Doug Kase
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 ERE IS our practice’s philosophy: we as endodontists help you (our family of referrers) to be the best you can be! No, this is not an advertisement for the armed forces, but merely a statement of fact that through continuing education we want those who want to tackle an endodontic problem in their own dental chair to reach the level to which the bar for standard of care has been raised in years of progress in our field.
For a quick second, let me state the obvious: we want your business! Shocking I know, but clearly our reality. We have taken great pride in the educational side of our office, helping those who want to do root canal better and safer with less stress and less overhead cost. But let’s also remember that we are here to help you and your patients. There are some endodontic cases that should be referred. A good practitioner must realize the complications of the case long before something happens that may undermine the relationship with the patient. We all love a challenge, but for the benefit of your patient and medico-legally as well, it is sometimes more prudent to share the risk with a specialist to avoid the stuff hitting the fan. When I do malpractice review to defend my fellow dentists, every “Bill of Particulars” contains in its list failure to refer to a specialist. So let’s face it; it’s what we are trained to do. At our last in-house course, an eager-to-learn colleague asked me at the end of the program, after the hands-on demonstration of the SafeSiders® technique, how she could find calcified canals within a calcified chamber. Besides that topic’s evolving into a full-day course, I pointed to the endodontic microscope and basically said that you need one of these! So there goes the $64,000 question! When the case gets complicated, instrumentation that is absolutely necessary might not be available to the general dentist. As endodontists, our technologically advanced armamentarium includes endodontic surgical microscopes, 3-D scanning for advanced diagnosis, ultrasonic files for refined excavation, and much more. Thus the referral reinforces your expertise and maintains your position of treatment planning, direction, and control over the case. Hence making sure the patient is referred back to your office for continued treatment is also one of our primary goals—whether after case completion or covering your on call for an emergency visit on a weekend.
Thus I want to present my Top Ten Reasons why you may want to refer to your Friendly Neighborhood Root Canal Man!
Number 10: You just don’t like root canal! Number 9: Two-rooted lower canines. They do exist. Number 8: Mid-root canal splits. Number 7: MB2 canals in an upper 2nd molar. They also exist! Number 6: Calcified canals filled with concrete. Number 5: Severe dilacerations or curves. Number 4: Loved Avatar, so the tooth needs a 3-D scan. Number 3: Did I say that you hate doing root canal? Number 2: Endodontist is your brother-in-law. And the Number 1 reason: Patient brags about new Mercedes she bought with last malpractice settlement.
Okay, so here are some cases that may fall into one of the above categories. I want to admit that even for an endodontist these are a little nightmarish! The first case is a 27 mm lower molar with severe curves and dilacerations with close proximity to the mandibular nerve (Figure 1). Need I say more? This case was instrumented using 31 mm files starting with a #.06 (pink) file placed by hand to apex. A small 45-degree bend was placed at the tip to negotiate the apical curve or dilaceration. Once measurement was attained with an apex locator each subsequent file was hand-positioned the same way and attached to the reciprocating handpiece while in the mouth. After instrumentation to a #20 I opened the orifice with my Pleezer then stepped back a millimeter at a time to a #35 while making sure that I was clear to the apex each time with my #20. I then opened the apex to a #30. Due to the extreme curvature and length, I decided to use only a 30/.04 NiTi SafeSiders to the apex as my last instrument by shaving off approximately 2 mm of the handle and placing it in the handpiece to the extent of the modified handle, thus 27 mm. EZ-Fill® was placed up to the curve and then carried further to the apical architecture with a reamer, and the canal was obturated with gutta percha (Figure 2). The second case was a little more of the same, an upper second molar from the same nightmare. This too was instrumented and obturated in much the same manner (Figures 3 and 4).
So not all cases are easy dream cases. Do what is within your comfort zone; refer those that are not. Your patients will be happy, you will be their hero, and you can sleep well at night. See you next issue.
July - September 2010
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