Doug Kase
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 AITHFUL
READERS, I know you are expecting another bizarre and twisted tale of endodontic
experience that keeps your eyes glued to the page and your stomach on an
emotional roller coaster. This time, however, I am going to wax a
bit philosophical! To do endodontics and enjoy what you do, you must
accomplish it with the least amount of stress. In order to have less
stress, the first thing you must master is to visualize your final product.
Once you can do this, you can create a plan that will lead you to that
goal.
My philosophy is simply “be one with the tooth.”
Now, I am no Obi Won Kanobi; however, being one with the tooth is the most
important starting point of stress-free endodontics. We are, of course,
making the assumption that the tooth in question has been properly diagnosed
and the need for endodontics is apparent. Now it is time to observe
and think! Make sure your radiograph is current, and take a new one
if necessary. Take any additional radiographs to check for additional
roots or canals by varying the angle. Try to use the paralleling
technique so that there is a realistic one-to-one relationship between
the tooth and the film, thus eliminating foreshortening or elongation.
Look at the distance between the occlusal table and the roof of the pulp
chamber to avoid drilling too deep and to avoid an unnecessary perforation.
Check for mesial and distal angulations of the tooth so that your access
will be in line with the coronal and root anatomy. It is also important
to check for radiographic calcifications and visibility of the canals in
addition to root curvature. A calcified curved canal will change
your expectations and thus your final product. Knowing this and accepting
it may alter your treatment plan, thus extending a one-visit endodontic
procedure to two or more. It may also mean that you require the use
of the endodontic microscope to locate the canals, so perhaps this isn’t
one of those 45-minute one-visit molar root canals that we have all been
speaking of. Make sure you check the clinical root anatomy and compare
it with the radiograph. Sometimes it may be beneficial to gain access without
the rubber dam so that your perception of actual anatomy is not distorted.
You will find that your patient will actually be pleased to be informed
that you have changed your expectations before the longer procedure begins,
and you will find that by informing the patient you reduce your stress
astronomically. Sharing your expectations with your patient makes
you a better practitioner in your patient’s eyes and your own!
You now give the local anesthesia. This is
one situation in which it can’t hurt to over-do. Make sure that your
patient is numb. To patients who arrive after a rough night of pain
and discomfort, give marcaine so that they are anesthetized for a longer
post-operative period of time and can go home or to work and enjoy the
feeling. You can even give them an additional injection just as they
leave your office to extend the anesthetic relief that much longer!
Don’t be afraid to use the periodontal ligament injection. If used
conservatively, this can be a great adjunct to anesthetize a hot
tooth, but tell the patient that using this injection may cause a bit more
post-operative discomfort during chewing. The patient’s expectations
are critical to a positive endodontic experience.
It’s time for access. Go back to your radiograph
and look at the external anatomy of the tooth to verify your plan of action.
Once inside the pulp chamber, find the canals and always suspect the bizarre.
Look for that extra mesio-buccal canal in maxillary second molars and check
for a lingual canal in mandibular first bicuspids. Again remember
. . . be one with the tooth.
O. K., you found the canals and it’s time to whip
out your faithful apex locator. Make sure your reading is repeatable.
Watch out for contact with metallic restorations either physically or by
conduction with blood or irrigating solution. Use an instrument that
fits the canal intimately so that there is adequate contact in the apical
regions. A good fit will give you a very accurate reading.
Make sure you check your measurement control before you obturate, for the
working length will change in curved canals as they are instrumented and
straightened coronally.
Now you are in the meat-and-potatoes of endodontics,
and the E-Z Fill Technique will show you the way. If you follow the
technique, you will achieve the end result you visualized. Do not
try to shortcut the technique, for the slower you work, the quicker you
will achieve your expected result. That sounds like a paradox, but
it’s so. If the canals are calcified, start out with a .06 or .08
instrument. To avoid blocking the apex, be careful to use the instrumentation
with the correct motion when filing the canal. If you have to reiterate
the canal with the same instrument, it’s O.K. to make sure the apex is
clear. Do not worry about taking an extra five or ten minutes to
achieve the result you want! Close your access with a temporary restoration
that will not leak and will not wash out. Nothing can be more frustrating
for patient and dentist than to have to retreat a perfectly done root canal
because the temporary restoration washed out and leaked. I use ZOP
or glass ionomer cement to close my access cavities.
Your post-operative instructions and a patient’s
post-operative expectations can be as important as the procedure itself.
Use medications as needed and when needed! Do not be afraid to tell
your patients that they will have discomfort. A patient “in the know”
is a happy patient. Information is the key to a post-operative night
that is smooth and telephone-call free.
July-August 2001
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The
patient’s
expectations
are
critical
to a
positive
endodontic
experience.
|
