowing what to do when and then how to do it. In any nonsurgical endodontic treatment, the dentist has ten essential and distinct decision making moments. The purpose of this article is to distinguish these decision points for the dentist, suggest how each decision builds on and influences the next decision, and to be clear about the importance of each choice point in influencing endodontic predictability. Each of the ten decisions are discussed first as a question (Q) and answer (A), and then summarized with a corresponding guideline.TEN ENDODONTIC DECISION MOMENTS
Decision No. 1: Do Your Clinical Skills Match the Rules of Endodontic Predictability (Figures 1a and 1b)?
Q: Is endodontic predictability about what is good enough or about what is possible?
A: The purpose of endodontics is to cure or heal lesions of endodontic origin. Success or failure depends on the quality of the Endodontic Seal.1 Without the Endodontic Seal, endodontic predictability is left to other factors: quality of root canal system cleaning, resistance of the host to endodontic disease, biologic variability, presence or absence of bacteria, presence or absence of previous lesion of endodontic origin, or presence or absence of radicular symptoms.
In order to create the Endodontic Seal, it is important for the endodontic clinician to remember exactly what he or she is intending to seal in the first place. First, each dentist should know how many canals are typically make up the tooth being treated, and a quick and simple reference will often help missing an obvious canal.1 Second, the dentist should consult with toothatlas.com and examine the wide root canal system varieties that exist for the particular tooth that is going to be treated. The ToothAtlas reminds us that, in fact, teeth are really not made of canals. Root canal system anatomy is comprised of systems, labyrinths, and unpredictable complexities. Root canal systems are analogous to “banners in the breeze,” according to the late professor Herbert Schilder.2 Canals are a name and distinction given to the root canal system anatomy by dentists and, at best, are only an illusion of their true uniqueness and curvatures.
All endodontic anatomy is potentially significant. The first and perhaps most important endodontic decision is to slow down, respect nature’s fragile anatomy by using great restraint with the endodontic files, and continuously celebrate and embrace all of the root canal systems’ nuances. Develop the attitude that focusing on “what’s possible” in endodontic mechanics is energizing, increases endodontic predictability, and is personally satisfying.
Guideline No. 1: Mother Nature has been teaching us how to do endodontics for years. Be delicate; root canal systems are always curved, complex, and one of a kind. Listen to Mother Nature’s Rules of how to play the game.
Figures 1a to 1f. Endodontic Decision No. 1: Rules; and No. 2: Seeing.(a) Extracted tooth demonstrating nature’s dental curves. (b) Extracted endodontic failure cleared after centrifuge in Pelikan Ink. Silver cones sealed the portals of exit that they were cemented in but undiscovered portal of exit between silver cones allowed leakage from internal labyrinth of root canal system anatomy (red). Nature does not make straight lines or duplicates. Root canal systems are no exception. (c, d, e) Endodontists at the Center for Endodontics (Tacoma, Wash) benefit from Global Surgical observer scopes, enabling the dental assistant’s second set of eyes, intimacy with the delicate skills, superior anticipation, and collegial energy. (f) New Kodak 9000 3D CBCT recently installed at the Center for Endodontics. The cone beam instrument has the capacity to revolutionize endodontics in the same way as the operating microscope. Decision No. 2: Is Your Endodontics Illuminating (Figures 1c to 1f)? Q: Do you see and then believe, or do you believe and then you see?
A: The truth is that the answer is both: in endodontics when we see, we have to believe. The converse, when we believe, we see is also true. When we believe that anatomy is novel and mysterious, we are not surprised or foiled during endodontic mechanics. Nature gives us the microscopic roadmap to perform masterful endodontics.
So what is the best, most efficient, and superbly ergonomic way to see? It is what we see with the endodontic microscope. While the first significant endodontic decision is to know your endodontic anatomy, the second is to see your endodontic anatomy in an optimal way. In order to perform the endodontics of possibility, your second decision is simple: test drive the microscope, get trained, and purchase the microscope for your endodontic treatment…start to finish. The proof of the pudding is 99.9% of trained microscope users never return the microscope (Global Surgical Microscope Accounting Statistics).
Training in established microscope training centers comes as a significant added value when you purchase the microscope from the Global Surgical (globalsurgical.com/dental). The learning curve is not steep when procedures are first accomplished using previous illumination/magnification techniques; and then use the microscope to inspect first at lowest magnification. Almost always, the dentist observes areas of refinement or frank correction that are needed in any procedural step. Then it is only a matter of time before the dentist is seeing and doing at the same time versus doing blindly, then seeing, and then attempting to correct while in the blind again. The microscope makes delicate endodontic movements intentional, efficient, and safe.
`The biggest buzzword in endodontics, however, is not the microscope, although most master endodontists believe the microscope is still the profession’s best-kept secret. The next transformation in endodontics is the cone beam computed tomography (CBCT) imaging (Figure 1f). For the first time, the dentist can see a tooth and its surrounding conditions in 3-dimensions (3-D). In addition, the CBCT is the first step toward seeing the root canal system itself with the same kind of accuracy as the ToothAtlas is able to scan an actual tooth.
Guideline No. 2: Get trained in the mastery of the microscope and you will experience newfound control and confidence in unraveling the roadmap of endodontic anatomy.
Figures 2a to 2g. Decision No 3: Access. (a) Line diagram of anterior root canal system (lateral view). (b) Access with restricted access. (c)Incisal or essentially enamel triangle No. 1 removed. (d) Lingual or essentially dentin triangle No. 2 removed. (e) Both triangle Nos. 1 and 2 removed. (f) Line diagram of posterior tooth where distal canal has unrestricted dentin access but mesial canal requires removal of internal dentin triangle. (g) Line diagram illustrates how chamber calcification creates chamber triangles that are easily seen and can be removed with the illumination, magnification, and precision of the microscope. 
OfflineRegistered On: 14/05/2011Topics: 253Replies: 277Has thanked: 0 timesBeen thanked: 0 timesDecision No. 4: Are You Willing to Learn How to Simultaneously Use Intention and Restraint in Order to Follow the Canal to its Terminus? Q: How is the decision to learn how to “follow” canals is the third, and in many ways, the most important decision for optimizing endodontic predictability?
A: While eventually reaching the radiographic terminus of the root canal system is ultimately prerequisite to the Endodontic Seal, how and when to reach the end to the canal is the distinction that makes the difference in GlidePath management4 (Figures 3a and 3b). When a file does not easily follow down the entire length of a canal, it is due to 4 possibilities or a combination of these possibilities (Figure 3c). First, there may be pulp or necrotic tissue blocking the advancement of the file. Second, the angle of the access of the file may be different than the angle of incidence of the file. In other words, the curvature of the file does not sufficiently mimic that of the canal for the file to easily follow. For example, the dentist has placed a 5-mm length apical canal curvature on the file and yet the actual canal is an abrupt 1 mm turn, or perhaps an actual hook, as often is the case in maxillary lateral incisors, the DB root of maxillary molars, and the distal canal of mandibular molars. Third, the D1, or tip diameter, of the file is wider than the canal it is attempting to follow. Forth, the shaft diameter of the file is wider than the coronal portion of the canal. Restrictive dentin requires restrictive dentin removal before the file can follow deeper toward the radiographic terminus.5 Some endodontic teachers refer to this skill as “early coronal enlargement” or “crown down.”
Guideline No. 4: After removing coronal radicular restrictive dentin, follow your smallest file to the radiographic terminus. Never force or push. Irrigate copiously and after every instrument’s withdrawal. Be patient. The endodontic game is won or lost at decision No. 4.
Figures 3a to 3g. Decision No 4: Follow, No. 5: GlidePath, and No. 6: Rotary Shaping. (a) Small hand file follows to the radiographic terminus.(b) Obturated maxillary first molar. Note the rotary shaping and subsequent packing of the mesiobuccal canal follows the flow of the small hand file and preserves the position of the original portal of exit. Absolutely no apical transportation has occurred. (First molar endodontic treatment by Dr. Loubna Pla.) (c) Four dilemmas and 4 solutions during GlidePath preparation. (d) Small hand file following to radiographic terminus in wide apical curve. (e) ProTaper rotary (DENTSPLY Tulsa) wants to and can easily follow smooth GlidePath regardless of the extent of curvature. (f) Abrupt distal apical curve followed by small hand file. (g) ProTaper file is capable of abrupt turn shaping. Decision No. 6: What Rotary Shaping System is the Right One for You (Figures 4a to 4e)?
Q: So many rotary systems and so little time: What really matters in rotary?
A: First, remember that the biggest difference in rotary systems is not the rotary system. It is the dentist using the system. Are you careful, do you follow the rotary companies’ specific directions for use for the rotary files that they produce, do you always use new files for every treatment, are you sufficiently irrigating, are you constantly cleaning and inspecting the file’s flutes to detect unwinding?8
Second, be aware of a company that changes its file design about as soon as you have learned the system. Any reputable system’s geometries should be able to stand the test of time. Choose a file line that has been around a few years and can demonstrate sustainability and consistency. Rotary endodontics is too challenging and too dangerous for you to be part of the market test. Let someone else do it with someone else’s patients. Not yours.
Third, the essential qualities you should look for in rotary endodontics are safety, simplicity, efficiency, and consistency. In total, the rotary file system should give you a sense of control. You tell the rotary file what to do; not the reverse, as in many file systems where the file is nothing more than a fixed taper drill. The only difference is that you are not drilling into wood; you are carving delicate human tissue. The file design you choose should reflect this understanding in every file in its sequence. Each file should have a specific purpose and you should be able to easily measure that purpose has been served.
Fourth, the best way to compare rotary systems is through your own education. Take the rotary systems that you are considering learning. Then collect 3 mandibular molars for each rotary system you want to test. Prepare access cavities and make a GlidePath in all mesial canals. Then compare the systems head to head with your dental assistant, who may also be a good and less biased observer. Shape the ML canal with one file system and the MB with another, and discover which is right for you. The best education in the world is your own!
Be sure to follow the directions for use. It will not take long to discover the rotary system that’s for you. It’s really that easy. It will be the system that puts you in control and actually does what it says it will do.
Guideline No. 6: Choose the rotary system that is best for you by testing them yourself. You will discover the truth about which rotary concept and technique is the safest, simplest, and most efficient.
Figures 4a to 4f. Decision No. 7: Cleaning, No. 8: Conefit, and No. 9 Oburation. (a) Conefit. (b) Image from ToothAtlas.com. (c) Pretreatment image of mandibular molar. (d) Perpendicular image of obturation. (e)Oblique image of obturation. (Endodontic treatment by Dr. Jason West.)(f) ToothAtlas image of typical atypical molar.
OfflineRegistered On: 14/05/2011Topics: 253Replies: 277Has thanked: 0 timesBeen thanked: 0 timesDecision No. 8: Should I Make a Conefit Prior to Obturation (Figure 4a)? Q: “Is it necessary to validate your radicular shape before you pack?”
A: Is it necessary to make an accurate impression before you cast an onlay? Of course it is. In endodontics there is an old saying that goes like this: “You don’t get what you want; you get what you measure.” Regardless of your obturation technique: vertical compaction of warm gutta-percha, continuous wave, carrier-based, or lateral condensation, you need to know if you are ready. The conefit tells you that you are ready. In warm gutta-percha techniques, the conefit additionally allows you to modify the cone itself before compaction which gives you additional refinement in endodontic finishing.10
Guideline No. 8: Develop the skill of making an accurate conefit prior to obturation.Decision No. 9: What Obturation Method Is For Me (Figures 4c to 4e)?
Q: How do you create the maximum cushion of warmed gutta-percha and mold it 3-dimensionally?
A: The easiest obturation method to learn is lateral condensation. The next is carrier-based. The next is continuous wave. And the next is vertical compaction of warm gutta-percha.
The easiest to control is, in the opinion of the author, in this order: vertical compaction of warm gutta-percha, lateral condensation, continuous wave, then carrier-based.
The method that gives you the most choices are in this order: vertical compaction of warm gutta-percha, continuous wave, lateral condensation, then carrier-based.
The best 3-D endodontic seal is achieved in the following order: possibly carrier-based first, then vertical compaction of warm gutta-percha, continuous wave closely behind, and then lateral condensation.
The most technique sensitive order is: vertical compaction of warm gutta-percha, carrier-based, lateral condensation, and then continuous wave. Guideline No. 9: Choose an obturation technique where you don’t have to think too much. Obturation is a time to relax. It should not be a sporting event!Figures 4a to 4f. Decision No. 7: Cleaning, No. 8: Conefit, and No. 9 Oburation. (a) Conefit. (b) Image from ToothAtlas.com. (c) Pretreatment image of mandibular molar. (d) Perpendicular image of obturation. (e)Oblique image of obturation. (Endodontic treatment by Dr. Jason West.)(f) ToothAtlas image of typical atypical molar.
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