Ajay Dhunna presents his top tips for starting out in endo, to improve your workflow and allow you to enjoy this treatment.
Endodontic treatment is something that many GDPs do not like. From speaking to colleagues, it would seem the reason why they hate seeing it on their day list is because people do not have a sufficient workflow for this treatment.
I have come up with a few top tips for endodontics as a GDP that I have picked up and implemented over the years. Hopefully these tips will help improve your workflow to hopefully allow you to enjoy this treatment.
Proper radiographic analysis
This is the first important aspect you need to fully analyse before you start endodontic treatment. I like to think of this as a question: ‘Is the tooth restorable?’ Start with the end in mind. Use a periapical to assess the amount of coronal tissue left, the extent of any caries or cavities present and assess the general factors affecting root canal treatment. These endodontic assessments can involve:
- Roots: curvatures, length, number of roots, calcification, sclerosis, any signs of fracture
- Pulp chamber: size, shape, position, obstructions, deep caries close to pulpal floor
- Periapical periodontitis: size of lesion, position of lesion, furcation involvement.
Isolating the tooth to be treated with rubber dam should be a mandatory factor in carrying out endodontic treatment. However, some clinicians feel inefficient in using rubber dam.
Practising isolation is thus very important, in order to provide a dry, clean working field that allows full disinfection of the root canals. I actually recommend isolating more than one tooth now as this provides a wider working field, as well as allowing you to fully visualise the angulation of the teeth, which reduces the chance of perforation.
Multi-tooth isolation seems tedious to some, but once you start getting used to single-tooth isolation, start isolating one tooth in front and behind the tooth to be treated and this will improve your vision immediately.
Something else that will improve your vision of root canals is magnification. The easiest way to achieve this is dental loupes, although a microscope will give unparalleled vision.
Magnification will allow you to see more and observe the really intricate details. You will be able to see the orifices clearly and make sure there is clear access to the canals free of dentine ledges and obstructions.
Access: design and making the access
Learn about the access designs for the different teeth. You want to ensure you preserve as much coronal tooth tissue while achieving proper disinfection. Your access will need to be altered if there are existing restorations present, as these will preferably need to be removed first to ensure a caries-free tooth. You can then incorporate this cavity in to the access design.
When accessing the tooth, enter through the enamel and the roof of the pulp chamber with a high-speed fissure bur. Straight after this, change the bur for a non-end cutting bur to remove the roof of the pulp chamber with a high-speed bur, such as an EZ bur.
Once this initial access is achieved, switch to a rose head bur to cut through the dentine and find the orifices of the tooth to locate the root canals.
Use the non-end cutting bur to create straightline access for your files, which will prevent excess forces and strain put on these files. Spend time on creating good access so that you can create easy path for entry of files.
Once you have accessed the tooth it is important not to just go straight for the apex. If you do this, you are more likely to fracture the files.
I recommend starting off with a size 10, 15, 20 K-file to first establish a glide path for the eventual rotary or oscillating system.
Prepare and widen the coronal aspect of the canal a bit first to provide better access to the canal and reduce stress on your stainless steel instruments, as well as providing a reservoir for the irrigant.
This article was first published in Clincal Dentistry magazine. Sign up to receive the latest issue of Clinical Dentistry here.