Endo lab

[ItsGavinC]

So, we've just finished our first week of endo lab here at Arizona, and I'd like some feedback from those who have gone before me. Here's the general procedure I follow on a molar endo, and I'm wondering what everybody else does (ie, I'd like any tips/tricks that work!):

1) Access canals (rubber dam is in place/anesthesia is done) with #4 round bur.
2) Clean out pulpal tissue with same round bur.
3) Make occlusal adjustments if necessary for better access.
4) Use #8 K hand file to find working length for canals (take digital radiograph).
5) With working length noted, move through #10, #15, #20, and #25 handfiles (irrigating with NaOCl in between each filing).
6) Use #2 Gates to widen orifice if needed.
7) Apply prolube directly to NiTi rotary files/or apply it to the canals.
8) Use rotary files in crown down method and go within 4mm of my working length (the first rotary is the same size or one size down from my final hand file).
9) Dry canals with air, then place paper points and then use air again.
10) Use auto-fit gutta percha and sealer

I'd like to use apex locators, but we won't have those available until we are in our clinic. Does anybody who finds working length using radiography use rotary before finding working length?

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[DrRob]

I don't find working length right away - I access the canals - and then I place a 8 file without forcing it to length to verify i have found the canals. Then I widen the orfices with gates glidden before I attempt to find working lenght with the apex locater. I found that when I tried to find the working lenght right away I would have problems in some cases where the canals were very narrow coronally (the file would bind) - so now I open the canal a bit before working length is found.

 

[DrJeff]

A nifty little trick for you to improve your acces visibility on ANY tooth. I learned this one from Dr. Steven Buchannon, one of the pioneers of rotary endo.

Once you've made your acces prep and found and opened up the pulp chamber with whatever bur your prefer, go back with an inlay type diamond bur (read as big a divergent taper bur as you have access to), and refine the edges of your access prep. Basically picture the axial walls of your access prep as an inlay prep with 10+ degrees of diveregnt taper. You'll find that this will really help you to see the canal orifi Also, don't be too conservative with your access, when they say get STRAIGHTLINE ACCESS to the canals, do it, and then remove the proper amount of tooth to accomplish that. Afterall, 98%+ of the time you'll be crowning the tooth afterwards, and its very, very easy to remove a little more tooth at the access time to make your endo life easier, and fill it back up with core material prior to the crown prep.

The two major shifts in my preps that I've noticed over my career have been that my direct restorative preps have gotten smaller, while my endo access preps have gottne larger. Both of these have made my life easier

 

[Tightseal]

We use endo Z bur for refining the access cavity after using round bur. This bur does not cut at the end so this helps us refine the prep with less risk of perforation.

 

[Energon]

Hey how many of you are out there learning (in pre clinic) with rotaries? We had the opportunity to work with rotary instruments from the get go. So far in the clinic I haven't had an endo case yet, unfortunately all my patients with endo problems had to be referred to PG endo coz their cases were too complex. I just hope I start doing endo pretty soon.

 

[groundhog]

Hey how many of you are out there learning (in pre clinic) with rotaries? We had the opportunity to work with rotary instruments from the get go. So far in the clinic I haven't had an endo case yet, unfortunately all my patients with endo problems had to be referred to PG endo coz their cases were too complex. I just hope I start doing endo pretty soon.

I went to the student clinic last week for a root canal on my lower molar. It was the student's first live molar. The student is left handed and the school has only one chair set up for left handers in the endo clinic. I get numbed, we are ready to start up, and the water for the hand pieces won't come on. So, we have to move to the next cubicle. It is a right handed chair which turns out to be a real pain for the student when trying to get the cumbersome mechanical suction holder positioned so that the work can be done from the left side of a right handed chair. We get ready to go again, the water starts up ok, but springs a leak in the manifold. I'm laughing inside at the comedy, but the student is not amused and mumbles something about looking so forward to getting out into the real world. Well, the technician shows up and starts working on the water system at the left handed chair. Meanwhile the one assistant assigned to the endo clinic makes a command decision to do more than her normal function (which apparently consists of making sure that each station is well stocked with cotton). She tries to disconnect the student's hand pieces and messes them up while we are in the process of moving to yet another cubicle. The student, by now, is fit to be tied. Thank goodness, at this point, the tech gets the water working at the left handed station and we are finally able to get on with the job at hand. The root canal went well with lots of good experience for the student (inflamed pulp, heavy bleeder canal etc.) Plus no post op infection for me (I've experienced that before and it hurts like heck). I go back next week for final prepping of the canals for filler.

 

[dc-10]

This may be a little off topic but, what percentage of endo do general dentists refer out? It seems like general dentists do a majority of their own endo. How do endodontists get enough patients to keep busy?

 

[trypmo]

Wait a sec - dental students have to do RCTs without the benefit of one of those electronic apex detector instruments?? Is it illegal to bring in your own to make sure you do it right? The endo I shadowed always used that electronic doohickey as his primary method of apex detection and then, if that was less-than-definitive (maybe 10% of cases), he'd do the xray to check the position of the file-thingy. I can't IMAGINE doing an RCT without the electronic apex finder dealy. (I'm sure they have a real name.) Wow.

 

[aphistis]

Wait a sec - dental students have to do RCTs without the benefit of one of those electronic apex detector instruments?? Is it illegal to bring in your own to make sure you do it right? The endo I shadowed always used that electronic doohickey as his primary method of apex detection and then, if that was less-than-definitive (maybe 10% of cases), he'd do the xray to check the position of the file-thingy. I can't IMAGINE doing an RCT without the electronic apex finder dealy. (I'm sure they have a real name.) Wow.

Dental schools typically teach any given procedure using technique & technology dating from approximately the mid-thirteenth century. Ever wondered why practicing dentist point at what dental schools teach and laugh?

 

[trypmo]

Dental schools typically teach any given procedure using technique & technology dating from approximately the mid-thirteenth century. Ever wondered why practicing dentist point at what dental schools teach and laugh?

Daaaang, that's some scary stuff. No wonder I heard all those doors slamming in the operatory corridors when I went for interviews - those must have been extractions!

 

[organic]

I don't find working length right away - I access the canals - and then I place a 8 file without forcing it to length to verify i have found the canals. Then I widen the orfices with gates glidden before I attempt to find working lenght with the apex locater. I found that when I tried to find the working lenght right away I would have problems in some cases where the canals were very narrow coronally (the file would bind) - so now I open the canal a bit before working length is found.

the essence of crown down technique

 

[organic]

We use endo Z bur for refining the access cavity after using round bur. This bur does not cut at the end so this helps us refine the prep with less risk of perforation.

I like the equivalent of Endo-Z bur, non-end cutting, but diamond burs. Carbide burs are just so so so inefficient and dull up really fast

 

[organic]

Wait a sec - dental students have to do RCTs without the benefit of one of those electronic apex detector instruments?? Is it illegal to bring in your own to make sure you do it right? The endo I shadowed always used that electronic doohickey as his primary method of apex detection and then, if that was less-than-definitive (maybe 10% of cases), he'd do the xray to check the position of the file-thingy. I can't IMAGINE doing an RCT without the electronic apex finder dealy. (I'm sure they have a real name.) Wow.

I think he meant that because it is an endo lab, he CANNOT use apex locator. There is no voltage difference between the non-existing PDL and non existing human body. Probably just a mounted extracted tooth in stone or PVS.

 

[Tightseal]

I like the equivalent of Endo-Z bur, non-end cutting, but diamond burs. Carbide burs are just so so so inefficient and dull up really fast

That is some good info....................did not know they also come in diamond.

 

[ItsGavinC]

We use endo Z bur for refining the access cavity after using round bur. This bur does not cut at the end so this helps us refine the prep with less risk of perforation.

I also use the Z bur--it's great.

 

[ItsGavinC]

Wait a sec - dental students have to do RCTs without the benefit of one of those electronic apex detector instruments?? Is it illegal to bring in your own to make sure you do it right? The endo I shadowed always used that electronic doohickey as his primary method of apex detection and then, if that was less-than-definitive (maybe 10% of cases), he'd do the xray to check the position of the file-thingy. I can't IMAGINE doing an RCT without the electronic apex finder dealy. (I'm sure they have a real name.) Wow.

MANY endodontists don't use apex finders, and many do. It's really a matter of personal preference. And, as I understand it, you can still be 1-2 mm short with an apex finder.

In our clinic we'll use apex finders, but right now in the simlab we're just using radiographs. No big deal, it isn't THAT hard to find the apex. It is more time consuming, but I'm not on any sort of time schedule. Finding the apex involves literally nothing more than sticking a file in until you have resistance, then taking a radiograph and seeing where you are.

 

[organic]

MANY endodontists don't use apex finders, and many do. It's really a matter of personal preference. And, as I understand it, you can still be 1-2 mm short with an apex finder.

In our clinic we'll use apex finders, but right now in the simlab we're just using radiographs. No big deal, it isn't THAT hard to find the apex. It is more time consuming, but I'm not on any sort of time schedule. Finding the apex involves literally nothing more than sticking a file in until you have resistance, then taking a radiograph and seeing where you are.

try working on 10 extracted teeth and fill them all the way to radiographic apex. Take them out of your mounting block afterwards, you will most often find GP sticking out of the orifices. A lot of perfect obturations to the apex or 1mm short on radiogrpah are actually over.
I personally would trust apex locator more, especially when apex locator tells me that I am over while radiograph shows I am short. Most of the orifices aren't at the tip of the roots.

But of course, tactile sensation is above all the most important.

I agree that it is more important, while in school, to learn tactile sensation and radiograph technique. Apex locator will be a piece of cake for later.

 

[ItsGavinC]

try working on 10 extracted teeth and fill them all the way to radiographic apex. Take them out of your mounting block afterwards, you will most often find GP sticking out of the orifices. A lot of perfect obturations to the apex or 1mm short on radiogrpah are actually over.
I personally would trust apex locator more, especially when apex locator tells me that I am over while radiograph shows I am short. Most of the orifices aren't at the tip of the roots.

But of course, tactile sensation is above all the most important.

I agree that it is more important, while in school, to learn tactile sensation and radiograph technique. Apex locator will be a piece of cake for later.

I would also trust an apex locator more. My general point, which you mentioned in your final paragraph, is that learn by sensation and radiograph makes the apex locator a cinch.

 

[ItsGavinC]

I can't IMAGINE doing an RCT without the electronic apex finder dealy. (I'm sure they have a real name.) Wow.

See this SDN post by an endodontist who has practiced for 18 years and done over 20,000 procedures: http://forums.studentdoctor.net/showpost.php?p=892763&postcount=7

The kicker: "I don't usually take working length xrays and I don't use apex locators."

He just does it by feel.

 

[texas_dds]

a caution from one of my instructors: when 'refining your access' try to do it before you have much of the cleaning/shaping done, otherwise cover the orifices w/cotton when drilling away more at the access (could be yucky dentin or amalgam, etc debris that can get into the canals where you dont want it if the orifices are uncovered)

 

[DrRob]

you really have to spend most of the time with access - straight line access is essential and often the access opening is much larger than they would want you to do in dental school.

Don't be in hurry to get to working length either - trying to jam a file to WL right away will just jam debris/ cause ledging. I know in dental school this was one of your first steps - I had so many problems with endo until my partner helped me out with this step.

 

[DrJeff]

a caution from one of my instructors: when 'refining your access' try to do it before you have much of the cleaning/shaping done, otherwise cover the orifices w/cotton when drilling away more at the access (could be yucky dentin or amalgam, etc debris that can get into the canals where you dont want it if the orifices are uncovered)

When I'm refining my access prep, I do 2 things to help prevent eronious debris from "migrating" into the canals.

#1 I'll generously fill between 1/2 to 3/4ths of the access prep with RC prep(this way, if I do endo up "forcing" any debris into the canals, its going in there on a lubricating agent which is easily removed

#2 I'l refine the access prep WITHOUT irrigation from the handpiece. This way the RC prep isn't washed away, and while the smell may not be the best for a minute (although the high volume suction placed near the tooth will help immensly), it works well. Also, it'sot like I'm worried about "frying" the pulp when I'm already doing the endo.

Best bet for improving your endo technique is to "pick the brains" of your instructors and then take multiple speakers CE courses when out in practice. This way, with different people presnting their opinions, you'll pick up litttle personel tid bits from each which you may(or may not) find out to be a great help to you!

 

[organic]

When I'm refining my access prep, I do 2 things to help prevent eronious debris from "migrating" into the canals.

#1 I'll generously fill between 1/2 to 3/4ths of the access prep with RC prep(this way, if I do endo up "forcing" any debris into the canals, its going in there on a lubricating agent which is easily removed

#2 I'l refine the access prep WITHOUT irrigation from the handpiece. This way the RC prep isn't washed away, and while the smell may not be the best for a minute (although the high volume suction placed near the tooth will help immensly), it works well. Also, it'sot like I'm worried about "frying" the pulp when I'm already doing the endo.

Best bet for improving your endo technique is to "pick the brains" of your instructors and then take multiple speakers CE courses when out in practice. This way, with different people presnting their opinions, you'll pick up litttle personel tid bits from each which you may(or may not) find out to be a great help to you!

great tips

 

[gpg]

I hope I have got the spelling right. Basically what you got to do is once you enlarge with a larger file, go upto that length with one size smaller file to remove any Dentinal shavings that may be present towards the apical part of the prep.

Also start with a 8 or 10 no. file coated with a lubricant like Glyde(Dentsply).That way you slick the pulp tissue apart like a needle would rather than push it towards the apex which happens when you use a 15 no directly. Lots of times patient is fine but when you place a absorbent or GP point,patient feels a bit of pain in the last 2 mm or so. Thats because the very first time you placed an instrument in the canal, a small nerve fragment was pushed into that region.

In a radiograph,presence of a lateral radiolucency,even after obturation, indicates presence of a lateral canal opening towards the lateral surface. So try to bend the tip of your file and clean it up totally.Rotary really helps in such a case. You might want to use a bi-directional spiral for pushing the sealer in. The coronal half pushes the sealer apically and the apical half pushes it coronally. That you the sealer almost never goes beyond the apex and all the lateral canals are completely sealed up.

Just my 2 cents........

 

[groundhog]

I went to the student clinic last week for a root canal on my lower molar. It was the student's first live molar. The student is left handed and the school has only one chair set up for left handers in the endo clinic. I get numbed, we are ready to start up, and the water for the hand pieces won't come on. So, we have to move to the next cubicle. It is a right handed chair which turns out to be a real pain for the student when trying to get the cumbersome mechanical suction holder positioned so that the work can be done from the left side of a right handed chair. We get ready to go again, the water starts up ok, but springs a leak in the manifold. I'm laughing inside at the comedy, but the student is not amused and mumbles something about looking so forward to getting out into the real world. Well, the technician shows up and starts working on the water system at the left handed chair. Meanwhile the one assistant assigned to the endo clinic makes a command decision to do more than her normal function (which apparently consists of making sure that each station is well stocked with cotton). She tries to disconnect the student's hand pieces and messes them up while we are in the process of moving to yet another cubicle. The student, by now, is fit to be tied. Thank goodness, at this point, the tech gets the water working at the left handed station and we are finally able to get on with the job at hand. The root canal went well with lots of good experience for the student (inflamed pulp, heavy bleeder canal etc.) Plus no post op infection for me (I've experienced that before and it hurts like heck). I go back next week for final prepping of the canals for filler.

Update: Alls well that ends well. Molar is sealed, filled, and set for crowning next quarter. No further fiascos with the equipment either. This was the sixth molar root canal that I have had (counting one which was a redo) and I have to say it was the best experience I've had so far with that procedure except for the time required to get the job done in a dental school clinic setting. Was the beneficiary of a good technique for deadening an inflammed sensitive canal prior to boring out the tissue. Inject the deadener a bit at a time as you push that tiny syringe needle farther into the canal in mutiple steps. Sure beats the heck out of the one jolt technique which I had always experienced in the past. Rotary endo is not the "silver bullet" especially with molars. A lot of hand file work still has to be done nearer the end of the canals and also to handle other issues such as a curved canal which I had. Quote the student: "its hard to beat the feel you get with the hand file when working blind". Also learned that one cannot irrigate too often between borings with that "bleach" smelling stuff in order to prevent blockages (especially in older patients like me whoose canal tissue can become like "beef jerkey") and also control post op infection. Never had to take anything more than 2 self prescribed over the counter ibuprofens prior to each session. Still, from an economic standpoint, I can understand why a lot of GP's might prefer to send out the their molar cases to an Endo.