How to simplify endodontics with technology

Back when I was learning to do endo (of course this is when dinosaurs ruled the Earth and dirt had just started to form) there were not a lot of choices for any part of the procedure. Back then it was basically:

• Access

• Get working length via radiograph

• Hand file

• Step back

• Check fit/length of gutta percha master cone(s)

•  Fill with gutta percha

The process was time consuming, inefficient and difficult to perform. In fact, it was so difficult that most general clinicians preferred not to be involved with it. Instead, the majority of root canals were referred out to specialists. Anteriors, and sometimes premolars, were treated in house, but many of those, and especially molars, were referred.

While this did spare the general dentist the frustration of doing the procedure, the entire process of the referral introduced a whole new type of inefficiency into the system. Because so few root canals were performed in general dentistry settings, endodontists were sometimes overwhelmed with the volume of patients. This meant that patients frequently waited longer than they preferred for treatment and consequently the comprehensive dentistry being done in the general dentist’s office also took longer to complete.

Fortunately, many bright minds saw the advantage of improving the entire clinical process of endodontics and over the time since my initial training, we’ve seen amazing and dramatic improvements in the process. We have now reached a point where the procedure is much easier, much more predictable, and many are being performed by general dentists. In fact, according to the American Association of Endodontists, 72 percent of root canals are performed by general dentists.

Endo is one of the procedures in dentistry that can be greatly improved both in decreasing stress to the practitioner and better clinical result to the patient, through the use of technology. Over the years many systems have been created which use a series of proprietary instruments to cleanse, shape, and finish canal preparation.

While often times learning and depending on one system can be all that is needed to complete the majority of cases, there will always be cases that require a little something extra or “outside the box” as the situation may be.

For that reason, over the years I have developed a hybrid technique that incorporates several different systems. This has allowed me to adapt my treatment to a myriad of clinical situations for those times when it’s necessary to step outside the box. For this installment of Technology Evangelist, I’m going to discuss some of the products I keep in my “endo utility belt.” Keep in mind that since I’m using a hybrid technique, my endodontic cases are fluid situations and I do not use all of these products on every case. Also, this is not a “how to” article; there are many more steps and products used than what I am discussing here.

Apex locator

In my humble opinion, an apex locator is an absolute necessity to do quality endo. Today’s devices are small, lightweight and incredibly accurate. Today we are battling what I call “countertop real estate” and any device that takes up significant counter space begins to limit the number of counter-based devices you can have. With apex locators being such small devices, they can become a routine part of your endo setup.

Some of my current favorite devices in this category are the Sybron Endo Elements Diagnostic Unit (an apex locator and electric pulp tester in one unit), the Sybron Endo Apex ID, and the Ultradent Endo-Eze FIND.

Apex locators are now so accurate that I believe their readings much more than I believe the position of a file on a radiograph.

Instrumentation

Over the years there have been more endodontic files created and marketed than I can even remember. Some have withstood the test of time while others streaked across the dental landscape like a near-miss comet and were gone. Both manufacturers and clinicians are looking for the magic bullet of one design that can do everything. Unfortunately, that design doesn’t exist-at least not yet. Hence my preference for a hybrid technique.

Since I’ve yet to find the magic bullet file, here are some files I keep in the toolbox to help make some cases easier.

Ultradent Endo-Eze Genius files are used with the Genius motor. These files can be used in either reciprocating or rotary motion depending on the clinical situation and the comfort/skill of the operator. Any file that can be used in a reciprocating motion is harder to break.

Coltene Hyflex EDM files are incredibly flexible. This makes them a very nice option when instrumenting curved canals. The other advantage is that while they are nickel titanium, they also possess a property called CM (controlled memory effect) which means they can be pre-curved for instrumentation of highly curved canals. I’ve found this to be a great advantage in curved cases. The other interesting property delivered by CM is that when autoclaved, these files go back to their original straight shape. Personally I advocate a one use file inventory of single use and toss, but if you like to reuse files, these are an excellent choice.

Sybron Endo Twisted Files are created by twisting nickel titanium wire instead of grinding the cutting flutes into it. This makes the files less susceptible to fracture as they tend to unwind (or untwist) before they fracture. I’ve found these files to be durable and difficult (though not impossible) to break. My philosophy with rotary files is to use as few as possible per case which statistically reduces the incidence of breakage. I have found that when using TF files I can frequently complete a case with two rotary twisted files. The first TF is .06 taper and the second is .08 taper.

Endodontic motor

A company can have the best files on the market, but if there is no way to properly use them in the canal system, they do nobody any good. Most instrument companies also have motors in their inventory. I cannot remember ever test driving a motor that didn’t perform, however there have been a couple I have really liked.

The first motor is the Coltene CanalPro CL. From an ease of use and countertop real estate perspective, the CanalPro CL is a dream come true. It is a cordless device that is about the size of a Sonicare toothbrush. Ergonomically it is very easy to hold and is nicely balanced. Since it is cordless, it takes up very little counter space because it does not have a controller unit that it is attached to via a cord. It is fully programmable for up to five different files so you can use it with any rotary file on the market. Just put in the file parameters and you are ready to instrument. The battery will last for 80 minutes of usage and will recharge in just 90 minutes. I have been using this handpiece for about 18 months and it has been a great piece of equipment.

The second motor is the Ultradent Endo-Eze Genius. This motor is corded and has a control unit. It is also fully programmable and works in rotary or reciprocating mode. The reciprocating mode is even programmable to degrees of reciprocation which is a great feature. It has a much smaller footprint than most countertop based motors and comes preprogrammed with the settings needed for the Genius file system. It is included as part of the complete Genius Endo system and is one of the best endo motors I have had the privilege to use.

Wrapping up

These are a few of the products that I reach for when performing endo in my practice. They are most assuredly products/devices that have been vetted “in the trenches” over the last couple of years.

Our profession requires that we are planners. If you aren’t good at planning when you enter the profession, it certainly doesn’t take long for the profession to make a planner out of you. Along those lines, we all approach any clinical situation with a plan in mind. Usually we go so far in our planning to even plan what to do if our current treatment scenario doesn’t give us the long term results we were expecting.

If you are a clinician who performs endo, you know what it’s like when cases throw you a curveball. On those occasions when something goes sideways, it’s nice to have a few extra options at your fingertips.

Even if it is something as simple as just having a few different boxes of files in the armamentarium, those little nuances can go a long way to helping work around an unexpected clinical complication. Many of these complications are ones that couldn’t be predicted preoperatively and not the fault of the treating clinician. Frequently these situations are simply something that could not be avoided.

Being prepared and using technology to the best of your, and its, ability can frequently create a favorable outcome simply by being prepared to step outside