Dr. Garry Bey

“Dr. Garry Bey describes the challenges of doing a live patient demonstration. His enthusiasm for endodontics and passion for his chosen instrumentation and obturation system are contagious."
	-

	When I was asked if I would perform a root canal in front of a live audience at the 2009 Greater New York Dental Meeting (GNYDM), my first inclination was, “Wow, how exciting!”

	The chance to disseminate my knowledge and expertise after 30 years of practicing dentistry (27 as an endodontist), while treating a patient live in front of 300 dentists seemed like an ideal way to share my tips, techniques and philosophies.

	What better way to teach than in a room full of big screen TVs showing close ups of my instruments, and microphones picking up every sound? What a great way to learn-close up through a surgical operating microscope-how I navigate, clean, shape and fill a complex root canal system. Fantastic!

	Then reality set in. Where would I get the right patient? How would I set up a makeshift operatory to approximate the friendly, professional and ergonomic confines of my own office? What happens if an unexpected complication arises?

	Was I thinking this through? Did I imagine it was going to be easy to do a molar root canal on a stage in unfamiliar surroundings? Every dentist knows even the simplest-looking cases can be fraught with unforeseen complications. Just like in golf, when it comes to root canal therapy, “There is no such thing as a gimme.”

	To secure the proper patient, I turned to my referral base. About one month before the GNYDM, long-standing friend and excellent dentist Dr. Ronald Herrmann sent me an x-ray and clinical history of a patient, who we’ll call “Jane,” in need of root canal treatment. Tooth No. 19 had a pulpotomy and could wait for treatment, but a tooth with an apparently complex root canal anatomy-this was certainly not a gimme!

	Setting up the makeshift operatory was the next big task. I needed to have everything available to do the procedure properly while also showing the audience as many tips, tricks and “pearls” as I could in the short one hour I’d have.

	If I attend a lecture and take home just one piece of knowledge I can use in my practice, I consider the time well spent. My goal was to share multiple “pearls” with my audience. Having an A-Dec chair, a Zeiss surgical operating microscope and Schick digital radiography at my disposal was a great help and I thank those companies for their support.

	Three days before the event, my wonderful dental assistant for the past 12 years, Linda Cordaro, and I headed to the convention center with two boxes of instruments, many of which I knew I would need and others I thought I might. Prior to this I had never sat down to figure out how many instruments I use during a routine endodontic procedure. After going through this exercise, I know most of you would be surprised at how many there actually are.

	The two most important pieces of the armamentaria were Discus Dental’s LightSpeedLSX for instrumentation and EndoVac for irrigation. I use these two systems for every patient, every canal. I believe-without a doubt-that they allow me to provide my patients the best endodontic treatment on the planet.

	On the big day, everyone is at the Javits Center and everything was running like clockwork as our time to go on arrives.

	I anesthetized Jane with a mandibular block using two carpules of 3% mepivacaine and added an intraligamental injection using a third of a carpule of articaine with 1:100,000 epinephrine. This is my secret for achieving profound local anesthesia on even the most sensitive teeth. While that was taking effect, my pre-treatment lecture described my philosophy of root canal instrumentation calling for instrumenting to wider apical sizes.

	Wider canal preparations produce cleaner canals; cleaner canals give the case a better chance of success-it’s just that simple. My talk espoused the virtues of LightSpeed files as the only non-tapered nickel-titanium rotary files, and I explained how their design allows me to instrument canals so each is prepared to its proper width based on its own anatomy, thus they are never over- or under-prepared.

	I continued by showing how proper access is the cornerstone of successful endodontics. Additionally, I transilluminate with a handheld fiber optic light from Welch Allyn. This is a great way to visualize even the most calcified canals.

	Canal exploration followed a standard sequence, and once measurement was attained and patency established, I instrumented with a #20 K file to working length. It was now time to begin the rotary portion of instrumentation.

	As I went through the usual LightSpeed sequence, the #30 separated in the distal canal. Because LightSpeed files are designed to separate at the hub when they bind or encounter too much force rather than break at the tip, this was a non-issue. Instrument separations are rare and they also are easy to deal with. In this case, a 20 mm piece of shaft was visible in the orifice opening and easily removed with Discus’ MicroRetrieval Forceps. Six seconds later, I continued instrumentation.

	I finished the mesial canals to a #45 and the distal canal to a #50. Those sizes might sound large, but because LightSpeed files are designed to only cut at the tip and not bind in the coronal third or mid-root, I know when the canal has been properly prepared. The spade blade gives excellent tactile feedback and lets me know when I’m engaging and debriding all canal walls.

	With instrumentation complete, we were ready for final irrigation. For this I use the EndoVac, a ground-breaking, true apical negative-pressure irrigation system. I start with full strength sodium hypochlorite and a MacroCannula to remove gross debris from the coronal half of the system and continue with full-strength sodium hypochlorite and a MicroCannula that allows me to safely flow irrigant to the canal’s full working length. The tip design allows it to suction irrigant from the chamber all the way down to the very end of the root.

	I repeat this step using 17% EDTA to remove the smear layer, then repeat the process once more with sodium hypochlorite to achieve deep cleaning into the exposed dentinal tubules. Because EndoVac uses negative pressure at working length, I’m not concerned about extruding sodium hypochlorite out of the foramen.1 Studies have convinced me I can achieve significantly better debridement and bacterial kill with EndoVac than with traditional needle irrigation.

	For obturation I used Discus’ HotTip for warm vertical compaction of a master gutta percha cone and then backfilled with Discus’ HotShot cordless backfill obturation device. A cotton pellet was placed in the chamber and the access opening was filled with 3M ESPE’s Cavit™ W temporary filling material.

	I completed the treatment in roughly 50 minutes, and while quality is my biggest priority, I’m sure Jane appreciated the speed.

	The day ended with a large round of applause. Jane, my fantastic patient, was very appreciative. Words cannot describe the gratification I felt. To have a procedure go so well, in front of so many peers, is priceless.

	So, if someone ever asks you to do a live root canal, think long and hard. When you are completely comfortable with your technique and instrumentation the answer just might be yes.

Dr. Garry Bey has been in private practice limited to endodontics for 27 years, and currently practices in Pearl River, N.Y., and Woodcliff Lake, N.J. He completed his endodontics residency at NYU. Dr. Bey lectures across North America, Europe and the Middle East, training doctors from more than 30 countries in advanced endodontic techniques.

	1. Desai P, Himel V. Comparative safety of various intracanal irrigation systems. Journal of Endod 35(4):545-549, 2009.

	2. Hockett JL, Dommisch JK, Johnson JD, Cohenca N. Antimicrobial efficacy of two irrigation techniques in tapered and nontapered canal preparations: an in vitro study. Journal of Endod 34(11):1374-1377, 2008.

	3. Nielsen BA, Baumgartner CJ. Comparison of the EndoVac system to needle irrigation of root canals. J Endod, 33(5):611-615, 2007.

Articles

 THE SET-UP  “Dr. Garry Bey describes the challenges of doing a live patient demonstration. His enthusiasm for endodontics and passion for his chosen instrumentation and obturation system are contagious." -Dr. Richard E. Mounce, team lead  When I was asked if I would perform a root canal in front of a live audience at the 2009 Greater New York Dental Meeting (GNYDM), my first inclination was, “Wow, how exciting!”

Putting on a show

The primary goal of root canal therapy is to create an environment in which the root or roots of a tooth are maintained in a healthy periodontium. This, in turn, allows the tooth to be restored to normal function.

To achieve this objective it’s important to minimize or eliminate microorganisms and pathologic debris in root canal systems. This becomes more challenging when we are presented with teeth having calcified canals.

Much has been written about achieving a proper glide path from the canal orifice to the root terminus. With the advent of nickel titanium rotary files, proper glide path becomes essential. However, all of this becomes a moot point if we cannot locate a calcified canal within a root canal system, as we cannot clean a canal that we cannot find.

Typically, root canals calcify from the coronal portion down apically. Root canal calcification can occur as a natural process of aging. In addition root canals will calcify as a result of decay, restorative treatment, gingival recession and trauma.

Finding and treating teeth with calcified canals is an orderly progression of important steps, each one’s success dependant on how well the previous one has been carried out.


	“Root canal success or failure can depend on the location and negotiation of calcified canals. This article describes a proven technique on how to help locate these elusive canals. Use of these methods will allow the clinician to locate canals that might have previously been left untreated.”- Dr. Garry Bey, Team Lead


	Careful attention to our pre-treatment radiograph is important to not only give us an idea of how calcified a particular root canal system may be, but also to give us initial information on how many canals there are in a tooth. The severity of any root curvatures also can become apparent.
	It’s important at this time to decide on whether this is a tooth we want to attempt to treat, or might this be one we should consider referring to an endodontist.


	After proper diagnosis, examination of the pre-treatment radiograph and administration of adequate local anesthesia, isolation of the tooth to be treated is accomplished.

I routinely place the rubber dam clamp on a tooth posterior to the tooth I will be treating. I then extend the rubber dam one or two teeth anterior to the tooth to be treated, making sure the rubber dam fits tightly enough around the isolated teeth so as not to allow an instrument to be aspirated or swallowed.

Unfortunately, single tooth isolation doesn’t give the clinician a good 3-dimensional feel for root anatomy and angulation. The problem is further compounded when there’s a full crown present and the original anatomic landmarks are gone. The clamp also can impede handpiece orientation, which further steers the clinician astray.1


	When I was a dental student at NYU College of Dentistry, I was taught that proper access was the cornerstone of successful endodontics. That’s as true today as it was then. An access opening that’s too small or misdirected can not only affect canal location, but also can affect proper instrumentation, irrigation and obturation. Possible iatrogenic complications such as perforation also can occur.

I usually begin access with a surgical length FG-557SL (SL557) bur from SS White (sswhiteburs.com) in a highspeed handpiece when no crown is present. I prefer the use of a surgical length bur because it moves the head of the highspeed handpiece away from the tooth’s occlusal surface. This allows visualization of the proper apical angulation of the bur during initial access preparation.

After my initial access with a SL557 bur to approximately the level of the pulp chamber, I then flare the walls of the access preparation in a coronal direction. Although I use a SL557 to flare the walls, there are a myriad of access burs on the market that can be used for this purpose.

They range from flared diamond stones with safety tips, to conical shaped carbide burs. I will then stop and flush out any accumulated debris.


	Once my initial access is accomplished, my next step is to use surgical length round burs of varying sizes in a slowspeed handpiece. For example, in molars, I will start with either a surgical length #8 (RA-8SL) from SS White or a surgical length #6 (RA-6SL) round bur also from SS, White, to gently remove the pulpal roof. In vital cases where there is bleeding, I will extirpate as much tissue as possible and begin instrumentation of the canals that have been located.

I will then carefully look for any microscopic canal openings. If only one canal can be located, I will instrument that canal until I am able to get the orifice to the size of a #4 Gates-Glidden drill from DENTSPLY Maillefer (maillefer.com). This allows me a better orientation of where the other canals are located. If any or all of the canals are calcified to the degree where they cannot be located, the next step I will describe will be a game changer!


	Transillumination is the technique of sample illumination by transmission of light through the sample. Transillumination is used in a variety of methods of imaging.

In medicine transillumination generally refers to the transmission of light through tissues of the body. In dentistry, bright transilluminated light through the tooth can highlight dental caries, show signs of dental trauma such as coronal fractures and assist in the location of calcified canals.

As we progress through an orderly sequence of treatment, we begin to see how each previous step makes our next step more easily accomplished. Recall during isolation that we isolated the tooth at least one tooth posterior to the tooth being treated. This now allows us to use transillumination without interference from the rubber dam clamp.

With my microscope in focus, I turn the microscope light off, and then use a transillumination light from Welch Allyn (welchallyn.com). By moving the transilluminator around the neck of the tooth, both a calcified pulp chamber and calcified canals can be visualized. After visualizing where the calcified canal is, I incrementally progress apically with progressively smaller surgical length round burs, stopping from time to time and flushing away any dentinal debris.

Surgical length round burs allow me to search for canals by smoothing out calcified tooth structure. This is done without gouging, keeping the landmarks intact. The surgical length of the burs allows me to see the head of the bur as  I advance apically, keeping me on the proper path.

Placing sodium hypochlorite into the chamber and letting it soak for about one minute also can help in canal location by bleaching secondary dentin. It’s best to dry out the chamber before canal location is continued.

If you have never attempted this technique, it will open your eyes to a whole new world.


	The first piezoelectric ultrasonic was introduced into the market by Satelec in the late 1970s. Since that time, there has been an evolution in the technology, operation, ergonomics, and the design of the machines.2 For both general practitioners and endodontists, the ultrasonic is a valuable tool to treat calcified and difficult to find canals, as long as it is complemented by the proper tip, and sufficient magnification and light.2

In our practice we have a P5 Newtron, Satelec piezoelectric unit from Acteon North America (acteongroup.com) available in every operatory. They are invaluable for isthmus and pulp stone removal, coronal shaping and finding hidden canals such as MB2 canals in upper molars.
	In addition, when searching for a calcified canal, once we approach the middle third of the root, the continued use of surgical length round burs becomes complex. It’s in these cases that I will then switch to piezoelectric ultrasonics, as the tips are thin allowing better visibility and more precise dentin removal.


	It’s quite evident that today many different modalities exist to help increase our current rate of endodontic success. If we all believe that the best dental implant is a natural tooth, then it behooves us to do all in our power to save as many teeth as we can for our patients.
	When it comes to increasing our success rates, it’s universally accepted that canals have to be instrumented, irrigated and obturated as best as possible. Before that can be accomplished, canals have to be located and negotiated to their terminus. This becomes more difficult to achieve when we are presented with moderate to severe calcifications.

With the aforementioned technologies and techniques I have presented a blueprint on how to locate these types of canals. Consider using these strategies and both you and your patients will benefit. 

References
	1. Dave Clark DDS, Inside Dentistry, April 2011, pg. 40.
	2. Gary Glassman, DDS and Sam Kratchman, DMD, Dentistry Today, September 2011, pg. 114.

The primary goal of root canal therapy is to create an environment in which the root or roots of a tooth are maintained in a healthy periodontium. This, in turn, allows the tooth to be restored to normal function. To achieve this objective it’s important to minimize or eliminate microorganisms and pathologic debris in root canal systems. This becomes more challenging when we are presented with teeth having calcified canals.