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Volume 17; 2007

Dental Updates ™

"CUTTING EDGE INFORMATION FOR THE DENTAL PROFESSIONAL "

200 SEMINARS AND 30 JOURNALS REVIEWED YEARLY FOR THE LATEST, CUTTING EDGE INFORMATION

Excerpted Article e-mail: re777@comcast.net

1 Hour Molar Endo

Molar endo in less that 1 hour using conventional
instruments and without instrument breakage issues

Richard Erickson, MS, DDS

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© 2007, DCI Dental Careers TM, All Rights Reserved.

Incorporated
Volume 16; 2007
for anterior teeth. Tay has Bio Pure MTAD
recently reported19 that tetracy-
cline from Bio Pure remaining
in the dentin of anterior teeth
may become oxidized over
time, resulting in iatrogenic
tetracycline staining of the
tooth. This may be prevent-
able, according to Tay, by
pre-rinsing the tooth with
ascorbic acid solution which
will prevent the oxidation of
the tetracycline. Bio Pure may
need a wait-and-see from clinicians before using routinely in
practice.
Still Think the Canal Filling Material Matters?
In a recent issue (Vol. 14, pg. 9), we reported on a review of
the factors contributing to the successful clinical outcome for
endo treatment. In that review, it was noted that the quality of the
final restoration was paramount over the quality of the completed
root canal treatment. A new study on how quickly bacteria
penetrate through any root canal filling material shows how
important this final restoration really is.
Yucel, et al, tested the bacterial penetration of canals filled
with the following materials: AH Plus, AH 26, Sealapex and
Ketac-Endo. Bacterial colonies were harbored at the sealed canal
orifice and were judged to have penetrated the canal when they
could be cultured at the apex. After 30 days, 75% of the speci-
mens were penetrated. After 60 days, 100% of the specimens had
been penetrated. So much for our futile efforts at sealing canals.
The real endodontic treatment begins with the final restoration.
Molar Endo in One Hour or Less:
Because of continued requests for our one hour (often less)
molar endo technique which first appeared in Vol. 2 of Dental
Updates, we are rerunning the article here. I have updated the
technique and materials as necessary but it remains basically
unchanged. While many dentists are doing engine-driven NiTi
file endodontics, file separation continues to be an issue and an
uncomfortable one at that for the practitioner and the patient. For
that reason and the fact that this method is nearly as fast but
without the concerns of file breakage, I have continued to prefer
this technique over NiTi.
With this technique, you can complete most molar endo in
one hour or less (3 canal, first molars frequently take 45 minutes)
and anterior teeth can be completed in 20 minutes. Why would
you want to refer out this easy, one appointment, no lab fee treat-
ment? The patient will never complain about the “shade” or the
esthetics of endo. It’s a practice builder of the first order.
Studies of Resilon-type (EpiphanyTM) filling materials have
not conclusively shown that the seal and quality of fill is better
than achieved with gutta percha. Much of the research is
authored by names with a commercial interest in it, which tends
to cloud the credibility of the data.
19
Tay F: J Endo, 2006; 32: 354-58
11
While the warm gutta percha technique (Buchanan) has its
proponents, simple lateral condensation is perfectly adequate as a
filling technique, especially since all research shows that it is the
coronal seal (restoration) which determines the ultimate success
or failure of the endo treatment. All, repeat ALL canal sealing
systems currently on the market have been shown to leak bacteria
to the apex within 30 days if exposed to oral fluids. Therefore, it
remains essential to permanently seal the canal orifice area with
an appropriate restorative material.
I feel there are two primary reasons some general dentists
prefer to send out this highly profitable procedure. One is visibil-
ity, they can’t see into the pulp chamber and must rely on “touch”
to find the canals, a very stressful technique. The second is the
difficulty in accurate measurement of the working length and
difficulty in obtaining this measurement with xrays, even digital.
These stressful impediments to endo treatment are addressed #1
in the materials and equipment list below. The materials and
equipment you must have to perform this “one hour molar endo”
procedure are:
1. Magnification, Apex Locator, Headlight: These three items
are #1 because if you don’t have them, there’s NO REASON
to go any further with this technique. The three absolutely
essential things needed for fast, easy, high quality endodontic
treatment are: Magnification-preferably 3.5X or higher;
Fiber-optic headlight; and a high quality, dual circuit apex
locator. Without this equipment you will be in the dark,
groping your way by touch alone, doing endo like you had to
in dental school which everyone hated. You would agree
that if you can see a crown margin, a good prep is possible.
Why should it be any different with endo? The only way one
can visually see the canals (including the frequently present
4th canals in molars) is with magnification and illumination.
There is NO need to purchase a microscope for quality endo
unless you want to learn separated instrument retrieval.
We have talked about Apex Locators in past issues and there
is no debate any longer as to their accuracy and reliability.
There are probably a half dozen good, dual circuit apex
locators on the market. The two I am familiar with and have
used are the Root ZX (J Morita) and the Endex (Osada). The
Root ZX seems to be the industry standard. You cannot do
rapid, easy endo if you have to stop and take measurement
xrays. Period.
Volume 16; 2007
2. Medidenta 1500: This instrument has been around for a long
time (see photo below). It is a sonic filing system which uses
its own proprietary files called Shapersonic and Rispisonic.
The Rispisonic files are too aggressive and can strip open a
canal if one is not careful. The shapersonic files are less
aggressive and suited to the purpose of flushing out debris.
You will only need size #15 and #20 shapersonic files
(25mm) for this technique.
3. Clorox Full Strength and RC Prep: While many newer
irrigation products have come on the market, nothing is as
effective for dissolving tissue AND killing bacteria as 5%
sodium hypochlorite, PERIOD. RC Prep is useful to
lubricate the hand files to prevent ledging and to work past
ledging should it occur.
4. Extended Working Time (EWT) Sealer: (Sybron-Kerr)
Many now are using AH-26 which is a resin type sealer. I
don’t have any experience with AH-26 but it has favorable
literature research.
5. K-Flex™ files: K-Flex files
(Sybron- Kerr) Yes,
they’re about a zillion
years old but they work!
They cut dentin, they’re
flexible and they almost
never break, even after
unwinding abuse.
K-Flex files differ from
regular files in that the
blank is rhomboid
shaped, not square like a regular file, thus has sharper cutting
flutes. If you like using Barry Musikant’s Safesider files,
they’re fine too. Your choice. Recently CRA evaluated the
EDS engine driven endo system which uses reciprocal
SafeSider files in a reciprocating handpiece. While no file
separations were reported using this system, only 62% of the
evaluators stated that this system was superior to the one they
currently use20.
6. Gates Glidden drills: You will use only the #2-4 to actually
enter the canal, #5&6 may be used to widen the orifice if
desired for ease of instrument or filling material entry.
Never, repeat NEVER use a #1 Gates Glidden in a canal
unless you want instrument separation at the head.
7. Miscellaneous: Long shank, latch-type #2-4 round burs for
unroofing the pulp chamber in molars. Safe tipped
disposable irrigation syringes. Gutta percha points (ISO
sized) and Fine sized gutta percha points.
20
CRA Newsletter, 2007; 31(2) February
12
Over the years of doing endo (including 2nd molars), I have
had the occasion to hear numerous speakers and have tried many
systems. This is the technique that works best for me. It is a
straight forward gutta percha technique with some "high tech"
and will have your post op xrays looking as good as the special-
ists!
Evaluation and Diagnosis
Molar endo is no more difficult than anterior, albeit a little
more time consuming. If the patient is moderately to severely
swollen and/or in extreme pain, we medicate for several days to
relieve the symptoms. Amoxicillin 500mg tid is the usual choice
but some recommend clindamycin as being more effective. If the
signs and symptoms are less than obvious as to which tooth is the
culprit, then a series of tests are in order. Evaluation of xrays and
electronic pulp testing is universally known and won't be
discussed here.
Other tests such as tapping on the facial aspect of various
teeth with a mirror handle, having the patient bite on a "tooth
sleuth", as well as hot and cold testing, will usually identify the
correct tooth. An inexpensive way to cold test is to buy a can of
Component Cooler from Radio Shack and spray it on a cotton
tip applicator. Applying it to suspect teeth in a quadrant usually
unmistakably identifies the culprit. Most healthy teeth will
momentarily react painfully to this ultra cold stimulus, however,
an abscessing tooth will be excruciatingly painful and/or the pain
will linger beyond when the tooth returns to mouth temperature.
Evaluation of the patient and the involved tooth should occur
next. Can the patient open wide enough to maneuver a standard
length endo file into the tooth? Can canals and pulp chamber be
seen on the xray? If the answer is no to either question, I gener-
ally refer the case. There’s no point in struggling when there are
so many easy cases out there.
Access Opening
After anesthesia and rubber dam placement, adjust the bur
length by holding the handpiece with a
330 bur against a bite wing xray so that
the flat chuck surface is even with the
cusp tips and the tip of the bur just
penetrates the pulp chamber (see illus-
tration at right). The big fear is a
perforation. However, if you use this
technique and follow the long axis of
the tooth, it is almost impossible since
the head of the handpiece prevents you
from going too deep.
Again, looking at the bitewing xray (the least distorted of all
xrays), see if the pulp chamber lies
directly below the confines of the molar
cusps, and if so, then you need to stay
within these landmarks. I always open all
pulp chambers (anterior and posterior)
with a 330 bur. It gives you control,
visibility and very little bur chatter on the
tooth. Another trick is to flatten the
occlusal surface (photo right) of molars
Volume 16; 2007
with a C&B diamond about 2mm IF you are going to crown the
tooth afterward. This will give you better visibility and access
into the pulp chamber.
Crowns, especially poorly
anatomical PFMs, present some diffi-
culty in locating the pulp chamber
without perforation. For this reason as
well as avoiding repairing the hole
afterward, I recommend removal of the
crown, if possible, using an Almore
(Richwil) crown removal “jelly bean”
(1-800-547-1511). Once the crown is
removed, the position of the pulp chamber is much better visual-
ized.
With tipped teeth, it is often difficult to visualize the proper
angle of penetration to the pulp chamber. These cases are the
most frequently perforated by the inexperienced clinician,
however it need not be so. In these cases, DO NOT apply the
rubber dam until access to the pulp chamber has been realized.
The rubber dam often masks and distorts the long axis of the
tooth, especially if it has been crowned with a PFM. There is no
need at this point for the rubber dam and its role in asepsis and
preventing aspiration. Once pulpal access has been gained by
visualizing the tooth in its natural state, the rubber dam is applied
and further exploration with files can begin.
After opening into the pulp chamber, you may want to
remove the entire roof with the 330 or elect to use a low speed #4
or #6 round bur. Extend the opening so that you have a straight,
vertical access to the entrance of the canals. The biggest mistake
inexperienced practitioners make is having too small of an access
opening. I will sometimes use a tapered C&B diamond to smooth
and taper the access opening toward the occlusal on molars.
Next, fill the pulp chamber with a few drops of full strength
Clorox. Using a #10 or #15 K-flex file and an endo explorer,
locate all canals and insure that there is patency to the apex.
Estimate the working length of the canal using a pre-op xray.
Flush the canals for 10-15 seconds with the Medidenta 1500
(800-221-0750) (photo below), lots of water, and a #15 shaper-
sonic file, again estimating the length with a PA xray. NOTE: the
#15 shapersonic file will not ledge the canal if you are short, so
don't worry about it and if you're a little long, that won't hurt
either. NOTE: if you BEND the tip of the #15 shapersonic
trying to find the canal, discard it!! The tip will break off in
the canal if you straighten it and try to use it (ask me how I
know).
If you suspect intact nerve tissue in any of the canals, insert a
FINE broach into the canal, do a quarter turn to engage the tissue
and remove the nerve tissue in one piece. If this is not done
before instrumentation, compacted nerve tissue may block out the
apical 1/3 of the canal and make it very, very difficult to penetrate
to the apex (See “Blocked Out”, below).
13
Instrumentation of the Canals
You now need to widen the upper half of the canals with
Gates Glidden drills. NOTE: never use a #1 Gates Glidden in
any canal as they fracture easily at the head! Always begin with a
#2 and be sure the pulp chamber is filled with full strength
hypochlorite (Clorox) which acts as a lubricant, disinfectant, and
also digests tissue in the lateral canals. With the #2 Gates
Glidden, try to negotiate it about half way down the canal. Next,
do the same with #3 and #4. Anything larger than a #4 Gates
Glidden may perforate the root at its concavity so only use the #5
and #6 to flare the canal orifice.
In between Gates Glidden drill changes, flush and instrument
with the Medidenta 1500 sonic and a #15 shapersonic file. Run
it for about 5 to 10 seconds up and down with lots of water spray
from the 1500. For upper bicuspids especially, the Medidenta
1500 is excellent at removing the thin, ribbon connection between
the buccal and lingual canals. Withdrawing the Medidenta
toward the buccal while in the lingual canal and vice versa will
quickly widen the ribbon isthmus and enable you to clean it of
debris. Debris left in the canals from a cutting instrument
(whether it is a hand file or Gates Glidden drill) will make use of
the next size slow and difficult. Also, ledging of the canals and
instrument breakage occurs more easily if debris remains in the
canals. After flaring the canal orifice with the #6, you are ready
to measure with the electronic apex locators. The electronic apex
finders and the 1500 sonic handpiece are the key pieces of equip-
ment which make it possible to do molar endo in under an hour. I
have heard many nationally recognized endodontic speakers
remark on the incredible accuracy of the current generation of
apex locators. Two that I have used extensively are the Endex
(Osada; 800-426-7232) and the Root ZX (J. Morita; 888-909-
3636; www.jmorita.com). The Osada and the Root ZX do not
use the "resistance method" employed by the less expensive
brands or the early models from years ago. Rather, they use a
dual-frequency reference comparison method which can operate
accurately in wet, dry, hypochlorite filled, necrotic, or bloody
canals.
Numerous research studies have confirmed the accuracy of
these apex locators. Several published studies were done on
teeth to be extracted and compared radiographic measurements
against those from apex locators. The results showed that while
neither method was 100% accurate, these apex finders were
accurate more often and had the least error with regard to the true
apex as opposed to the radiographic apex which is often beyond
the true apex.
Volume 16; 2007
The xrays at the left
are of endodontic proce-
dures on teeth #19, 31 and
3 done in our office. Only
the apex locator was used
to determine working
length, no measurement
xrays were taken. Tooth
#19 had an existing metal
crown which was left in
place making the electronic
measurements more diffi-
cult. In cases like these,
you need to blow out the
excess hypochlorite from
the pulp chamber to
prevent conductance from
the canal to the crown, and
avoid touching the metal
crown with the file as it is
advanced toward the apex.
Note the sealant "fins" in
the lateral canals of #3.
Over the years, I have
become so confident in the
accuracy of the apex
locators, I rarely take a
measurement xray except
for the final to check the
gutta percha fill. When the
instrument is not capable of giving a true reading, you will know
it by the erratic reaction of the dial readout.
Use a small file for all measurements (#15 or #20) as these
seem to give the most consistent results and yes, these apex
locators (AL) work well in the presence of blood, Clorox, local
anesthetic or whatever else is in there. If the reading is a little
erratic or “squirrelly”, try using a larger file as studies21 have
shown that the largest file which can reach the apex will often
give the most accurate reading. When the AL "shorts out" or
becomes erratic, it is usually due to conducting fluid contacting a
large MOD amalgam which then shorts to the PDL. It can also
occur when the root is fractured. Touching the file to the metal of
a PFM or gold crown will do the same thing so stay clear of that
while inserting for measurement. If you accidentally contact the
metal edge, the needle indicator will become erratic but you need
only to get back to the center of the access opening to continue
your measurement. For large MOD amalgams, do not have the
pulp chamber wet with anything, blow it bone dry just prior to
measurement. It is OK, however, to have some conducting fluid
in the canals, as long as it does not complete the circuit to the
amalgam and PDL. Follow the instructions with the instrument
and you will become proficient at rapid measurement and confi-
dent of its accuracy.
OPTIONAL: A very accurate check of the measurement can
often be made using a "fine" or "extra fine" paper point (Bucha-
nan). If the apical foramen is patent, insert the paper point to
where it is 1-2mm beyond the apex and remove. If there is blood
21
Ebrahim A: Aust D Jour, 2006; 51: 258-62
14
at the tip of the paper point, the exact length of the canal can be
found by measuring the distance between the point where the
blood stops and where the paper point was grasped by cotton
pliers at the landmark reference. Buchanan reports there is no
"wicking" up the paper point and that the blood at the tip covers
only that which extended beyond the apical foramen.
Once measurement of all canals is obtained, instrumentation
can begin. Start with the sonic 1500 and a #15 shapersonic file
and measure the file exactly to the working length. Insert into the
canal and with copious water spray from the handpiece, move the
1500 up and down to the working length until it moves smoothly
(about 5 - 10 seconds). If the #15 shapersonic will not move
freely to the working length, use a #15 or #20 hand file until you
can. Now you can begin hand filing.
Hand filing brings to mind tedious, finger numbing dental
school nightmares. This is not like that at all. Because the upper
half of the canal has been widened with the Gates Gliddens
(crown down technique), the hand files work only in the apical
1/3 of the root and only take seconds per file.
If the #15 shapersonic file has done its job, you can usually
begin hand filing with a #20 file (K-Flex files). With a couple of
quick "watch winding" strokes, you should be able to go to the
full working length easily. Go back with the #15 shapersonic and
the 1500 to remove the debris (full length). The few seconds it
takes to flush the canal with the Medidenta is extremely
important. The next larger file will go easily to the working
length with a little watch winding if ALL the debris has been
removed from the last file. Next, squirt a little hypochlorite into
the pulp chamber and/or canals and use the #25 K-Flex in a
similar fashion as before. Repeat with the #15 shapersonic to
remove the debris (lots of water). The #15 shapersonic is so
flexible and gentle, it does not seem to ever ledge a canal and the
debris removal surpasses anything else I know of. On straight
canals or gently curving ones, a #20 shapersonic file can be used
but nothing larger or you will ledge and make the case very diffi-
cult from that point forward. Remember, the sonic irrigation is
for debris removal, NOT to enlarge the canal.
N.B.:Always lubricate each hand file with RC Prep before
using. This will keep you from becoming blocked out.
This back and forth alternation between #15 shapersonic
irrigation and increasing size hand files goes quickly up to #30 or
#35 in curved molar canals since constrictions in the upper half of
the canal have been removed with the Gates Gliddens. Once the
hand filing with the K-Flex to the working length becomes diffi-
cult, you should stop at that number. Molar canals are usually
finished to #35, sometimes #40 to full working length. Occasion-
ally I have stopped at a #25 on narrow canals. If you cannot
reach the apex with the next hand file, sonic irrigate and go back
to the last smaller size and re-instrument to the working length.
One last step needs to be done, insure patency of the apical
foramen. You do not want a debris plug filling the foramen
(Buchanan). Measure a #10 hand file 1-2mm longer than the
working length and insert up to the measurement stopper. You
can usually "feel" it go through the apical foramen. By doing
this step, you will see a small puff of sealer cement beyond the
apex on the post-op xray (it gives those macrophages something
Volume 16; 2007
to do!!). As Drs. Ruddle and Buchanan state, "Cases don't fail
due to slight overfill of gutta percha."
A note on engine driven nickel - titanium files or hand ni-ti
files. I have tried them and they don't (in my hands) increase the
speed or quality of the end result. In addition, there are breakage
problems with Ni-Ti instrumentation which have not been solved
by the manufacturers. Engine driven Ni-Ti systems are very
technique sensitive and file breakage within the curved canal is a
problem -- I did it on my first case!! If you: (1) push the rotating
file too hard, (2) linger too long within a curved canal or (3) use
the file once too often, breakage occurs. Then you have to tell the
patient, "We've decided to put a high tech titanium plug in the
root canal instead of the old fashioned rubber stuff." So until the
system becomes more idiot proof, I prefer to stick with this
method.
A note on irrigants during shaping and filing procedures.
Some say that disinfectant irrigants (Clorox) are unnecessary and
that ordinary water works fine, especially when using the 1500
sonic instrument. The 1500's sonic waves are very effective at
flushing debris out of canals. However, in order to dissolve
tissue and bacteria in the lateral canals, only full strength (5%)
Clorox is effective. In order to dissolve the tissue in the lateral
canals, Buchanan states that Clorox must sit in the canals for a
minimum of 30 minutes. You can see the "digestion" of tissue
within the canal by the frothing bubbles. Replenishment of irrig-
ant should occur every 5 minutes and can be done by the assistant
while the doctor is doing something else. I frankly have not been
able to sit idly for 30 minutes during a RCT and have not
followed this rule. I have used the 1500's sonic vibration (#15
shapersonic) with Clorox to speed up tissue digestion. Here’s
how to do it. Turn the water spray on the Medidenta OFF.
Holding the Medidenta in my right hand, I insert the tip of the
Clorox irrigating syringe into the pulp chamber ONLY. With the
Clorox flowing slowly, I activate the Medidenta. Now you have
sonically agitated, slightly warmed Clorox, digesting tissue in
lateral canals as nothing else can.
Gutta Percha Fill
I won't go into the details of fitting the master cone as this is
basic Endo 101, but suffice it to say, I do like a small amount of
"tug back". Once all the master cones are fitted and laid out so as
to be clear which goes where in multi rooted teeth, mixing of
sealer can begin. We have been using Extended Working Time
Sealer (EWT)™ by Kerr/Sybron (photo left) for many years and
it performs very well. It must be the powder / liquid kind as the
"tube" kind sets too quickly. It
is extremely slow to set which
is what you want. There are
some brands (TubliSeal &
Sealapex - Kerr) on the market
which seem to be fine until
they contact a little moisture
which causes them to set
quickly and prevents their flow
into lateral canals. It is hard
not to have some moisture
from humidity within the tooth.
15
The cement is mixed to the consistency of syrup.
Thoroughly dry all the canals with paper points followed by air
syringe drying.
The master gutta percha point is test fitted then coated liber-
ally with cement. It is placed in the canal and pumped up and
down about a half dozen times to work the cement throughout the
canal. The gutta percha is removed, re-coated and "pumped" a
few more times. On the final pump, run the gutta percha to its
"seat" position at the apex. Lateral condensation using "fine"
gutta percha points and spreaders is done until canal is filled.
Each gutta percha point is coated with cement before placing in
the canal.
Next, heat the tip of a small spoon or endo plugger with a
butane torch to melt off the excess gutta percha down to the canal
orifice. Re-heat the instrument several times until the small
amount of gutta percha within the pulp chamber and the top 3mm
of the canal is softened. Using a warm endo plugger, somewhat
smaller than the orifice to the canal, firmly compress the softened
gutta percha and sealer mass into the canal several times until
well compacted. Sealer applied to the plugger beforehand will
keep the gutta percha from sticking to it. Compressing the
softened gutta percha & sealer with the plugger, will force the
sealer into lateral canals and slightly out the apex. You will then
see the desired little "puffs" of cement in the PDL on the post-op
xray. Apply Cavit as a temporary to close the access opening and
take the final xray. You will note that even when finishing up,
the EWT sealer has not begun to set which is what you want.
Summary
1. Open to pulp chamber (330 bur) and extend for vertical,
straight line access to all canals.
2. Insure patency of all canals to estimated working length with
#10 or #15 file. Using #15 shapersonic with lots of water,
move the instrument in an up and down or circular motion
(10-15 seconds) to enlarge canals slightly. Estimate length
with undistorted PA xray. You won't ledge the canal with
the #15 if you're short so don't worry. Use a fine or extra
fine broach if you suspect intact nerve tissue within the
canals.
3. Gates Glidden canals to #4 (do NOT use the #1!!!) about half
way down root and widen orifice with #5 and #6. Between
Gates Glidden drill changes, flush with #15 shapersonic and
lots of water spray.
4. Blow out excess water from pulp chamber and using the #10
or #15 file together with the apex finder, measure the
working length. Until you gain confidence with the
instrument, you may want to check it with an xray.
5. At this point, you can usually begin filing (watch winding
motion) with a #20 to the working length, then #25, #30, #35
hand files. Always irrigate and flush between files with the
#15 shapersonic, blow dry and refill canals and pulp chamber
with full strength Clorox for next file. If the canals are not
too curved, a #20 shapersonic can be used instead of a #15.
However, a #25 shapersonic will almost certainly ledge a
Volume 16; 2007
curved canal which means you're cooked!!! Curved molar
canals can usually be instrumented to working length to a
#30-35 K-Flex file. I have sometimes stopped at a #25
because of constricted resistance. Remember to always
lubricate each file with RC Prep which is easy to do if you
use the Jordco EndoRing (see below)
6. Dry with paper points, air, and test fit the master gutta percha
(MGP).
7. Mix the cement (EWT Sealer; Kerr Sybron) (not runny, not
too thick), coat the MGP and pump up and down in the canal
to force the cement out the lateral canals and the apex. Seat
the MGP.
8. Using spreader and "fine" gutta percha, continue with lateral
condensation. Coat each gutta percha with sealer before
placing.
9. Heat sear off the excess, soften the remaining GP in the pulp
chamber and within the canal.
10. Using an endo plugger, firmly compress the softened GP
mass and sealer into the canal until well filled. Pre-coating
the plugger with sealer will keep the GP from sticking to it.
11. Temp with Cavit, take final xray. Give yourself a pat on the
back.
12. Finally, buy an EndoRingTM
kit (Jordco - $75) to help
organize files and Gates
Glidden drills. It has a
convenient ring-finger
holder, a well for EDTA
(RC Prep) and an endo
ruler. It's a real time saver
and totally autoclavable.
Baring complications, tight
tortuous canals, etc., an upper or lower molar endo should be able
to be completed (finished) in under an hour. I recently completed
an endo procedure on #29 (I know it's an easy tooth) AND a
crown prep on #3 in 45 minutes total. My assistants did take the
final endo xray and made the temporary crown for me afterward.
Tooth #30 was recently completed in our office in 45 minutes
using this technique.
If you can see a visible pulp chamber and visible, moderately
curved canals on the xray, it should be a piece of cake to
complete molar endo in one hour or less with a minimum of
hassle. Endo can be relaxing if you use the equipment described
in this section. I am less stressed doing endo than crown and
bridge. Remember, you must have magnification AND high
intensity illumination. If you can SEE it, you can DO it.
22
Lee: Gen Dent, 1998; 46(4): 378
16
ThermaFil Filling Technique
Many recommend using the ThermaFil technique for filling
the canal with a preheated, softened, gutta percha coated carrier.
The carrier can be a plastic post or metal file similar in size and
shape to that of an endodontic file.
I began to use this technique when it first became popular but
always had mixed results. Perhaps you have had similar experi-
ences. On some post-op xrays, the canals looked well filled with
some sealer/gutta percha expressed out the apex and/or lateral
canals. On others, however, the post-op xray looked as if just the
carrier (the metal file) was occupying the lower ½ of the canal
with all the gutta percha stripped off.
I was perplexed for an explanation until a research article
discussed this technique and the problem of "back pressure".
When the salespeople demonstrate the technique at meetings, it is
always done with a Lucite block replica of a canal with the apex
exiting the Lucite block at the side or bottom. Thus, when the
ThermaFil carrier is pushed into the canal entrance, the trapped
air exits out the lateral and apical ports, and the plasticized gutta
percha is carried in a continuous wave ahead of the carrier to the
apex. Much of the research was carried out on extracted teeth
which allowed the same thing to happen. In real life, in vivo
however, the air cannot escape a tooth surrounded by periodon-
tium. Back pressure builds up which can strip the gutta percha
from the carrier. Thus, by the time the carrier reaches the apex,
no gutta percha remains, giving a “denuded look” to the carrier
on the post-op xray and resulting in an unacceptable apical seal.
A article by Lee22, et al, studied in vitro the effects of strip-
ping of gutta percha from Thermafil carriers. Dye penetration
into the apical portion of the completed root canal was signifi-
cantly higher than that of those done using a conventional lateral
condensation technique. These are the factors which preclude my
use of this technique.
Overcoming “Blocked Out” Problems
Instrumenting too aggressively, not removing debris
adequately with irrigation and/or the Medidenta 1500, and
compacting residual nerve tissue at the apex can all result in
being “blocked out”. Becoming “blocked out” occurs when
obstructions within the canal, usually at the apical 1/3, prevent all
attempts to instrument beyond the blockage point. The clinician
may then elect to fill to the point of blockage and “hope for the
best.” It need not be so, blockages can be penetrated and treat-
ment continued to the proper resolution.
Several things are needed to overcome blockages: very small
files, RC Prep, and full strength Clorox. Files no larger than #15
should be used in the attempt to penetrate the blockage,
sometimes files as small as #6 or #8 are used. Particularly useful
are the Schewd “C” type (extra stiff) #6 and #8
files(www.schwed.com/pg2.html#ant). All files used in the effort
to penetrate the blockage must be pre-bent as shown here with a
very small radius curve at the tip so as to prevent ledging of the
canal. The canal should be loaded with RC Prep (use the file to
carry it into the canal)
and a few drops of full
strength Clorox. With
Volume 16; 2007 17
firm but gentle “watch-winding” motion, the small files are favorite flowable and
worked into the blockage. Remove the file frequently, inspect the cure, thin layer please!
tip for deformation, re-bend if necessary and reload with more Begin to fill the deepest
RC Prep. parts of the cavity with
any shade of good
It may take 5-15 minutes of careful work but the blockage composite (A), using 2mm
will eventually be cleared. Further instrumentation with larger increments, be sure and
files can then commence. Remember, the best way to prevent condense to remove voids.
“blocking out” is to lubricate each file with RC Prep before Continue filling and
inserting it into the canal. The reservoir on the EndoRingTM is After curing until you are within
particularly useful for keeping the RC Prep handy. 4mm of the cavo-surface
Separated Instruments margin. Next, flow in a
thin layer (1-2mm) of
As I mentioned, the above method’s most noteworthy benefit Pentron's flowable
is the lack of separated instruments. In over 20 years of doing Universal Opaquer.
endo -using K-Flex (Kerr) files, I have had only one separate. Pentron’s Universal
That file was over used and it’s separation was iatrogenic. Unfor- Opaquer is the only one I
tunately, it could not be retrieved so it was bypassed as can often know of that is opaque
be done using the technique below. Attempting to bypass a enough for this task. Use
separated instrument is probably the least invasive of all the an explorer if necessary to
methods used to resolve this issue. Many experts recommend push the opaquer (B) up to
that this should be tried first. cover the metal core line but NOT the porcelain (don't obsess if
you get a smidgen on it, however). Cure the opaquer and apply a
The technique for this has been discussed in previous issues
second and third layer if necessary to block out ALL the darkness
but is basically the same as that for working through a “block
and metal. Finally, fill the remainder of the cavity with any good
out” mentioned above. Only #6 or #8 extra stiff carbide “C”
posterior composite of the appropriate shade (C). The before and
type files should be used with copious amounts of RC Prep. The
after photos shown here have not been retouched -- it looks that
files should be pre-curved slightly prior to use. Once the file
good ! Plus, your patient will be convinced their crown is
works its way past the separated piece, take an xray for confirma-
"undamaged".
tion that you are within the canal. Carefully enlarge the canal to
a #25 and fill.
Local Anesthesia:
Hiding the PFM Access Hole
Nasal Spray?
Your patient’s new PFM molar or bicuspid crown needs an
Researchers at the University of Buffalo dental school23 have
endo and you're dreading the "dark hole" composite filling. I’ve
been experimenting with a local anesthetic nasal spray. Principle
seen a zillion composite plugs in PFMs and they all look like crap
investigator, Dr. Sebastian Ciancio stated, “It may mean the end
because no composite is opaque enough to block out the DARK
of dental injections when performing procedures on the maxillary
interior of the PFM. No need to fret, this tip will make these
arch.” Testing is currently underway to determine the optimal
repairs INVISIBLE.
dosage for assuring dental anesthesia.
First remove all temporary filling material and cotton plug
The idea for this evolved from nasal treatment of patients by
from the access opening. I like to begin my composite build-up-
ENTs using a nasal anesthetic spray. The patients reported that
restoration at the canal orifices. Next, use H-F porcelain etching
the spray also numbed their teeth.
for 2-4 minutes on the band of porcelain, rinse and dry. Now etch
and bond all interior surfaces using your favorite total-etch or Bevel Concerns?
self-etch system. I prefer to use SE Bond™ or Liner Bond 2V™
(Kurarary) because of its Some practitioners (myself included) believe that turning the
Before bevel away from the ramus insures that any needle deflection will
excellent porcelain bond
activator, which in my therefore be toward the bone and that’s a good thing. Studies
view, produces the strong- confirm24 that this is not necessary. Using a 27 Ga needle (1¼”
est porcelain to composite long), there was no difference in success of anesthesia whether
bond on the market. In the bevel was turned toward or away from the ramus. Whew, one
fact, Reality™ reported more piece of baggage I can remove from my anal brain.
that it even exceeded the
experimental control. The Wand

Line the deepest parts The Wand is an expensive local anesthetic device which
of the cavity with your uses costly disposable materials on each patient. Many swear by
it but does it help in highly anxious children?

23
Ciancio S: Univ of Buffalo School of Dentistry, 2007; as reported by R Goldstein in www.dentalxp.com, 2007
24
Steinkruger G: J Amer Dent Assoc, 2006; 137:1685-91
 ¼ ½ ¾ µ mW/cm2
Volume 17; 2007 2

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