Dentaltown June 2020 - 36

Incorrect armamentarium
I remember working in an office near Los Angeles as a general dentist. I was performing a molar root
canal and asked for another #10K file. The assistant said, "I'm sorry, we're all out of those." That moment
never left me. I am a big proponent of having the correct tools for the job. How can you perform quality root
canal treatment without the right instruments?
So, what are the intangibles?
1. 21mm, 25mm and 31mm #6-80 K hand files. Buy one pack of the larger files #50-80 in each length.
Make sure you have plenty of #6, #8 and #10K files. These are the files that you will use the most.
Use these for only one case and then throw them away.
2. Electronic apex locator. These devices are extremely accurate in electronically measuring working
length and save you treatment time. I love the ProMark Apex locator from Dentsply Sirona.
3. New shaping files with an endodontic motor. I love the ProTaper Gold and WaveOne Gold shaping systems.
These shaping systems allow me to efficiently shape the canals and achieve a very predictable, beautiful shape.
4. Obturation systems such as GuttaCore or GuttaSmart. These systems allow you to perform predictable 3D obturation.

No rubber dam
It's imperative to use a rubber
dam for every endodontic case. It's
the standard of care. The rubber dam
prevents microbes in the oral cavity
from contaminating the root canal system.
It retracts the lip, cheek and tongue and allows you to
focus on the treatment tooth. It also keeps the patient
safe and prevents sodium hypochlorite and 17% EDTA
from running into the oral cavity. Also, if you drop a
file into the mouth, it falls into the rubber dam, not
down the throat.

Missed canals
Accessing and locating all of the canals
is one of the general dentist's main concerns
when performing endodontic treatment.
One question I often hear when I lecture
is, "How do I find all the canals?" The answer
is vision and experience. Let's start with high-magnification
loupes and a bright light source: You can treat what you can
see. Secondly, assume all molars are guilty of four canals until
proven innocent of three. Third, take high-quality straight and
angled periapical radiographs and a bitewing. The bitewing
helps you determine how calcified the pulp chamber may be
or if a large pulp stone is present. Use CBCT if you have one.
Preplan your access by viewing the axial slices. Look for extra
anatomy and refer back as needed during access.

Non-negotiation to patency
This is one of the most important pillars of endodontics: If you can't get to the end of the canal, you can't
be sure you cleaned it all. If any part of an infected canal is not clean, there could be potential for reinfection.
After coronal flare with the ProTaper Gold SX, I take a #10K 25mm file, dip the tip into RC Prep and insert it
into the canal until it hits resistance. I then reciprocate it gently through the resistance and continue to advance
down the canal until I either hit a "brick wall" or pop out the foramen.
On simple cases, the #10K file will exit out of the foramen (patency) and you'll sometimes feel a little pop or give as it enters
through the minor constriction, then out into the periapical tissues. If the #10K hits a "brick wall," then most likely there is a slight
apical curve. I remove the #10 file and select a #8K 25mm file and create a 45-degree apical bend with my fingernails. I then place
the file back in the canal down to the block and take the file on a walk around the cul-de-sac of the apex.
By slightly lifting up on the file, then rotating the curved part of the file around the apex, I can usually find where the canal
curves and subsequently negotiate to patency. One trick to make this process easier is to first shape the coronal and middle thirds
of the canal with a ProTaper Gold Shaper 1 (purple) file. This opens the coronal/middle thirds and allows the #10K file to easily
advance down to the apex. Shape only the coronal/middle thirds and shape short of where the #10K extended.

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Dentaltown June 2020

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