Endodontics for undergrads: let’s get down to the roots

endodonticsEndodontics is far from simple. Sara Member has come up with 10 top tips to help make treatment a lot less stressful for those starting out.

Starting any procedure for the first time as a dental student is daunting. Starting your first root canal treatment is a whole new ball game.

Considering all those hours spent with our heads in books and practising in clinical skills, you’d think it would be a walk in the park.

However, once that patient is sat in your chair and you’re searching for canal orifices in what feels like a never-ending black hole, you quickly realise it’s far from simple.

In dental school, it’s easy to keep telling ourselves that once out in practice our struggles will naturally pass. Or perhaps we can book onto a course that will rapidly remove these anxieties.

In reality, from the early stages of our careers, we can ease a lot of the burdens we face to quickly make endodontic treatment much less stressful.

Nurturing good habits from day one will pave the way for more predictable outcomes. By following these 10 top tips from leading endodontists in the field, we hope we can make your next treatment a lot more enjoyable.

1. Prepare with your pre-op

Once certain in your diagnosis and decision that endodontic treatment is needed, spending time properly assessing the preoperative radiograph can allow us to gain so much information and prevent major errors later on.

Dr Kreena Patel advises measuring the distance from the occlusal surface of the tooth to the pulp chamber. In turn transferring this measurement onto your bur.

This tip is especially useful in cases where the pulp chamber is calcified. You often don’t feel the ‘drop’ to signal you are in the correct location.

Also, paying attention to the angulation of the root is valuable. It allows you to angle your bur similarly, to avoid that dreaded perforation.

2. Get your equipment right

Starting with the simple things really will make your life easier.

Dr Kreena Patel says using a front surface mirror is a must for endodontics. If using a rear surface mirror, a ‘ghost’ image is produced. This makes it significantly harder to see fine details. But this is what endodontics is all about!

Alongside this, a DG16 makes a perfect partner. It is longer and sharper than a standard probe. The explorer is useful for both identifying canal orifices and determining the correct canal angulation. Meaning less time fishing around the pulp chamber.

3. Magnification is a must

A tip you’ve heard many times before, but one that can’t be stressed enough.

The difference a pair of loupes makes is a huge game changer for endodontic treatment.

Although a costly investment as a student, Dr Ahmed Almokhatieb advises even a cheap pair is enough to help with that fear of perforating with every millimetre movement you make.

4. Accessing the anatomy

For many of us, the most unnerving aspect of root canal treatment is the initial access. However, Dr Vishal and Dr Aaron provide us with handy tips to help combat this fear.

Firstly, build up missing walls before beginning the endodontic treatment.

When then ready to access, they advise rather than trying to create a shape with your access cavity, it is much easier to instead locate the roof of the pulp and focus on its removal.

This will automatically result in the access cavity being in the exact right shape and only as big as necessary.

Also, in order to prevent over prepping, Vish and Aaron recommend regularly forcing ourselves to stop drilling whilst accessing to assess positioning. It’s a good time to wipe away the sweat beads too.

5. Damage control with Endo-Z

When accessing posterior teeth, Dr Kreena Patel recommends a blunt ended-bur such as the Endo-Z.

With its non-cutting end, use the bur to safely remove the pulp roof without damaging the floor. Whilst the lateral cutting edges flare and refine the internal axial walls.

The ultimate goal is conserving as much natural tooth structure as possible. This bur is great to work non-invasively with and to keep our accesses as pretty as the ones you see on Instagram.

6. Hand files are your best friends

Perhaps the most emphasised and recurring tip from the specialists was the need to work gently.

Dr Almokhatieb stresses the importance of inspecting files for distortion as a routine before, even nearing a canal.

Once satisfied with its appearance, remember to never force a file into a canal. The key is to always negotiate gently!

However tempting it can be to rush to rotary for what we think will be an easier life, Dr James Darcey reminds us of the need to first establish a glide path up to size 20 using hand files. He speaks about the benefit of continually using fine files to get to length.

Dr Darcey also points out the importance of being familiar with both rotary and hand filing techniques. He reminds us to never take rotary files where hand files haven’t been.

It may feel longwinded, but take your time to avoid bigger problems like ledges and perforations.

7. The coronal flare

A good coronal flare allows for a reservoir of irrigant to form. It also means you only engage files at the tip, reducing the risk of file fracture.

Dr Mitul Patel recommends a good coronal flare should be up to the straight portion of each canal and should be estimated using a radiograph.

By doing this, you will also reduce your risk of pushing contaminated tissue or debris apically. Helping to prevent any unwanted complications.

8. Work your sodium hypochlorite hard

Sodium hypochlorite is a proven endodontic irrigant with excellent antimicrobial and tissue dissolving capabilities. Using it is almost a no brainer.

With the evidence to support it, Dr Darcey reminds to use plenty of it and to work it hard for maximum benefit.

To do this, simply warm up your hypochlorite and agitate it, improving its bactericidal and pulp dissolution activity.

Of course, it also has its risks. So be sure to take caution when using it and know how to manage any potential accidents.

9. Irrigation and activation

At the end of your preparation, Dr Mitul Patel advises to ensure the irrigant is delivered to the apical tissues.

To do this, take a 04 or 06 taper GP cone, which matches your apical diameter. Measure it to working length. Then, fill the pulp chamber and canals with sodium hypochlorite and pick up the cone with locking tweezers.

By pumping the GP cone in the canal, you will allow the irrigant to flow into the apical anatomy. This should be done with the final rinse protocol of EDTA followed by sodium hypochlorite to clean out any pesky lingering bacteria.

10. You aren’t finished at obturation

Once satisfied with your obturation, a useful tip from Dr Almukhadub is to use a layer of GIC over canal orifices.

This tip is valuable if the tooth needs re-treatment in the future and you must relocate the canals.

To seal the deal, Dr Darcey tells us the importance of having a definitive core to ensure all our hard work doesn’t go to waste. With the aim of keeping the pulpal space free of microorganisms to prevent recurrent infection, our coronal seal must then be accompanied by an appropriate restoration to form the final step.

Remember, particularly vulnerable teeth will require an indirect restoration. After all this, the last thing we want to deal with is a root fracture!

A special thank you to

  • Dr Kreena Patel BDS MJDF RCS(Eng) MClinDent(Endo), MEndo RCS (Edin): specialist endodontist
  • Dr James Darcey BDS MSc MDPH MFGDP MEndo RCSEd FDS Rest Dent RCSEd: consultant in restorative dentistry and specialist endodontist
  • Dr Ahmed Almokhatieb BDS MSc PhD: assistant professor and specialist endodontist
  • Dr Mitul Patel BSc (hons) PGCE BDS MJDF MSc(Endo): specialty doctor in endodontics and practice limited to endodontics
  • Dr Aaron Yusuf BDS (Lon) MFGDP(UK) RCS Eng
  • Dr Vishal Jasani BDS (Lon).

References

Madarati A, Watts D and Qualtrough A (2008) Factors contributing to the separation of endodontic files. Br Dent J 204: 241-5

Mandke L (2016) Importance of coronal seal: Preventing coronal leakage in endodontics. J Res Dent 4: 71-5

Spencer H, Ike V and Brennan P (2007) Review: the use of sodium hypochlorite in endodontics — potential complications and their management. Br Dent J 202: 555-9

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