The day you got better at endo

[Sbosu]

The day you get better at endo is the day you stop using thermafil.

What are the advantages to thermafil? --Your fill looks dense on a radiograph

What are the disadvantages to thermafil/guttacore/every other obturator based system?

-No length control. You cannot control where your fill goes. It could go significantly out the end of the root. It could be short. You simply have no way to adjust your fill once it is done.

-False sense of security. Even though the carrier may make the final radiograph look nice, the tooth may not actually be clean. If you cannot get a traditional gutta percha cone to passively seat to the end of a canal, then you haven't properly prepped and cleaned the canal.

-What you use to fill the canal doesnt really matter. It's about what you take out, not what you put in. What matters is finding all canals, and thoroughly cleaning and debriding them of pulp/bacteria. Lateral condensation works just as well.

-They are very difficult to retreat

-They are expensive. Some carriers cost $6 each! That could buy a lot of gutta percha.

Theres a reason endodontists dont use thermafil or carriers. It's because they are terrible. Salespeople want to sell them because they're expensive. They will say you get a 3 dimensional fill when you use them. Well that doesnt matter at all if you didnt 3 dimensionally clean everything out. And if you did 3 dimensionally clean everything out, then your sealer will get into those little nooks and crannies anyway.

Thermafil/guttacore, etc... they all do nothing for you. So why use them? Use a tapered gutta percha cone that matches the taper of your file. This will help ensure that you have prepped the canals nicely, and cleaned them thoroughly. You have length control with them as well. You can seat them, take an xray, and adjust as needed.

Using a thermafil never made a case successful that would have failed with regular gutta percha. I have seen thermafil make cases fail that would otherwise have worked though.
If all of that melted gutta percha doesnt get removed from the pulp chamber and it is sitting next to a leaking buildup, then you will ha e a tooth that needs to be retreated. Coronal seal really matters!

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[Cold Front]

I used Wave 1 and did about 50-70 Endo cases a month from 2010-2018. I don’t use Endo anymore - started to focus more in other areas of my practices and side businesses.


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[e00z]

@Cold Front, 50+ cases is quite a bit for a GP. Could you expand more on why you stopped?

 

[Cold Front]

I averaged about 3 Endo cases/day - a combination of anterior and posterior teeth (including second molars). I didn’t refer out much, except for retreats or some seriously curved and calcified canals. I did few MB2 cases. My patient population were from very high caries risk communities, and I see a lot of walkin emergency cases - about 5 a day. I now refer my Endo cases to a local general dentist. I’m tapering off from doing the daily grind dentistry - Endo was fun but also gets boring eventually after the learning curve. My Endo supplies rep once told me I was doing more Endo than many Endo specialists he knew. That’s what’s cool about general dentistry - you don’t have to specialize (with more debt and time) and you still get to do almost any aspect of dental specialty.


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[ToothJockey]

I averaged about 3 Endo cases/day - a combination of anterior and posterior teeth (including second molars). I didn’t refer out much, except for retreats or some seriously curved and calcified canals. I did few MB2 cases. My patient population were from very high caries risk communities, and I see a lot of walkin emergency cases - about 5 a day. I now refer my Endo cases to a local general dentist. I’m tapering off from doing the daily grind dentistry - Endo was fun but also gets boring eventually after the learning curve. My Endo supplies rep once told me I was doing more Endo than many Endo specialists he knew. That’s what’s cool about general dentistry - you don’t have to specialize (with more debt and time) and you still get to do almost any aspect of dental specialty.


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Why do you refer your endo to another GP now, why not an Endodontist?


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[Cold Front]

Why do you refer your endo to another GP now, why not an Endodontist?


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Because the community I was serving could not afford the specialist fees, and many had state insurances that general dentists (like myself) in the area accept - so Endo was at no cost to the patient. It was $500 paid by medicaid at a general dentist, versus $1k out of pocket to an endodontist. Like I said, I was busier than most endodontists in my area were doing Endo at a lower fee, but those patients were also keeping my hygienists busy, and even paid some service out of pocket that were not covered by Medicaid. I would also do the Endo + quadrant dentistry + the holistic procedures (diagnostic casts, intraoral pics, tobacco consults, etc) in a single visit. So my time in production $$ for doing Endo with those additional services was higher than an endodontist doing just the Endo case.


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[Cold Front]

Cold Front doesn’t believe in specialty training.

I thought you were having second thoughts about residency in Endo?

I probably don’t know everything Endodontists do - but then again, I didn’t have to go to school for additional years for archaic literature reviews and spend countless long nights looking things up on PubMed... not to say Endodontists are not needed, but they are truly “difficult cases only” specialty to me. The rest can be done by “enthusiastic” general dentists with a very keen interest in Endo.


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[FutureDent020]

I thought you were having second thoughts about residency in Endo?

I probably don’t know everything Endodontists do - but then again, I didn’t have to go to school for additional years for archaic literature reviews and spend countless long nights looking things up on PubMed... not to say Endodontists are not needed, but they are truly “difficult cases only” specialty to me. The rest can be done by “enthusiastic” general dentists with a very keen interest in Endo.


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If price wasn’t an issue, and you needed a root canal on your own 1st or 2nd molar, would elect to have an Endodontist (w/ scope and CBCT) do it or an enthusiastic GP?

 

[FutureDent020]

My Endo supplies rep once told me I was doing more Endo than many Endo specialists he knew. That’s what’s cool about general dentistry - you don’t have to specialize (with more debt and time) and you still get to do almost any aspect of dental specialty.


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3 cases a day and you were doing more Endo than Endodontists he knows?

 

[TanMan]

The day you get better at endo is the day you stop using thermafil.

What are the advantages to thermafil? --Your fill looks dense on a radiograph

What are the disadvantages to thermafil/guttacore/every other obturator based system?

-No length control. You cannot control where your fill goes. It could go significantly out the end of the root. It could be short. You simply have no way to adjust your fill once it is done.

-False sense of security. Even though the carrier may make the final radiograph look nice, the tooth may not actually be clean. If you cannot get a traditional gutta percha cone to passively seat to the end of a canal, then you haven't properly prepped and cleaned the canal.

-What you use to fill the canal doesnt really matter. It's about what you take out, not what you put in. What matters is finding all canals, and thoroughly cleaning and debriding them of pulp/bacteria. Lateral condensation works just as well.

-They are very difficult to retreat

-They are expensive. Some carriers cost $6 each! That could buy a lot of gutta percha.

Theres a reason endodontists dont use thermafil or carriers. It's because they are terrible. Salespeople want to sell them because they're expensive. They will say you get a 3 dimensional fill when you use them. Well that doesnt matter at all if you didnt 3 dimensionally clean everything out. And if you did 3 dimensionally clean everything out, then your sealer will get into those little nooks and crannies anyway.

Thermafil/guttacore, etc... they all do nothing for you. So why use them? Use a tapered gutta percha cone that matches the taper of your file. This will help ensure that you have prepped the canals nicely, and cleaned them thoroughly. You have length control with them as well. You can seat them, take an xray, and adjust as needed.

Using a thermafil never made a case successful that would have failed with regular gutta percha. I have seen thermafil make cases fail that would otherwise have worked though.
If all of that melted gutta percha doesnt get removed from the pulp chamber and it is sitting next to a leaking buildup, then you will ha e a tooth that needs to be retreated. Coronal seal really matters!

I don't think you can blame thermafil, but thermafil isn't a shortcut or panacea for all things endo. It can cover up poor instrumentation/cleaning, but if the case is cleaned well, using thermafil properly should result in endodontic success. You're right though, they are a little tricker (especially the thermafil metal carriers) to retreat unless you get the hang of spinning the carrier out of there. If the carrier is heated properly, placed properly, and sized properly, it should be no worse than other obturation methods. I don't do thermafil, I do guttacore in specific cases and I'm a fan of BCsealer + single cone. I don't support lateral condensation at all, puts a lot of stress on the root.

That gets to your main point, cleaning the canals. Since the canal is a 3 dimensional system, this is where irrigation activation is very important to get your solution to all corners of the root canal system. This is what makes or breaks your endodontic treatment (along with proper isolation). This is why I'm a believe in using the Er:Yag laser or PUI to clean your canals. Look at all the junk that floats up when you initiate activation of your solution... that's all the stuff that should've been removed by traditional instrumentation but wasn't. Right now, in my most efficient state, I have molar endos dialed in at around 14-18 minutes. For some reason, I hover around those times since I sometimes make changes to my technique to improve quality or speed, but never compromising quality (but sometimes speed for quality).

I wish I had the volume that ColdFront has, but in 2019, I only did 545 endos, with 376 molars. I would like to try the GentleWave system one of these days, but I wonder if it's an improvement from Endo PIPS. RCTs are fun. RCTBuCrown is even more fun.

3 cases a day and you were doing more Endo than Endodontists he knows?

Reps tell you anything to make you feel better about yourself and to make a sale.

 

[Cold Front]

3 cases a day and you were doing more Endo than Endodontists he knows?

I guess the general dentists in my neck of the wood don’t refer as much. I can’t speak for everyone, but Endo is/has been getting easier to do for general dentists. Schools drill all new grads - “you must refer! you must refer! you must refer!”.


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[Cold Front]

If price wasn’t an issue, and you needed a root canal on your own 1st or 2nd molar, would elect to have an Endodontist (w/ scope and CBCT) do it or an enthusiastic GP?

Classic question. Price is always an issue for the majority of people, or all dentists would be fee for service. A lot of people don’t see a general dentist, let alone an endodontist - due to cost. Almost 100 million people are on Medicaid, another 50 million are too old and don’t have a dental coverage in their Medicare plans.


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[Cold Front]

You practice in a completely different market then I did. There’s a reason most established GPs stop doing endo. At least where I’m from.

It is. I don’t do Endo anymore, I did it as a phase to explore what Endo was like through CE courses and picking the easy cases - and sending the rest to an endodontist. I’m NOT discrediting Endo, but it is like Pediatric dentistry and oral surgery to me. Majority of Endo cases and Pedo cases and wisdom teeth in this country is done by general dentists. I’m just one of them - and like anything else, I was fortunate to be in the right market to cherry pick a flood of those cases.



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[Cold Front]

I wish I had the volume that ColdFront has, but in 2019, I only did 545 endos, with 376 molars.

I think we did about the same. I averaged about 550-600 cases a year, half were molar Endo - at least 5 were 3rd molars.



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[Awarara]

I think we did about the same. I averaged about 550-600 cases a year, half were molar Endo - at least 5 were 3rd molars.



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half your cases were molar, but you only did few mb2 cases? how many maxillary molars do you do?

 

[FutureDent020]

Classic question. Price is always an issue for the majority of people, or all dentists would be fee for service. A lot of people don’t see a general dentist, let alone an endodontist - due to cost. Almost 100 million people are on Medicaid, another 50 million are too old and don’t have a dental coverage in their Medicare plans.


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Meant you personally. Your tooth.

 

[Cold Front]

half your cases were molar, but you only did few mb2 cases? how many maxillary molars do you do?

Half of my cases were molar Endo (maybe 200-250) maybe 1 in 4 of those molar Endos were first molars (so about 50 or so), and out of those about 10 or so were MB2. I think the MB2 incidence is about half of all first molars, so with no microscope - I might have missed 1 or 2 initially, but that’s a probability I could only confirm when the patient came back with a post-operative pain and I would go back in and look for it - or refer it out if I couldn’t. We are talking 5-10 very difficult cases here - out of 550-600 in a different patient’s mouths. Depending on which literature you read - Endo failure rates is about 5-10%.


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[Cold Front]

Meant you personally. Your tooth.

I know. I was making a point about the “affordability” of Endo for the masses. I personally am not (by any means) the average patient, in terms of what I can afford. However, if I needed an Endo work done, I would be so picky over which endodontist that would operate on me. Probably would stay away from residents and new grads for sure. But that’s just me.


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[Torshammer]

Half of my cases were molar Endo (maybe 200-250) maybe 1 in 4 of those molar Endos were first molars (so about 50 or so), and out of those about 10 or so were MB2. I think the MB2 incidence is about half of all first molars, so with no microscope - I might have missed 1 or 2 initially, but that’s a probability I could only confirm when the patient came back with a post-operative pain and I would go back in and look for it - or refer it out if I couldn’t. We are talking 5-10 very difficult cases here - out of 550-600 in a different patient’s mouths. Depending on which literature you read - Endo failure rates is about 5-10%.


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Incidence of MB2s overall in maxillary 1st and 2nd molars was found to be 95% (Kulild)

 

[Sbosu]

Because the community I was serving could not afford the specialist fees, and many had state insurances that general dentists (like myself) in the area accept - so Endo was at no cost to the patient. It was $500 paid by medicaid at a general dentist, versus $1k out of pocket to an endodontist. Like I said, I was busier than most endodontists in my area were doing Endo at a lower fee, but those patients were also keeping my hygienists busy, and even paid some service out of pocket that were not covered by Medicaid. I would also do the Endo + quadrant dentistry + the holistic procedures (diagnostic casts, intraoral pics, tobacco consults, etc) in a single visit. So my time in production $$ for doing Endo with those additional services was higher than an endodontist doing just the Endo case.


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I believe there are 4 reasons a general dentist does root canals and this is one of them. You are certainly providing a service where access to care is a problem and there are no endodontists in the area that take the patients insurance.

The other 3 reasons are:

1. You enjoy doing them
2. You are forced to do them (by owner, corporate, patient pressure)
3. You dont want to lose the production by referring out
(4.) Access to care, no local endodontist

I believe 1. and 4. Are the only reasons a general dentist should do endo

 

[Sbosu]

I don't think you can blame thermafil, but thermafil isn't a shortcut or panacea for all things endo. It can cover up poor instrumentation/cleaning, but if the case is cleaned well, using thermafil properly should result in endodontic success. You're right though, they are a little tricker (especially the thermafil metal carriers) to retreat unless you get the hang of spinning the carrier out of there. If the carrier is heated properly, placed properly, and sized properly, it should be no worse than other obturation methods. I don't do thermafil, I do guttacore in specific cases and I'm a fan of BCsealer + single cone. I don't support lateral condensation at all, puts a lot of stress on the root.

That gets to your main point, cleaning the canals. Since the canal is a 3 dimensional system, this is where irrigation activation is very important to get your solution to all corners of the root canal system. This is what makes or breaks your endodontic treatment (along with proper isolation). This is why I'm a believe in using the Er:Yag laser or PUI to clean your canals. Look at all the junk that floats up when you initiate activation of your solution... that's all the stuff that should've been removed by traditional instrumentation but wasn't. Right now, in my most efficient state, I have molar endos dialed in at around 14-18 minutes. For some reason, I hover around those times since I sometimes make changes to my technique to improve quality or speed, but never compromising quality (but sometimes speed for quality).

I wish I had the volume that ColdFront has, but in 2019, I only did 545 endos, with 376 molars. I would like to try the GentleWave system one of these days, but I wonder if it's an improvement from Endo PIPS. RCTs are fun. RCTBuCrown is even more fun.



Reps tell you anything to make you feel better about yourself and to make a sale.

Thermafil is certainly not to blame. As you said, if the tooth is cleaned and shaped properly thermafil works, it is easy to retreat, etc... But proper use is the key. And it cannot cover up poor instrumentation.

As far as speed goes, the more canals in the tooth, the longer the procedure. This is strictly anecdotal, but the endodontist I work with has been in practice for 12 years. It takes him 30-40 minutes for a molar.

 

[Sbosu]

Incidence of MB2s overall in maxillary 1st and 2nd molars was found to be 95% (Kulild)

This is true. Histologically there is a second canal in the mesiobuccal root of maxillary molars 95% of the time. It seems that about 80% (at the very least) can be negotiated, cleaned, and shaped. So 4 out of every 5 maxillary molars (regardless of 1st vs. 2nd molar) will have a second mesiobuccal canal that can and should be cleaned, shaped, and filled.

 

[Sbosu]

I listened to a podcast recently that discussed a study that looked at risk. They asked surgeons and pilots a series of questions on risk (do you perform as well when tired, etc...). They found pilots were far more risk averse. Now, both pilots and surgeons have important, stressful, high risk jobs. If something goes wrong, people can be affected in a big way. However, the difference between a pilot and a surgeon making a mistake is that if the pilot makes a mistake he goes down with the plane. He dies too. Which is not the case if a surgeon makes a mistake. I found that very enlightening. It gave me a new perspective. I think we should all keep that in mind.

I also love this quote: "the knowledge and intelligence that are required to be good at a task are often the same qualities needed to recognize that one is not good at that task"

We don't know what we don't know. And that goes for all of us.

 

[TanMan]

Thermafil is certainly not to blame. As you said, if the tooth is cleaned and shaped properly thermafil works, it is easy to retreat, etc... But proper use is the key. And it cannot cover up poor instrumentation.

As far as speed goes, the more canals in the tooth, the longer the procedure. This is strictly anecdotal, but the endodontist I work with has been in practice for 12 years. It takes him 30-40 minutes for a molar.

Yeah, I don't see why anyone would use thermafil. It's not any easier, it's not any better, and costs more. Definitely, more canals, more time. I think the time limiting factor for me now is how fast I can push 12-24mL of hypochlorite during irrigation activation. Don't want to push too fast otherwise you might extrude and not have enough time for the hypochlorite concentration gradient to reestablish, don't want to go to slow otherwise your hypo concentration drops to subtherapeutic levels.

I listened to a podcast recently that discussed a study that looked at risk. They asked surgeons and pilots a series of questions on risk (do you perform as well when tired, etc...). They found pilots were far more risk averse. Now, both pilots and surgeons have important, stressful, high risk jobs. If something goes wrong, people can be affected in a big way. However, the difference between a pilot and a surgeon making a mistake is that if the pilot makes a mistake he goes down with the plane. He dies too. Which is not the case if a surgeon makes a mistake. I found that very enlightening. It gave me a new perspective. I think we should all keep that in mind.

I also love this quote: "the knowledge and intelligence that are required to be good at a task are often the same qualities needed to recognize that one is not good at that task"

We don't know what we don't know. And that goes for all of us.

This is why I love being a dentist. No one's life is in my hands, nor do I want to given that society will punish me greatly for killing or severely injuring someone (Although a lawyer has told me it's better to kill someone than hurt someone in terms of corporate liability). In dentistry, you have to mess up real badly to kill someone. As a general dentist, I can choose what I want to do and what to send out to other colleagues/specialists. If you're not a starving general dentist, you can easily stay in your comfort zone and do whatever you want.

 

[Sbosu]

The day you get better at endo is the day you get patent on all canals with a size 10 hand file before using any rotary instrumentation.

It is not quicker to start with a rotary file to see how far down it goes. Ledged canals take a long time to get patent and all canals need to be patent in order to properly clean to the apex.

 

[FutureDent020]

The day you get better at endo is the day you get patent on all canals with a size 10 hand file before using any rotary instrumentation.

It is not quicker to start with a rotary file to see how far down it goes. Ledged canals take a long time to get patent and all canals need to be patent in order to properly clean to the apex.

Funny, this is the exact advice I gave a GP friend when he asked me for advice after my first month in residency. Some may think this is obvious based on what they have learned and some may think this is not necessary. But the more Endo you do, the less issues you will run into if you follow this advice. And keep that 10 file active during your instrumentation process.

 

[Combine33]

The day I got better at endo was the day I got accepted to perio and stopped doing them hahahaha! But jokes aside, endo is truly the most abstract portion of dentistry, at least to me.

 

[TanMan]

The day you get better at endo is the day you get patent on all canals with a size 10 hand file before using any rotary instrumentation.

It is not quicker to start with a rotary file to see how far down it goes. Ledged canals take a long time to get patent and all canals need to be patent in order to properly clean to the apex.

I'll agree with this statement in 99% of cases. Only times I can think of where you might be able to bypass this rule (hypothetical, I haven't tested it yet on newer models, is to have the rotary file w/ a built in apex locator) or in some instances, if I cannot get a 6, 8, or 10, then I need to use the waveone primary/small to get to length. In my early days (before reciprocating files), I used protaper universal w/ a builtin apex locator. I was not a fan due to inaccuracy. Maybe technology has gotten better, I might give it a shot with reciprocation-enabled motors w/ apex locator builtin.

 

[Sbosu]

This is highly empirical, however in my experience I have never been able to get a rotary file to length without getting hand files there first. I will say I have never used a reciprocating file or a hand piece with a built in apex locator.

 

[2TH MVR]

Interesting. There is the specialist technique and the generalist technique. I guess at the end of the day ..... technique should be driven by the efficacy of the procedure. Which procedure delivers more success.

 

[TanMan]

Interesting. There is the specialist technique and the generalist technique. I guess at the end of the day ..... technique should be driven by the efficacy of the procedure. Which procedure delivers more success.

As long as we understand the objectives of root canal therapy, I think there's always more than one way to do things.

 

[Faux]

The day I got better at endo was the day I got accepted to perio and stopped doing them hahahaha! But jokes aside, endo is truly the most abstract portion of dentistry, at least to me.

how do you like perio? where are you studying?

 

[Combine33]

how do you like perio? where are you studying?

Havent started yet, just matched in Nov for this June at Uni of Washington

 

[Sbosu]

As long as we understand the objectives of root canal therapy, I think there's always more than one way to do things.

I agree. A rotary file could get to length without a hand file first. But it also might not. And if it doesnt get patent, then you have blocked and ledged yourself out. Starting with a hand file, you are far less likely to do something that can't be fixed. It is far more predictable. The goal is to get patent, not just close to the end of the root, but to actually be able to get patency. Once a canal is patent with a 10 file, you can do whatever you want to shape it, it doesnt matter, the important part is done.

The difficult part in endo is:

1. Proper diagnosis
2. Proper anesthesia (a successful block (lip anesthesia) in a lower tooth with irreversible pulpitis only has a 25% success rate in getting pulpal anesthesia). So don't be surprised when you ask if the patient feels numb, and they say yes, and you start the procedure and the patient still feels it. Supplemental anesthesia is usually needed. And test the tooth with cold before you start.

3. Finding all canals

4. Getting patent on found canals

I believe these are fundamentals that cannot be disputed. After these steps are done, there are 1,000 ways to successfully complete a root canal.

 

[Sbosu]

Interesting. There is the specialist technique and the generalist technique. I guess at the end of the day ..... technique should be driven by the efficacy of the procedure. Which procedure delivers more success.

Studies have shown endodontists have a higher success rate, as I would imagine, would be a surprise to no one.

 

[TanMan]

I agree. A rotary file could get to length without a hand file first. But it also might not. And if it doesnt get patent, then you have blocked and ledged yourself out. Starting with a hand file, you are far less likely to do something that can't be fixed. It is far more predictable. The goal is to get patent, not just close to the end of the root, but to actually be able to get patency. Once a canal is patent with a 10 file, you can do whatever you want to shape it, it doesnt matter, the important part is done.

The difficult part in endo is:

1. Proper diagnosis
2. Proper anesthesia (a successful block (lip anesthesia) in a lower tooth with irreversible pulpitis only has a 25% success rate in getting pulpal anesthesia). So don't be surprised when you ask if the patient feels numb, and they say yes, and you start the procedure and the patient still feels it. Supplemental anesthesia is usually needed. And test the tooth with cold before you start.

3. Finding all canals

4. Getting patent on found canals

I believe these are fundamentals that cannot be disputed. After these steps are done, there are 1,000 ways to successfully complete a root canal.

I'll agree with you on all 4 points. Proper diagnosis is important, that's a given. I find it to be most annoying when you don't have a definitive diagnosis of whether it's odontogenic or non-odontogenic pain. If I cannot definitvely diagnose it to be a tooth issue, the diagnostics was just a large waste of time. Numbing a hot tooth is definitely difficult. If all else fails, the last and most painful resort is an intrapulpal septocaine injection into each canal orifice. I've only had it fail once, and I ended up using my laser to push/activate septocaine into the root canal system. That did the trick.

Third one too, finding all the canals, knowing when something "feels off" in the canal configuration/radiograph. That comes with experience.

My best bet for avoiding getting ledged/blocked is always flushing debris out with a constant flow of hypochlorite. When there's a file in there (except for finding length with EAL), you always have to be irrigating with hypo to remove any debris generated by your file(s). My assistant always has the suction on a cusp while I irrigate and instrument simultaneously. I don't know how people irrigate and instrument as individual steps, it makes no sense.

Studies have shown endodontists have a higher success rate, as I would imagine, would be a surprise to no one.

They have to be, especially as a referral base where restorative work depends on it. If an endodontist has too many failures, I can see the referral base drying up. Anecdotally, endodontists in my area that have corporate to feed them patients don't seem to care as much about endodontic failures. They'll break files all day long and when the patient has pain, schedule them many months off and cancel them at the last minute. I'm not sure if that's a common MO in corp offices or just my area.

 

[2TH MVR]

Anecdotally, endodontists in my area that have corporate to feed them patients don't seem to care as much about endodontic failures. They'll break files all day long and when the patient has pain, schedule them many months off and cancel them at the last minute. I'm not sure if that's a common MO in corp offices or just my area.

This isn't an issue with the Corps. This is an issue about the integrity of those endodontists which apparently ... they have none. Take care of your patients regardless of the setting.

 

[Sbosu]

I'll agree with you on all 4 points. Proper diagnosis is important, that's a given. I find it to be most annoying when you don't have a definitive diagnosis of whether it's odontogenic or non-odontogenic pain. If I cannot definitvely diagnose it to be a tooth issue, the diagnostics was just a large waste of time. Numbing a hot tooth is definitely difficult. If all else fails, the last and most painful resort is an intrapulpal septocaine injection into each canal orifice. I've only had it fail once, and I ended up using my laser to push/activate septocaine into the root canal system. That did the trick.

Third one too, finding all the canals, knowing when something "feels off" in the canal configuration/radiograph. That comes with experience.

My best bet for avoiding getting ledged/blocked is always flushing debris out with a constant flow of hypochlorite. When there's a file in there (except for finding length with EAL), you always have to be irrigating with hypo to remove any debris generated by your file(s). My assistant always has the suction on a cusp while I irrigate and instrument simultaneously. I don't know how people irrigate and instrument as individual steps, it makes no sense.



They have to be, especially as a referral base where restorative work depends on it. If an endodontist has too many failures, I can see the referral base drying up. Anecdotally, endodontists in my area that have corporate to feed them patients don't seem to care as much about endodontic failures. They'll break files all day long and when the patient has pain, schedule them many months off and cancel them at the last minute. I'm not sure if that's a common MO in corp offices or just my area.

Yes, unfortunately I know a non corporate endodontist that lacks integrity, so it is very much dependent on the individual

 

[TanMan]

I guess you'll always have good and bad specialists/GP's in any setting.

 

[Sbosu]

The day you get better at endo is the day you realize how important coronal seal is.

Alright boys and girls, here's the deal, research shows that a decently done rct combined with an excellent coronal seal has a much better prognosis than a perfect rct and a poor restoration (coronal seal).

Think of a root canaled tooth as having various layers of protection. The goal of endo is to prevent and treat apical periodontitis. Apical periodontitis results from bacteria in (or close to) the pulp (you can in fact have a periapical radiolucency and vital tooth, but that discussion is for another day). So, we are fighting bacteria. We want to do everything possible to prevent bacteria from getting down canals and infecting root canal systems. And what is full of bacteria? Saliva. So, we have to make it as difficult as possible for saliva/bacteria to get into the root canal space.

There are 2 ways to prevent infection. The first is to prevent bacteria from getting in there in the first place. This would be the use of a rubber dam for every root canal. The second way is to slow down and prevent new bacteria from getting into the system.

Now for the bad news. Gutta percha and sealer are actually really bad at sealing root canal spaces. All sealers leak. If you do a perfect root canal and leave that gutta percha/sealer exposed to the oral environment, your root canal will fail.

Gutta percha does virtually nothing to prevent bacteria from getting down the root (other than take up physical space in the canal).

Some sealers are better at slowing down leakage than others, but all will leak (again, research has shown gutta percha and sealer exposed to saliva is covered in bacteria and infected within 30 days). Gutta percha/sealer is the weakest part of your defense, and therefore it needs to be protected at all costs.

The best defense we have is a well placed filling/build up and crown. These are the strongest materials, and they bond to dentin and enamel. Studies have shown flowable composite conforms and adheres best to the pulpal floor and gutta percha. For this reason you will see a lot of endodontist use purple permaflo or some other flowable composite over their root canals.

If you dont have a good coronal seal, AND use a rubber dam when you place that filling or buildup after the endo is done, then no matter how well done the root canal is, it will eventually fail.

And the same mindset needs to be there with cracked teeth. A crack will allow bacteria to get into the root canal space. Your buildup needs to be below the level of the crack in order to properly seal.

And if you use thermafill or guttacore to obturate you must cut them off at the orifice level. If you leave globs of gutta percha and/or the plastic carriers sticking up into the chamber you are only making it easier for bacteria to get into the space. You need the gutta percha as far away from the oral environment as possible.

 

[schmoob]

The day you get better at endo is the day you realize how important coronal seal is.

Alright boys and girls, here's the deal, research shows that a decently done rct combined with an excellent coronal seal has a much better prognosis than a perfect rct and a poor restoration (coronal seal).

Think of a root canaled tooth as having various layers of protection. The goal of endo is to prevent and treat apical periodontitis. Apical periodontitis results from bacteria in (or close to) the pulp (you can in fact have a periapical radiolucency and vital tooth, but that discussion is for another day). So, we are fighting bacteria. We want to do everything possible to prevent bacteria from getting down canals and infecting root canal systems. And what is full of bacteria? Saliva. So, we have to make it as difficult as possible for saliva/bacteria to get into the root canal space.

There are 2 ways to prevent infection. The first is to prevent bacteria from getting in there in the first place. This would be the use of a rubber dam for every root canal. The second way is to slow down and prevent new bacteria from getting into the system.

Now for the bad news. Gutta percha and sealer are actually really bad at sealing root canal spaces. All sealers leak. If you do a perfect root canal and leave that gutta percha/sealer exposed to the oral environment, your root canal will fail.

Gutta percha does virtually nothing to prevent bacteria from getting down the root (other than take up physical space in the canal).

Some sealers are better at slowing down leakage than others, but all will leak (again, research has shown gutta percha and sealer exposed to saliva is covered in bacteria and infected within 30 days). Gutta percha/sealer is the weakest part of your defense, and therefore it needs to be protected at all costs.

The best defense we have is a well placed filling/build up and crown. These are the strongest materials, and they bond to dentin and enamel. Studies have shown flowable composite conforms and adheres best to the pulpal floor and gutta percha. For this reason you will see a lot of endodontist use purple permaflo or some other flowable composite over their root canals.

If you dont have a good coronal seal, AND use a rubber dam when you place that filling or buildup after the endo is done, then no matter how well done the root canal is, it will eventually fail.

And the same mindset needs to be there with cracked teeth. A crack will allow bacteria to get into the root canal space. Your buildup needs to be below the level of the crack in order to properly seal.

And if you use thermafill or guttacore to obturate you must cut them off at the orifice level. If you leave globs of gutta percha and/or the plastic carriers sticking up into the chamber you are only making it easier for bacteria to get into the space. You need the gutta percha as far away from the oral environment as possible.

Can you discuss this when you factor in post placement?

 

[Molar Whisperer]

I am too quick to declare the day you get better at endo because shortly after, I get humbled again. I've done over 9000 cases to my best ability to only learn new ways to make them better.

 

[Sbosu]

Can you discuss this when you factor in post placement?

Assuming the post is cemented/bonded in place then it is no different than a well placed core with regards to microleakge