Tales from the Chamber
Have I Got a Tip for You

Doug Kase
 
 

If in doubt . . . refer it out.
I’m honestly not trying to be funny, well maybe just a little bit.  It is important for all of us to recognize our limitations.  In this litigious world in which we find ourselves practicing dentistry, there is always an attorney looking for any reason to blame a bad result on someone on behalf of his or her client.  I have had the honor over the years of defending my fellow dentists as an expert witness to explain that good results are probable, not necessarily guaranteed, and that a bad result is not malpractice.  So, if you feel that a case is beyond your expertise, refer it to your specialist.  Don’t think of it as a lost fee, but as a lost headache, reduced risk, and a returning happy patient.

Get some kind of informed consent. 
Written informed consent is preferable; however, documentation in the chart of oral informed consent would be the next best thing.  The reality of the consent situation is that the dental profession is held to the same standards as the medical profession in a court of law.  We all certainly know the stack of papers regarding consent that physicians make us sign for a medical procedure.  A patient “in the know” is a prepared and ultimately happy patient and your tush is protected.

Use the product Endo Ice to test for vitality through a crown.
Endo Ice is colder than ethyl chloride and with it you can isolate a single tooth more easily than you can with ice or ice water.  Soak a cotton pellet with EndoIce and place it on the buccal or lingual surface close to the crown margin for best results.  P. S. it’s great on teeth without crowns as well.  I also use it to chill down individual teeth in areas where there is a generalized pain to heat response for diagnosis.  When you can’t get an individual tooth to respond to a heat stimulus, such as warm gutta percha, I have a patient rinse with hottish water and when symptoms build I then cool the “suspect” tooth with the EndoIce.  If the pain is relieved, then the diagnosis is correct. 

Anesthesia.
Boy, oh, boy do patients hate injections.  I have seen grown men cry and patients cower in fear not only at the sight, but also the thought of a needle.  I dry the tissue before the topical is applied and leave it there for a minute.  It works a little better, shows that you care, and gives the patient some psychological security.  For mandibular block anesthesia, I use a short 30-gauge first to give a primary numbing to the area.  Patients seem not to feel the shorter, thinner needle as much.  I wait five minutes and then give a second carpule using a 27-gauge long with aspiration for the full block.  I have been using a VibraJect attachment, which when snapped onto the syringe causes a vibration that seems to reduce patient discomfort during injection.  I use Septocaine for maxillary infiltrations.  It gives more profound anesthesia and lasts longer, which gets patients through the immediate postoperative inflammatory pain cycle.

Believe it or not patients love the rubber dam! Use it!
Explain to the patient that it is for their protection from all aspects.  You cannot render a tooth aseptic if it has saliva running into it.  You cannot keep an instrument sterile if your fingers are saliva-coated.  Clamp the tooth posterior to the tooth you are working on and drag the dam over the anterior tooth to give more visualization or if there is not enough tooth structure to clamp.  Sometimes the use of a bicuspid (#1) clamp on a brokendown molar will give you the retention you require.  A # 14 clamp will get under the gingival better than a # 4 clamp.

Access is the first key to success.
You want a minimum of straight-line access to the canal orifice, so don’t be conservative in your access opening.  Smaller holes don’t mean better endodontics.  Sometimes you have to go beyond straight-line access due to tooth angulation or extremely curved canals.  If you are not using the PulpOut Bur® system, then use a #4 round to gain access to the chamber and remove gross overhang.  Then use a barrel diamond to flatten out and shape the chamber walls.  Watch for rotated or tilted teeth by probing root anatomy.  Use an indelible marker to draw the correct angulations on the crown to guide you as you attain access.
    Finding calcified canals can be a real pain in the area just above your thigh, but below your lower back. Don’t ask me to be more specific. Sometimes finding and instrumenting one canal will give you the orientation to finding the others. Place a small bend (45 degrees) in the very tip of a new explorer to look for separate canals with a common orifice. Magnification is a fantastic adjunct to doing great endodontics. If you are not working with loupes, it is time to invest. 
    O. K. you’ve found the canals and now it’s time to get a measurement control. Invest in an apex locator. Finding the anatomic apex as opposed to the radiographic apex will yield a whole bunch of good will.  Instrumenting to the radiographic apex is usually over-instrumenting and will result in an overfill and a boatload of post-operative pain.  It is important to make sure that you have good contact in the entire apex locator circuit, so make sure that the canal is slightly wet and also that the lip ground and the tissue it is contacting are wet. 
    Having a consistent point to measure to is also important. Flatten a cusp if you have to, and if you can’t then use an indelible marker to mark a point on a cuspal incline to establish a consistent orientation. Measurement control changes as the canal is instrumented and the coronal anatomy is straightened. If it’s 20 mm to start, you can bet your booty it’s going to be 19.5 mm or 19 mm by the time you finish instrumentation. The fact that change is inevitable is a great reason to check your measurement control after the first pass with the Peeso reamer and check it again as you proceed with complete instrumentation. If you have a suspicion that two canals join, you can plug an additional instrument probe into the lip ground lead. Place both instruments into the canals under suspicion and attach both probes. If the meter swings wildly, then the instruments are in contact and you have got joining canals. 
    Time to clean and shape.  By now you know the SafeSiders sequence, and I don’t want to dwell and be redundant. For years, I have used the # 1, 2, and 3 Gates Glidden reamers before the #2 Peeso. This procedure works in my hands because it is what I have done since I was a resident. The sequential use allows me to get into the canal a little deeper, making room for the Peeso without the risk of strip perforating. Remember to use a passive pressure apically with these rotary instruments and widen and straighten the canal away from the furcation. Using a #1 Gates Glidden can be a bit risky, so in the words of Han Solo, in Star Wars Episode IV: A New Hope, “Don’t get cocky!”  After this sequence, the remaining instrumentation, particularly with the addition of the reciprocal handpiece, proceeds like a hot knife through butter. Sometimes after this you may find some debris has been impacted and now blocks the canal. Hedstrom files (#15) used with a light touch in a rotary motion are great debris breakers.
    So, my loyal readers, I can only hope that the insider tips and hints I have revealed to you thus far will make your endodontic experience that much easier. Keep an eye out for the next installment of Endo-Mail for the continuing saga of my insider tips.