How much time for Molar Endo?

[Jason49]

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Molar endo is frustrating at times. Sometimes I can complete treatment in 80- 90 minutes and then there are times when it takes me two hours or more. I’ve done hundreds of endo treatments and I’m still very inconsistent with treatment time for molars, especially lower molars.

How much time do you allow for molar endo? What do you do when you encounter a tooth that is much more difficult to treat than anticipated?

 

[OhioDMD]

Zero..... I have 3 endodontic practices within a reasonable distance to whom I refer all molars. They achieve better results in less time and with a lot less frustration (especially on my part) than attempting to keep these in house. I will do anterior and the occasional bicuspid where I feel my results are equal to what I receive from the endodontist.

 

[vellnueve]

Usually took me 30 seconds to cut and paste the appt to the endodontist's schedule...

The ones I did myself to keep current took about 1.5-2 hours.

 

[TanMan]

Bare minimum without half-assing it, 25 minutes(a half-ass endo can take 5 mins, but why would you put the patient and yourself through that). Before I get flamed about how it requires a minimum of 40 mins of NaOCl to kill e.faecalis, tools these days can speed that up such as heated NaOCl, solution activation (sonic handpiece, endoactivator, PIPS/ErYag laser) and multiple irrigation solutions, NaOCl, CHX, EDTA. Can take as long as 1.5-2 hours for extremely difficult cases (i.e full necrotic w/ purulent discharge or no canals/pulp chamber on radiographs). The main point is clean it until you're sure there's nothing left in there. Once you do enough cases, you can tell based on the smell a lot of times, along with whether you can visualize anything in the orifice, or any debris/organic tissue floats up as you irrigate.

More importantly, is not the amount of time the patient is in the chair, but the amount of chair time you are dedicating. Patient can be in the chair for 2 hours, but if you spent 10-15mins in chair time, then you're fine.

I use a combination of ErYag laser to initiate PIPS, NdYag for thermal disinfection, WaveOne Gold for instrumentation, NaOCl, EDTA, CHX. Obturation can be superquick with fitted/tapered cone (or guttacore)

 

[vellnueve]

In defense of my post above, I hand filed everything with .02 taper K-files. Like I said, did a few mainly just to retain the skills- so that I could do them in an austere environment if needed. Much faster to refer.

 

[Lane138]

It's not recommending irrigating with NaOCl and chlorohexidine because of the precipitate that forms.

Do you mind sharing your breakdown of what happens in the 25 minutes? When you say it's "your chairtime" that matters, I feel like endo is one of the few procedures where you cannot bounce in and out of the operatory. I'd love to hear you elaborate on that

 

[TanMan]

It's not recommending irrigating with NaOCl and chlorohexidine because of the precipitate that forms.

Do you mind sharing your breakdown of what happens in the 25 minutes? When you say it's "your chairtime" that matters, I feel like endo is one of the few procedures where you cannot bounce in and out of the operatory. I'd love to hear you elaborate on that

Irrigate with water between NaOCl and CHX.

After anesthetic, use a flat top bur so you only have 1 reference point. Takes 10 seconds or less. Open access with 557, remove all caries. Use fine fluted endo Z bur to remove and visualize all orifices. Place rubber dam. Use flowable composite to create barrier as needed around rubber dam, rebuild walls as needed. Apex locator w/ 10 file. WaveOne gold to length w/ lots of water irrigation, then naocl irrigation, check length with cones. Take PA. Afterwards use NaOCl with activation apparatus (whatever you got), if canals are clean, cones at length, start final irrigation protocol, otherwise cycle NaOCl. If it looks good, irrigate with water, flush and activate the water, use EDTA/CHX. Obturate and complete. Build it up and prep for crown. Note that I said 25 minutes minimum, if you got complications, could take longer. Upper, can't really hit that minimum very often b/c of MB2, isthmuses, etc..., lowers are much easier.

Edit: Now... if you need to jump b/w ops, there are some steps you can go in between. 1. anesthetic and prep. 2. after instrumentation and length check, 3. cycling NaOCl as needed, 4. while curing the buildup

 

[Lane138]

Irrigate with water between NaOCl and CHX.

After anesthetic, use a flat top bur so you only have 1 reference point. Takes 10 seconds or less. Open access with 557, remove all caries. Use fine fluted endo Z bur to remove and visualize all orifices. Place rubber dam. Use flowable composite to create barrier as needed around rubber dam, rebuild walls as needed. Apex locator w/ 10 file. WaveOne gold to length w/ lots of water irrigation, then naocl irrigation, check length with cones. Take PA. Afterwards use NaOCl with activation apparatus (whatever you got), if canals are clean, cones at length, start final irrigation protocol, otherwise cycle NaOCl. If it looks good, irrigate with water, flush and activate the water, use EDTA/CHX. Obturate and complete. Build it up and prep for crown. Note that I said 25 minutes minimum, if you got complications, could take longer. Upper, can't really hit that minimum very often b/c of MB2, isthmuses, etc..., lowers are much easier.

Edit: Now... if you need to jump b/w ops, there are some steps you can go in between. 1. anesthetic and prep. 2. after instrumentation and length check, 3. cycling NaOCl as needed, 4. while curing the buildup

I'm not familiar with the Wave One system... are you not handfiling at all beyond getting to length with a 10 file? That would definitely be a huge time saver!

 

[TanMan]

I'm not familiar with the Wave One system... are you not handfiling at all beyond getting to length with a 10 file? That would definitely be a huge time saver!

That's correct. Now, in rare instances I cannot get down to length, I'll use a protaper waveone to open it up (I dont use gates), then protaper next X1 to get down there, then finish with waveone. Works everytime. Now, with the waveone, you must have really good proprioception in that you need to know how to sweep the file apically to advance in very calcified cases and feel when your file is fatigued. If it's fatigued, stop using it, get another one. People complain about the cost, but if you time the midwinter specials or other conventions, you can get bulk discounts. I think retail is 66 dollars per pack, but if you buy 250-500+ packs it goes down in the 50's. Time = money.

 

[THS]

I'm just a student; we are taught the "older" hand-filing methods and more modern rotary methods, but Wave One is incredible. For most cases, I have been able to clean and shape with less than 4 files (not counting the hand files to find WL/AF1).