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- Apr 13, 2020
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I had the luxury of doing full time endo at my last DMO for 9 years as well as being mentored by an experienced endodontist. I like to pay if forward for all the tips & tricks I've learned through my experience of doing over 9000 cases, peer reviewed journals, as well as other endodontists. I love to receive feedbacks. For any of you who want to come after me with pitchforks, my name is John Smith, my license is #123456 at the state of NY. Feel free to PM any specific questions or concerns.
1. I hate unpleasant surprises and unknowns. I always ask patients their pain levels 1 to 10. I tell pts that there is a potential for your pain level to increase up to 4 of 10 after completion. If they are in intense pain, I usually don't obturate and put in Ca(OH)2 and finish in ~6 weeks. I know you are losing money and chair time. I like the results better. Down side: very rare patients may not return or they may lose insurance 6 weeks later. If so, I lost about 20 to 40 minutes chair time. Alternative: You can complete the RCT in 1 visit (I had a pt come back with even more pain after the anesth wore off and begged me to remove the obturation) or bill it as pulpal debridement or palliative tx and reschedule for full RCT appt.
2. Make sure you are working on a restorable tooth. It is hard to locate all fractures so make sure you get solid probings, tooth sleuth, etc and proper DX. I had to do a few cases on pts on IV Bisphosphonates and cannot extract. Do the best you can or punt it...see #4.
3. Anesthesia: Call me naive but I've never given intra bony injections and PDLs don't work for me. Usually other dentists get me to anesth their difficult cases. Worst case, I get them numb enough to give intra pulpal. Multiple times I've given oral sedatives (if the pt has an escort) or N2O and helped somewhat. If I have a difficult time with anesth, I just get them out of pain and reschedule for the full RCT.
4. Case selection: If you can't see the pulp chamber or if the canal becomes bifurcated or C-shaped lower 2nd molars, etc., just punt it. Other cases to punt: extreme resorption (no apical stop) and extremely curved canals, There are ~95% MB2, MB3, or more in Max 1st molars and ~50-60% in Max 2nd. If I see PARL on MB root, I will place Ca(OH)2 and punt if there is no improvement.
5. Access: I like to access the pulp chamber without Rubber Dam. That way, I can view different angles. Once I opened the pulp chamber, I quickly place the RD and flush with full strength NaOCl. I open the orifice(s) with rotary using slight and gently pressure to avoid any ledging and instrument damage. I had a colleague separate a rotary that way. Never use pressure that would break a fragile pencil lead. Once the orifice is opened, use the pulp shaping bur (Dentsply Endo Z bur or cheaper equivalent) and smooth all the ledges and refine the access so you won't have to hunt for canals. My idea of a good access is if your DA can place paper points on all canals in the 2nd molar. Access, access, access!
6. Magnification: I'm blessed with a operating microscope in most of my locations. I would document "Using 8x magnification, verified no internal caries, resorption, fractures detected, all canals located and all pulpal tissue removed."
7. I'm not qualified to give a hands on workshop. If you like more info on getting WL, patency, rotary inst, fillings, etc., PM me. I use full strength NaOCl and EDTA under activation to remove biofilm & smear layer, as well as most micro debris, etc.
8. Final Obturation: Whatever obturation system you use, make sure the fill is separated below bone. This would minimize discoloring the tooth and maximizing coronal seal. I use old school System B and Calamus/Obtura back fill to get more predictable results.
9. I've notice almost all endodontists in my region document prognosis of the completed case such as "Good Prognosis" or "Guarded Prognosis due to" structurally compromise, pre-exisiting periodontal attachment loss, etc.
If you like a copy of my endo write up template, you can PM me.
10. For a molar without any of the problems stated #4, it usually takes me 30 to 40 min chair time. I'm not as fast as some who can do it in 10 min but I'm happy and the patients doesn't feel rushed and they are happy as well.
1. I hate unpleasant surprises and unknowns. I always ask patients their pain levels 1 to 10. I tell pts that there is a potential for your pain level to increase up to 4 of 10 after completion. If they are in intense pain, I usually don't obturate and put in Ca(OH)2 and finish in ~6 weeks. I know you are losing money and chair time. I like the results better. Down side: very rare patients may not return or they may lose insurance 6 weeks later. If so, I lost about 20 to 40 minutes chair time. Alternative: You can complete the RCT in 1 visit (I had a pt come back with even more pain after the anesth wore off and begged me to remove the obturation) or bill it as pulpal debridement or palliative tx and reschedule for full RCT appt.
2. Make sure you are working on a restorable tooth. It is hard to locate all fractures so make sure you get solid probings, tooth sleuth, etc and proper DX. I had to do a few cases on pts on IV Bisphosphonates and cannot extract. Do the best you can or punt it...see #4.
3. Anesthesia: Call me naive but I've never given intra bony injections and PDLs don't work for me. Usually other dentists get me to anesth their difficult cases. Worst case, I get them numb enough to give intra pulpal. Multiple times I've given oral sedatives (if the pt has an escort) or N2O and helped somewhat. If I have a difficult time with anesth, I just get them out of pain and reschedule for the full RCT.
4. Case selection: If you can't see the pulp chamber or if the canal becomes bifurcated or C-shaped lower 2nd molars, etc., just punt it. Other cases to punt: extreme resorption (no apical stop) and extremely curved canals, There are ~95% MB2, MB3, or more in Max 1st molars and ~50-60% in Max 2nd. If I see PARL on MB root, I will place Ca(OH)2 and punt if there is no improvement.
5. Access: I like to access the pulp chamber without Rubber Dam. That way, I can view different angles. Once I opened the pulp chamber, I quickly place the RD and flush with full strength NaOCl. I open the orifice(s) with rotary using slight and gently pressure to avoid any ledging and instrument damage. I had a colleague separate a rotary that way. Never use pressure that would break a fragile pencil lead. Once the orifice is opened, use the pulp shaping bur (Dentsply Endo Z bur or cheaper equivalent) and smooth all the ledges and refine the access so you won't have to hunt for canals. My idea of a good access is if your DA can place paper points on all canals in the 2nd molar. Access, access, access!
6. Magnification: I'm blessed with a operating microscope in most of my locations. I would document "Using 8x magnification, verified no internal caries, resorption, fractures detected, all canals located and all pulpal tissue removed."
7. I'm not qualified to give a hands on workshop. If you like more info on getting WL, patency, rotary inst, fillings, etc., PM me. I use full strength NaOCl and EDTA under activation to remove biofilm & smear layer, as well as most micro debris, etc.
8. Final Obturation: Whatever obturation system you use, make sure the fill is separated below bone. This would minimize discoloring the tooth and maximizing coronal seal. I use old school System B and Calamus/Obtura back fill to get more predictable results.
9. I've notice almost all endodontists in my region document prognosis of the completed case such as "Good Prognosis" or "Guarded Prognosis due to" structurally compromise, pre-exisiting periodontal attachment loss, etc.
If you like a copy of my endo write up template, you can PM me.
10. For a molar without any of the problems stated #4, it usually takes me 30 to 40 min chair time. I'm not as fast as some who can do it in 10 min but I'm happy and the patients doesn't feel rushed and they are happy as well.
