readers of our newsletters will notice an increased emphasis on simplified
endodontics. I have taken many courses on new techniques available for
instrumentation and obturation, and have concluded that needless complexity
and expense has evolved from the insight that there is not a single canal,
but rather a system that may include various accessory invaginations.
To clean and obturate this system, leading endondontists
determined that all canals had to be thoroughly debrided and obturated.
Opening the canals to a wider taper allows them to be cleaned and irrigated
more efficiently. Shaping to a greater taper allowed the canals to be obturated
with thermoplasticized gutta-percha without pushing the gutta-percha over
the apex. These innovations, wider taper and thermoplastic obturation,
are improvements over the traditional .02 tapered canal shaping and obturation
with standardized points.
Improvements Brought Complication
While these innovations are improvements, many of
the instruments and techniques used to achieve them are complicated and
expensive. The introduction of Ni-Ti files of different designs to achieve
a wider taper requires the implementation of a crown-down technique because
of their metallurgic characteristics. Although Ni-Ti has super elasticity
to negotiate curved canals without distorting them, it has little tolerance
for deformation without fracturing.
To minimize instrument distortion, the crown-down
technique requires the use of thicker files first with thinner ones used
sequentially in a crown-down direction. This technique is delicate, requiring
keen tactile sense and patience. In the process of switching from stainless
steel to Ni-Ti, the cost of the average instrument increased from $1 to
over $6! This, without any promise that the Ni-Ti instruments would last
even as long as stainless steel ones. The increased use of Ni-Ti that must
be replaced frequently to achieve the continuously tapered canal shape
is common to most of the techniques employing crown-down preparations.
Replacing lateral condensation with various thermoplastic
techniques also produced a major increase in the cost of obturation. $6
thermoplastic points replaced $.07 gutta-percha points. Heating systems
costing thousands of dollars replaced Bunsen burners and lateral condensation.
One method of thermoplastic obturation requires placing a red-hot spreader
within 5 mm of the apex, releasing the heat ring, and further advancing
it another 3 mm over a matter of seconds,
reheating the spreader, and releasing it from the gutta-percha followed
by further obturation with a gutta-percha glue gun.
Are the improved results justification for the increase
complexity and expense? I do not believe so.
Simple and Economical Alternatives
Read the accompanying article on this site entitled “How
to Instrument and Obturate Canals Superbly and Economically” for alternative
methods that are simple and economical.
We have employed them in our office for ten months
with immense success, characterized by reduced flare-ups, excellent radiographic
results and ease of operation. The techniques described in this article
are in full conformity with the latest research in endodontics. The sealing
ability was at least the equal of thermoplastic and lateral condensation
techniques. These techniques have reduced cost and time.
The increase in complexity and expense to achieve
superior results has proved not to be inevitable after all; it has been
short-circuited by a little creativity and common sense.
Have you ever opened the chamber of a
pulp and experienced a fetid odor? I have. Using a mouthwash
in a syringe to irrigate the pulp canal works to eliminate that odor.
Many times I'll leave the rinse inside the chamber for a few minutes.
Afterwards, I'll rinse with sodium hypochloride. Then the odor will
dissipate. Patients who smelled the initial odor feel terrific, for
there is no longer an odor. Furthermore, they feel that you, as a
practitioner, have "really" done something for them. I hope you have
as much success with this technique and patients' acceptance of it as I
Amy Dukoff, D.M.D.