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endodontics message board

How Much Time for Molar Endo?

Is it really a question of time? Successful outcomes can be efficient.

russparker22
Molar endo is frustrating at times. Sometimes I can complete treatment in 80-
Posted: 12/9/2010
90 minutes and then there are times when it takes me two and a half hours or more.
Post: 1 of 51
I’ve done hundreds of endo treatments and I’m still very inconsistent with treat-
ment time for molars, especially lower molars. Today, I had a mesiobuccal canal on
#19 that was very difficult to negotiate at the apical one-third and I ended up strip-
ping the canal attempting to fully instrument it. How much time do you allow for
molar endo? What do you do when you encounter a tooth that is much more dif-
ficult to treat than anticipated?
Thanks. ■ Russell

davidpalmer At the risk of starting a huge argument, Scott Perkins showed a video of how to
Posted: 12/9/2010 do a lower molar in 15 minutes. I always think it is funny when people want to
Post: 2 of 51 argue with something they can watch.
I was at the first course he taught in Houston... amazing how efficient he is.
Of course the endo was a very routine lower first... not some difficult tooth with
MB2 and 3s. ■

russparker22 Thanks David. Of the hundreds of endo I’ve done, lower molars are just aggra-
Posted: 12/9/2010 vating to me sometimes. It’s frustrating to take an inordinate amount of time and
Post: 3 of 51 then have a crappy result. Endodontists will churn out these teeth in 90 minutes
and do it routinely. How? I will do three or four in this time frame and then all of
the sudden I’ll have a couple of stubborn teeth. Can’t get a good glide path, etc. I
just want it to be more predictable. ■

mattyboy Repetition! They do the same procedure every day, on every patient... endodon-
Posted: 12/9/2010 ■ Post: 5 of 51 tists get fast because that’s what they do. Some teeth are just brutal. ■

utdental Go shadow some local endodontists. They probably approach every tooth sys-
Posted: 12/10/2010 tematically just like you approach restorative systematically. Copy what they do.
Post: 7 of 51 After hundreds of teeth, I had a breakthrough when I realized not to rush the
access prep. Problems I was having later in the procedure were usually caused by
something wrong with the access so I would go back and refine it. ■

lancet The right answer would be to take as much time as needed to do it right the
Posted: 12/11/2010 first time.
Post: 11 of 51 I always schedule two-hour appointments for endo start... then I will almost
always add a second two-hour appointment for completion. And there are cases that
would take even more time. ■
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uscdds95 The more you know the longer it takes. ■

Posted: 12/11/2010 ■ Post: 13 of 51

mnbadger I’m with the last few guys – my first thought when I read your title and before
Posted: 12/11/2010 I opened the thread was “As long as it takes.”
Post: 15 of 51 It’s a tough thing to balance because we want to provide our patients with a
good service, but we also want to provide them with an efficient and comfortable
appointment. I’ve had a rubber dam on my face for an extended time before, it
gets old.
If you want nuts-and-bolts: I would wager that my mode time for molar endo
start-to-finish with build-up is a little more than two hours, but I have more than
exceeded that time than beat that time. I know I’m on the slow end of the curve.
Sometimes endo takes time. Most patients will understand. ■

rovster Good advice so far. It takes time to do it right. The best thing to do is to set up
Posted: 12/12/2010 a routine and establish certain goals at certain checkpoints. Also you must realize
Post: 17 of 51 that endo has one of the biggest “ranges of difficulty” of all the procedures we do.
Some four canalers I can do in one hour. Some three canalers might take more than
five hours. Learn to spot difficult teeth and avoid those at first. Also realize that if
you want to do the hard ones, expect to pay the penalty in time and aggravation. ■

russparker22 Thanks for all the feedback. It sounds like most of you see it the same way I do,
Posted: 12/13/2010 which is that the only thing predictable about molar endo is that it is unpredictable.
Post: 18 of 51 I wanted to know how you guys schedule for molar endo. We allocate three
hours for it, which seems to be too much, in my opinion. How much time do you
guys reserve for endo on molars?
Thanks. ■ Russell

swandog I schedule an hour and a half for a molar. But I almost always do it in two
Posted: 12/13/2010 appointments. Seems I do a lot of necrotic teeth, so I feel more comfortable
Post: 19 of 51 two-stepping them. I also have plenty of molars that take a third appointment.
Since taking a lot of endo CE and lurking on the endo threads here, it takes me
longer to do endo. But I do a much better job and have really learned when to
refer. ■ Swandog

rovster Case selection is the key. If you decide to do everything that comes your way,
Posted: 12/13/2010 you will encounter some surprises. If you learn to spot the time killers (calcified
Post: 21 of 51 chambers, long roots, pulp stones, high bends, apical bends, fast breaks, extra
anatomy, unusual anatomy, limited access issues, patient management issues, iso-
lation issues, etc.) you’ll save yourself a lot of aggravation. Some people (like me)
are gluttons for punishment, and I see these factors as challenges and opportuni-
ties to up my game.
For what it’s worth, I schedule two hours for a molar and 90 percent of the
time I finish with core. ■

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I always liked to schedule more time than I really needed to account for prob- barry1818
lems. If you finish earlier than you scheduled, then you can talk to the patient, and Posted: 12/13/2010
speaking with the patient can be a great practice builder. Post: 25 of 51
If it takes longer, then you have built in the time.
Sort of like Scotty from Star Trek, he became the hero because he always could
do things quicker than he said, but he had always built in the cushion to do so. ■

I schedule two hours for molars and schedule them at the end of the scheduling nareg
block as often as possible... this way I can take more time if I wanted to before my Posted: 12/13/2010
blood pressure goes up because people are piling up in the waiting room... and if by Post: 26 of 51
some miracle I finish faster... “woot” going home early (hasn’t happened yet)! ■

I am with Nareg and a few others; I book two hours for molar endo. Maybe sunbusrtlespaul
75 percent of the time I will finish with core in that. Otherwise I take two Posted: 12/16/2010
appointments when it’s a bit tougher than I expected. The toughies I just refer Post: 31 of 51
out. I always tell patients before how molars can be tough and usually takes two
visits and when its just one they are happy. If I am running out of time and won’t
have time to finish the core then I don’t obturate that day.
I also have those two hours uninterrupted. I never have two patients
booked when I am doing endo. I find endo is tough and I hate to be concen-
trating and interrupted so it really helps to arrange it without other patients and
helps with efficiency! ■

I block out two hours with nothing on the side other than hygiene checks. I Raj D
am ready to bite someone’s head off if I get interrupted mid-procedure. ■ Posted: 12/17/2010 ■ Post: 37 of 51

The reason I continue doing molar endo is because I do more than 100 root russparker22
canal treatments (RCT) per year. The vast majority of those are molars and at Posted: 12/17/2010
$850 per tooth, it’s a big revenue generator. I also enjoy it most of the time. Post: 38 of 51
Another reason is that it puts patients in my chairs that otherwise would be
empty. Early on, I also noticed that patients were very reluctant to go to another
office (endodontist). Many patients would end up delaying treatment until the
tooth would break, sometimes to the point where it was hopeless. So I decided to
make a more concerted effort with endo. Bought a microscope and Dual Calamus
for obturation.
My frustration is the unpredictability in time. I was just wondering what is
reasonable and customary. I agree that it takes as long as it takes, but everyone
needs to have a goal in mind with endo and all other procedures. ■

I’m curious to know how others schedule them. Nareg, I like your idea of CoachDDS
scheduling at the end of the day. The only problem then is I’m usually wiped out. Posted: 12/17/2010
I like to be able to focus on one start to finish without interruptions, but that’s Post: 39 of 51
not very feasible. How do the rest of you schedule RCTs or thirds or other com-
plicated doctor-intensive procedures? ■
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gregholm I schedule the two hours also. I think Delta Premier and Blue Cross Blue
Posted: 12/17/2010 Shield cover approximately $700 molar. At two hours I make money at that. I
Post: 40 of 51 have a pretty low overhead machine.
I do not do every molar that walks in my door. There are many that I just refer
out. I still get burned on some and wish I had never started. Some I have made a
poor decision to work on, so I just stop and refer, to cut my losses and to get a bet-
ter job done for the patient.
Some I do in two visits. Usually the second visit is far less than two hours,
maybe not even an hour.
You can’t win them all. But, the winners outweigh the losers.
Like Raj, I do not schedule any other operative during an endo, period. I will
always have hygiene going. Sometimes that is a welcome break – most times not.
I do try to check hygiene at say 8 a.m. and then not check them again until
about 9:45 a.m., so I have a good hour and a half or more to work endo.
But, no doubt, half the time when I get back in the endo room, I’ve forgotten
where I was and the endo rhythm is broken.
If you have plenty of other juicy operative things to do, unless you really enjoy
the endo, you are probably better off referring. ■

drfredc I average around 45 minutes to an hour, assuming there’s a recent filling that
Posted: 12/17/2010 removed all the decay. My actual chairtime is probably 15 minutes less than total
Post: 41 of 51 patient time since there’s time for chemistry to work and time to take an X-ray.
I’ve also found the eBay endo apex/rotary system to help a ton.
• Cost somewhere around $570, but could be cheaper now. I bought a mini
endo head for the HP – about $50, which I think MTI carries.
• Has five modes, but I generally use #5 which has programs for torque and
speed control as well as apex locator attachment to the handpiece.
• I’m using the Pro Taper GTX file system. Typically just the 20-.06 and
30-.06.
• Start by getting good access and hand files to the apex and tested length,
then enlarged to size 20 by hand.
• After attaching the apex locator sensor to the endo head, when the rotary file
touches the tooth, the HP starts up.
o It reverses if max torque is reached.
o As you near the apex, it beeps at a higher rate.
o When you reach within 1mm or less to the apex, it stops and reverses and
beeps really fast.
o It’s has 10 programmable speed and torque settings. I typically only use
two (250rpm with 10 & 15 torque).
o Most every pass at the beginning you check where the junk is accumulat-
ing on the rotary file. Then wipe clean and proceed with another pass.
o Every couple passes, you need to check patency with a small file to keep
the apex from filling up with filings.
o Takes perhaps five to 10 minutes per canal to complete.
o If it seems to not get anywhere, you’ve got to go back to NTI hand files
to #30 or larger and then proceed with rotary.
o I typically start rotary with NaOCl (Sodium hypochlorite) for the 20-.06
and switch to RC Prep for the 30-.06.
• Sometimes the device gets too strong a signal with NaOCl and it thinks
it’s at the apex when it’s not – switching to RC Prep gets that sorted out.

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It makes molar endo almost dead simple. Single canal teeth are dead simple.
Even the staff has commented, “Wow, I could do that.” ■

I schedule two hours for the endo and most of the time I can finish and do the mandm_sudz
core build-up. If I can’t finish the build-up, I place a Fuji II LC temp with no cot- Posted: 12/17/2010
ton pellet to try to get the best seal possible while in a hurry. Post: 42 of 51
I find that with a scope, you see more and tackle more difficult cases as well,
so it tends to slow you down in general.
However, I find that what slows me down the most is inefficient use of my
time. The more time you spend on the tooth and not on your tray set-up, the
quicker you will get it all done. Also, too often I am too conservative with my
access, which I have to go back and progressively correct throughout the rest of the
procedure because things aren’t working for me with the access. Huge time killer.
MB2s are another huge time killer. When I didn’t have a scope it was easy, I never
found it. Now that I have a scope, I always find it, but because it starts out going
almost horizontally to the mesial, it is a pain trying to get to length. In general it
is tough to get to length with an MB2. Another time killer is using my EndoVac
irrigation, but it is so good that I can’t go back. Ignorance was bliss. Having to take
check films is also a huge time killer.
Attaching the apex locator to each one of your rotary files is a huge timesaver.
I almost never get blocked out near the apex. Using Safe Siders and reamers for
my initial glide path to a 15 or 20 file has been a big
timesaver, and I rarely get blocked out.
I would love to find a cordless endo handpiece
that would work with my Pro Tapers. This way, my
assistant can put the files on while I work and alter-
nate with two cordless handpieces.
In the end, I find that avoiding unnecessary repet-
itive motions, as well as not progressing to the next
step before properly finishing the one you are on, are
the biggest timesavers. Also, a good evaluation of the
canal anatomy pre-op will save you needing to take
many check films during the procedure. (I always
review the anatomy of every tooth in the Ingle-
Bakland endo textbook prior to procedures. It tells
the probability of palatal hooks on max molars, distal
hooks on laterals, percent of premolars with
3-2-1 canals, etc.) But a difficult endo will always
be a difficult endo, you can’t rush it. ■

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