Barry L. Musikant, D.M.D., F.A.C.D.
SafeSiders®
and the Mindsets They Encounter |
Barry Musikant
 |
 ENTALTOWN.COM
has been a vital vehicle for SafeSiders growth. A wonderfully interactive
dental site with close to 35,000 members who participate in a slew of varied
message boards, the site is intuitive and easy to master. I recommend
that everyone join. You will be a better dentist for it. That,
however, while absolutely true, is not the thrust of this article.
As the main advocate of this relatively new system, the SafeSiders,
I have encountered a variety of reactions from the dental community.
Most reactions have been positive, coming as they do from dentists who
want to learn the technique to solve problems that they are having with
some form of rotary NiTi or with their traditional techniques. SafeSiders
have received so many positive testimonials that we could practically fill
a small book with them.
While I am grateful for those positive reactions,
they are not the reactions that amaze me. Instead, I am amazed by
the reactions of a handful of dentists, practically all of them rotary
NiTi users, who somehow feel that an aggressive discussion of the SafeSider
alternative is a violation of the status of rotary NiTi as the endodontic
paradigm. These dentists assert the superiority of rotary NiTi by
listing the assumed shortcomings of the SafeSiders, which—according to
them—include the following:
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The SafeSider system is a manual system and must, therefore, create far
more hand fatigue than rotary NiTi and take much longer time to shape the
canals.
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Canals cannot be shaped to a greater taper with SafeSiders.
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Gutta-percha points will not fit as well in canals shaped with rotary.
The assertions made by these dentists are inaccurate whether they come
from endodontists (the strongest advocates of rotary NiTi) or general practitioners,
who often quote the opinions of the endodontists they associate with.
In truth, in the SafeSiders technique, 85 percent
of the canal space is shaped with the number 2 Peeso reamer and the number
2 Gates Glidden in a crown-down fashion similar to, but a lot safer than,
the crown-down technique used with rotary NiTi. The procedure is
safer because it ensures that if the Peeso or the Gates breaks, the break
will be in the coronal section of the shank and therefore the broken piece
can be removed easily in seconds. Another reason for the safety of
the technique is the fact that as the Peeso straightens the coronal curve
it removes tooth structure from the outer wall of the canal, the wall away
from the furcation. Compare this pattern of removal with that of
the orifice openers of rotary NiTi instruments, which remove equal amounts
of tooth structure from the inner and outer walls, and you quickly realize
that the rotary NiTi instruments are more likely to cause strip perforations
on the furcal side of the root. The widest diameter of a number 2
Peeso is 0.9 mm versus diameters as high as 1.6 mm for the rotary NiTi
orifice openers.
The SafeSiders create a .08 mm/mm taper with 95
percent of the shaping first done with tough, fracture-resistant stainless
steel before the far more vulnerable NiTi is used. The remaining
5 percent is shaped manually, using NiTi SafeSider reamers with a reciprocating
motion that prevents fracture. A simple manually applied bend test
is used to confirm that the reamer can be used in the canal without fracturing
before it is placed into the canal. The SafeSiders produce an .08 mm/mm
taper, while the best that rotary systems create for the most part is an
.04 to .06 mm/mm taper. NiTi instruments are limited to smaller tapers
not because reduced tapers are superior, but because the dentist cannot
create an .08 mm/mm taper using rotary NiTi without increasing the risk
of separating an instrument around a curved canal. It is becoming increasingly
obvious that the limitations of rotary NiTi have a direct impact on the
results that can be obtained.
Like rotary NiTi, the SafeSiders work quite efficiently
in straight or mildly curved canals, producing a fully shaped canal in
minutes. As the canals become more curved, nickel titanium’s weakness
under torsional stresses and its low resistance to cyclic fatigue impose
a whole set of safety rules on rotary NiTi instruments. Because the
SafeSiders are predominantly stainless steel based, they are not nearly
as subject to these stresses and have far less likelihood of fracturing
in similar situations.
The physical characteristics of these two metals
means that in straightforward cases both systems will produce excellent
results in minutes, but as the curves become greater and sharper the NiTi
must be used with far more caution, and consequently take far more time,
than the SafeSiders in similar situations. Given the .08 mm/mm taper
produced by the SafeSiders, a medium gutta-percha point (preferably from
Dentsply Maillefer) fits perfectly, and when combined with the EZ-Fill
epoxy resin creates an excellent seal. If the canal is very elliptical,
there is no problem placing a second or even a third well coated accessory
point.
Supporters of rotary NiTi often contend that the cause for concern
about fractures really does not exist. They use data from their own
offices to demonstrate a minuscule fracture rate of less than 1 instrument
in 1000 used. While this is impressive, it does not come close to agreeing
with the far more pessimistic feedback we constantly receive from dentists
who are signing up to take the SafeSiders courses. The marketplace
also belies these dentists’ appraisals of the safety of rotary NiTi.
For example, the following products and procedures have been introduced
in recent years to avoid or overcome fractured instruments:
-
a spate of new systems, each promising a design that is more resistant
to fracture
-
auto-reversing handpieces that reverse at the first signs of excessive
torque
-
electric handpieces that allow precise control of the rotation speed
-
the concept of single usage
-
increasing limitations on the types of cases that can be done with rotary
NiTi as well as constant reinforcement of the meticulous technique that
must be employed to prevent these fractures, as reported in a number of
published articles
-
methods of removing fractured instruments once fracture has occurred
-
and finally, the contention in a number of articles that fractures generally
are not that bad, that they rarely result in apical problems, and that
when they do a “simple” apico wll suffice
This last point, in my mind, is a prime example of denial and a major impetus
to turn the clock back by rationalizing events that should be occurring
less frequently, not more frequently.
The endodontic publications also belie the upbeat
evaluations from rotary NiTi supporters. Not a month goes by without
an article in one or more publications concerning the causes of rotary
NiTi instrument separation and what is required to prevent it, so far to
no avail. Publications would not give this much attention to a problem
if it were virtually non-existent, as some endodontists claim.
What it all boils down to is an example of the prejudice
of those who have become quite good at rotary NiTi and don’t find the need
or the desire to learn a new alternative, especially one that by comparison
is so simple that it may detract from the effort and expense they have
already made to master the complexities of rotary NiTi. I say prejudice
because I have met very few advocates of rotary NiTi who have really learned
the SafeSiders technique. Most say that it is a manual system and
dismiss it as old technology without ever having tried it.
My persistence in making all of the above points
has also taken on a personal tone. Some, when they don’t like the
message, attack the messenger, but such an attack does not make the message
any less valid. Simply put, rotary NiTi has had all the time in the
world to refine itself and show solid progress in preventing instrument
separation. However, over the last 15 years or so, as more dentists
have employed these systems, the fracture rate has continued. The
most basic question should be whether you want to continue with these systems
or consider systems that are predominantly based on stainless steel and
virtually eliminate instrument separation while reducing the overall costs
by at least 90 percent.
Summer 2004
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SafeSiders
have received so many positive testimonials that we could practically fill
a small book with them.
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The Best Ways to Perform EZ-Fill®
SafeSider® Endodontics
by
Barry Lee Musikant, D.M.D., F.A.C.D.
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