It is estimated that more than 90% of endodontic treatment is done by GPs, yet their root canals still have a 20% failure rate. So what are endodontists doing that GPs aren’t? Dr. Allan Deutsch says there are four things you must master to achieve a successful clinical outcome for your endodontics procedures.
This article first appeared in the newsletter, DE's Breakthrough Clinical with Stacey Simmons, DDS. Subscribe here.
It’s no secret that more and more general practitioners are incorporating endodontics into their practices. It’s being done for one simple reason: practice growth. According to Gordon J. Christensen, DDS, MSD, PhD, it is estimated that more than 90% of endodontic treatment is done by the GP. However, Dr. Christensen goes on to say that root canals done by GPs only have an 80% success rate. (1)
Surveys suggest (2) that, for the most part, GPs are straying away from molar endo and sticking with straight, single-rooted canals, and still are experiencing a 20% failure rate. So what are endodontists doing that GPs aren’t? The difference is that endodontists have mastered the techniques and know the ins and outs of the materials they are buying.
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These four things are essential to achieve a successful endodontic outcome:
1. Clean the canal thoroughly.
The goal is to clean the canal thoroughly and produce a canal shape that can be fully obturated. Furthermore, it is important to remove as little tooth structure as possible to ensure maximum strength during the endodontic procedure.
When it comes to endodontic shaping there are two schools of thought: rotary or reciprocation. Rotary offers a continuous, 360-degree rotation, which can lead to binding and broken instruments. Due to the possibility of these iatrogenic incidences, reciprocating endodontics has become increasingly popular. Reciprocation moves in a back-and-forth, watch-winding motion. In recent years, there are more and more reciprocating systems on the market: WaveOne and WaveOne Gold (Dentsply), Reciproc (VDW), Endo-EZE (Ultradent), Tango-Endo (Essential Dental Systems), Endo-Express and SafeSiders (Essential Dental Systems).
I use the Tango-Endo System (Essential Dental Systems) in my endodontic practice. This system moves in true reciprocation, oscillating at 30 degrees. Thirty-degree oscillation is preferable to other reciprocating systems that progressively increase the degree of movement until reaching full rotation. Since its introduction in February 2015, many GPs have also added the Tango-Endo in their office due to its safety, efficiency, and low learning curve. Moreover, it is ideal for anterior teeth. With Tango-Endo, instrument breakage is virtually eliminated, making root canals more successful.
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2. Use an irrigant that disinfects.
Unfortunately, endodontic instrumentation alone does not remove 100% of bacteria and debris from the canal. Many studies have shown the limited ability of instrumentation alone to debride and clean the canal. (3–7) Wu, et al. reported uninstrumented areas in 65% of instrumented, oval canals. (8)The most frequently used irrigant is sodium hypochlorite (NaOCl). This irrigant has great advantages in that it dissolves necrotic tissue and kills bacteria quite effectively. However, it may not always kill Enterococcus faecalis. These bacteria can often be found in biofilm in the canal and in the tubules. They are persistent and often resistant to calcium hydroxide as well as NaOCl. E faecalis seems to be especially prominent in endodontic cases that have had root canal treatment and are failing. (9) Its prevalence in those infections ranges from 24% to 77%.
My endodontic protocol in the past was not only to use NaOCl but to add 2% chlorhexidine to combat E faecalis and also use EDTA to open the dentinal tubules and remove the smear layer. Just over a year ago, I switched to a new irrigation product, Irritrol (Essential Dental Systems). This product combines EDTA and chlorhexidine (CHX), thereby shortening my procedure time. More importantly to me, however, is the product’s 99.99% disinfection rate compared to CHX at 20%. For additional activation of this 2-in-1 endodontic solution, I use a PUI Piezo Tip (Passive Ultrasonic Irrigation). PUI Tips are designed to activate irrigants ultrasonically, making them more effective within the canal to aid in removing biologic debris and the smear layer.
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3. Don’t underfill.
Now that we have cleaned and shaped the root canal, our challenge is thorough obturation. There are many choices among obturation systems. Categories include lateral condensation, thermoplastic (heated gutta-percha) and single-point fills. Heated gutta-percha tends to shrink upon cooling, and lateral condensation can produce unnecessary stress to the root. I prefer placing a single point due its tighter sealing ability. (10) I use EZ-Fill (Essential Dental Systems), a resin-based sealer that won’t shrink. It is applied using the bidirectional spiral that whips the cement laterally in the canals, giving a complete 360-degree fill. The technique is inexpensive and quick to complete.
4. Take a course.
It all comes down to practice. The more endodontics you do, the better you will be. I recommend taking as many courses as you can until you not only feel comfortable, but relaxed and competent. For more information on a two-day hands-on endo course, visit essentialseminars.org.
This article first appeared in the newsletter, DE's Breakthrough Clinical with Stacey Simmons, DDS. Subscribe here.
References
1. Ask Gordon: What Percent of Endodontics Is Done by GPs? Video by Gordon J. Christensen, DDS, MSD, PhD. DentistryIQ website. PennWell Dental Group Community site. http://community.pennwelldentalgroup.com/video/ask-gordon-what-percent-of-endodontics-is-done-by-gps Published on YouTube on January 27, 2015. Accessed June 21, 2016.
2. Du Molin J. Root canal: Who needs an endodontist? http://thewealthydentist.com/surveyresults/100-root-canal-referrals.htm Accessed June 23, 2016.
3. Hülsmann M, Stryga F. Comparison of root canal preparation using different automated devices and hand instrumentation. J Endod. 1993;19(3):141–5.
4. Hülsmann M, Schade M, Schäfers F. A comparative study of root canal preparation with HERO 642 and Quantec SC rotary NiTi instruments. Int Endod J. 2001;34(7):538–46.
5. Hülsmann M, Gressmann G, Schäfers F. A comparative study of root canal preparation using FlexMaster and HERO 642 rotary NiTi instruments. Int Endod J. 2003;36(5):358–66.
6. Versümer J, Hülsmann M, Schäfers F. A comparative study of root canal preparation using ProFile .04 and Lightspeed rotary NiTi instruments. Int Endod J. 2002;35(1):37–46.
7. Hülsmann M, Herbst U, Schäfers F. Comparative study of root canal preparation using Lightspeed and Quantec SC rotary NiTi instruments. Int Endod J. 2003;36(11):748–56.
8. Wu MK, Wesselink PR. A primary observation on the preparation and obturation of oval canals. Int Endod J. 2001;34(2):1371–41.
9. Stuart CH, Schwartz SA, Beeson TJ, Owatz CB. Enterococcus faecalis: its role in root canal treatment failure and current concepts in retreatment. J Endod. 2006;32(2):93–8.
10. Cohen BI, Pagnillo MK, Musikant BL, Deutsch AS. The evaluation of apical leakage for three endodontic fill systems. Gen Dent. 1998;46(6):618–23.
Allan S. Deutsch, DMD, FACD, is an international lecturer and prolific author of articles in major dental journals. He holds 19 patents for co-inventing revolutionary endodontic obturation, instrumentation, post and composite systems, as well as laser tips. As a founder in the largest endodontic practice in Manhattan, Dr. Deutsch's 35-plus years of clinical experience have made him into one of the top authorities in the field. He is currently an assistant clinical professor of endodontics at Columbia University in New York City. Dr. Deutsch is co-founder of the tri-state area's HODEC (Hands-On Dental Education Center)—a hands-on training center that encourages general dentists and endodontists to upgrade and sharpen their skills. He is the executive vice president, co-director of dental research, and co-founder of Essential Dental Systems (EDS), a dental products manufacturing company in South Hackensack, New Jersey. Dr. Deutsch received his DMD from Tufts University Dental School in 1973 and completed his postgraduate studies in endodontics at Columbia University Dental School in 1976. He is a member of numerous national dental organizations and is also a fellow of the American College of Dentistry.
