Tips on Molar Endo

[Thetoothhurts91]

I'm doing my first endo and luck would have it, it's on a molar tooth. There's a large decay on the distal aspect of the tooth.

Do I remove the decay first and then do the access opening or do I make my access opening and then remove the decay because the tooth anatomy is easier to follow?

Any tips appreciated cause my stress level is at a 11/10 on this procedure.

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[cooliyak]

I'm doing my first endo and luck would have it, it's on a molar tooth. There's a large decay on the distal aspect of the tooth.

Do I remove the decay first and then do the access opening or do I make my access opening and then remove the decay because the tooth anatomy is easier to follow?

Any tips appreciated cause my stress level is at a 11/10 on this procedure.

The “proper” order is caries excavation and then the access, but more often than not, they happen at the exact same time since the caries will lead you into the pulp. Don’t overthink it. If anything, this should be way less stressful than a normal restoration because you don’t have to worry about pulping— you are going to do that on purpose after anyway if you don’t reach it initially. Remove the caries on the distal and if that doesn’t take you into the pulp, use the remaining occlusal anatomy to help make your access. Good luck!

 

[Vicviper]

My biggest piece of advice I give to every new dental student and resident in my program is this - DO NOT put the dam on until you're ready to put files into the tooth. There is no reason to have the dam on prior to that, the pulp is already infected, a bit of saliva won't cause much harm at this point. It will help you immensely with your access to be able to better visualize the tooth.

Next, I totally agree about doing caries excavation first, as yak said, it will often lead you to a pulp horn, and then you can expand the access from there. One other thing I see on people who are doing their first few root canals is that they think they're in the canal, and have unroofed the chamber, but actually have just opened up a pulp horn. On molars, you can usually read a "map" on the floor of the chamber, with lines leading to each orifice. An orifice won't just look like a sudden rough hole, that usually means it's just a pulp horn.

Lastly, the MOST IMPORTANT piece of advice - when in doubt, take a bitewing. If you're concerned you're not going in the right direction for the access, or you feel like you should be there already, just stop and take an X-ray. Taking a bitewing is quick, perf repair isn't! 😉

Good luck!

 

[cooliyak]

My biggest piece of advice I give to every new dental student and resident in my program is this - DO NOT put the dam on until you're ready to put files into the tooth. There is no reason to have the dam on prior to that, the pulp is already infected, a bit of saliva won't cause much harm at this point. It will help you immensely with your access to be able to better visualize the tooth.

Next, I totally agree about doing caries excavation first, as yak said, it will often lead you to a pulp horn, and then you can expand the access from there. One other thing I see on people who are doing their first few root canals is that they think they're in the canal, and have unroofed the chamber, but actually have just opened up a pulp horn. On molars, you can usually read a "map" on the floor of the chamber, with lines leading to each orifice. An orifice won't just look like a sudden rough hole, that usually means it's just a pulp horn.

Lastly, the MOST IMPORTANT piece of advice - when in doubt, take a bitewing. If you're concerned you're not going in the right direction for the access, or you feel like you should be there already, just stop and take an X-ray. Taking a bitewing is quick, perf repair isn't! 😉

Good luck!

Completely agree with everything, especially not putting the rubber dam on until after you have at least found the chamber. Once I started doing that, my accesses became a lot more straightforward. Keeping the rubber dam off allows you to better orient yourself by using the surrounding teeth to find the correct angle, etc. I almost perf-ed a few teeth during the access because I got lost and it was only by stopping to take a quick radiograph that I kept myself from that nightmare. Great advice.

 

[TanMan]

That's probably the best advice, don't use a rubber dam until you access the chamber. You may lose orientation and perf instead. If you perf, there's always MTA.
I go with this sequence: flatten occlusal (one flat reference point), also visualizes any fractures hiding under the cusps, remove caries, access chamber with 557, read the pulpal floor to see if there's any extra orifices (Mid-mesials, MB2, 2 distals on a mandibular molar, 2 buccals on maxpremolar, etc..) rebuild any walls with bond/composite (to contain the naocl and improve isolation). Then you can go rubber dam and use your apex locator to get to WL. Then do whatever the school requires you to do in terms of sequence.