February 1, 2005
by Richard Mounce, DDS
Efficient, predictable, successful and profitable endodontic therapy is dependent upon many factors, which fortunately are virtually always within the control of the clinician. Skipping a step is to court clinical failure or a less than desirable result.
These factors are (in no particular hierarchy):
1) Taking an accurate medical and dental history and history of the present chief complaint;
2) Obtaining a correct endodontic diagnosis before commencing treatment;
3) Performing therapy on a tooth which is either restorable at the time of treatment or can be made restorable through needed periodontal procedures;
4) Obtaining adequate anesthesia;
5) Using a rubber dam at all times;
6) Utilizing adequate visualization and lighting ideally through the surgical operating microscope;
7) Achieving straight line access to the canals;
8) Crown down instrumentation (preparing the coronal third first, the middle third second and the apical third last);
9) Achievement and maintenance of apical patency (the ability to place a small 6-10K file approximately 1mm out of the apical foramen at all times to prevent the accumulation of dentin and pulp debris in the apical third);
10) Efficient and safe rotary nickel titanium use;
11) Copious irrigation at all stages of the procedure;
12) For bonded obturation* complete removal of the smear layer via liquid EDTA solutions.**
Efficiency in endodontics might be thought of as speed and proficiency gained in performing a procedure that is derived from accomplishing all the needed steps well and in order rather than just quickly. Speed alone does not insure excellence- if anything, the reverse is true. Predictability in an endodontic context is derived from following procedure protocols that are endorsed in the endodontic literature and correlated with long-term endodontic success as opposed to empirical ones. Paste root canal filling techniques would be an example of empirical methods unproven in the literature. While paste filling might empirically be successful some of the time, long-term results not predictable relative to conventional treatment.
Successful root canal therapy is that which results in an asymptomatic patient with a tooth exhibiting complete radiographic healing, is functional, has been adequately restored, has no sensitivity to percussion or palpation, whose mobility is not increased and whose periodontal tissues that are within normal limits. True profitability can only flow from a procedure, which, in the long term, meets the above criterion. Conversely, empiricism, often results in, amongst other untoward outcomes, iatrogenic events, inadequate cleansing and shaping and unproven and toxic materials placed into the root canal system all of which take the patient further from the desired end point. I welcome your feedback and questions.
* Resilon, Resilon Research, Madison CT, USA and RealSeal, SybronEndo, Orange, CA, USA.
** SmearClear, SybronEndo, Orange, CA, USA.
Dr. Mounce is in private endodontic practice in Portland, OR.