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How to Avoid an Endodontic Nightmare Drs. Kenneth Koch and Dennis Brave

Start Discussion More by Dr. Kenneth Koch (15)More by Dr. Dennis Brave (15)




In our previous article (see p. 54 of the Feb. 2010 issue of Dentaltown Magazine), we discussed how to improve your predictability in endodontics as well as increasing your profitability. Expanding on this theme, we would now like to share our thoughts on how to avoid certain endodontic disasters. More specifically, the issue of separated rotary files and perforations. While neither is a welcome event, they should not be met with dread or fear.

Broken or separated instruments can occur during the day-to-day practice of endodontics. Breaking an instrument is not malpractice; however, failing to inform the patient that a separation has occurred is. You must inform the patient. The key is how you do it. In a confident and calm manner, inform the patient that during the procedure a sterile piece of the instrument separated from the file and will be incorporated into the final fill. Tell them you will recall the tooth at six- and 12-month intervals – the same as any other endodontically treated tooth. End of story. A separated instrument does not condemn a tooth.

In fact, long-term complications following a separation are rare but can be problematic. If a file separates in the coronal third of a canal it can often be removed with an ultrasonic. The key in this case is being able to see the separated portion of the instrument. However, it is our experience that most rotary files separate in the apical 2-3mm where they are essentially screwed into the canal.

When a separated instrument is located in the apical 2-3mm, it is extremely difficult to remove. A separated rotary file is very different from a hand file where the canal or apical constriction might be larger than the file diameter. Unless very experienced with a microscope (and an ultrasonic tip) attempting to dislodge the separated portion can actually destroy the tooth. Needless to say, this would be an endodontic nightmare. Practitioners should always try to bypass the instrument first, if possible. This is where using a rotary file with a reamer design has a big advantage over a landed instrument.

Because of the excess metal associated with landed instruments, it is extremely difficult (if not impossible) to bypass a separated segment of these files. However, a rotary file with a true reamer design (such as EndoSequence) has more than ample space in which to bypass an instrument (Fig. 1).

Regardless of the file used, a realistic question we must ask ourselves is the following: Is it really necessary to remove an instrument in the apical 2-3mm? Generally, the answer is no. Furthermore, what are the risks/benefits of performing such a procedure? The best way to answer this question is to say that we should carefully evaluate each situation. We must determine where the instrument is separated (within the tooth or past the apex), the vitality of the tooth, the presence or lack of symptomology, and if the tooth has a radiographic area associated with it.

If the tooth is vital and the instrument is separated within the tooth (in the apical 2-3 mm) chances are good that it will not be a problem. Simply obturate the canal using a little extra sealer and fill to the separated portion of the file. If the tooth is non vital, obturate the canal in exactly the same manner and make certain that you recall the case in a timely manner (six months, 12 months, 24 months). If the tooth is vital and symptomatic, it is less of a concern than if the tooth is non vital and symptomatic.

No dentist likes to break an instrument. It ruins your day. However, it is very important to know how to treat these incidents and how best to explain the situation to the patient. This is the key to mitigating the consequences of this potential endodontic nightmare. Of course, the best way to avoid the specter of broken instruments is through prevention.

Notwithstanding difficult teeth, another event that can cause a nightmare for a dentist is the perforation. Perforations generally occur in two types of patients: difficult individuals and geriatric patients. Sometimes when treating a difficult patient we proceed with the case and notice that they are having some sensitivity (Remember the axiom, “Bad things happen to bad patients”). The combination of a situation that is difficult to manage, along with less-than-ideal anesthesia, often makes both the patient and the dentist anxious. This is a nightmare waiting to happen. Unfortunately in their haste to get an effective intrapulpal injection (and see “red”), they go too far and inadvertently perforate the floor of the chamber. This can rapidly degenerate into an endodontic disaster.

The other common situation is searching for the pulp in an elderly patient. Quite often with geriatric patients, there is little or no pulp in the chamber and subsequently, in their haste to “find red” the dentist accidentally perforates the tooth. Now the dentist will see “red” but unfortunately, it’s coming from the PDL, not the pulp. The following tip will help you prevent this nightmare from occurring. Before you start the procedure, place your access bur against the pre-op X-ray to estimate how far you can drill before you reach the floor of the chamber. This will save you a lot of aggravation and consternation.

Unfortunately, perforations do happen, but how are they best handled? Three things are key to perforation repair: time, size and location.

It is absolutely critical (for the long term success of the tooth) to repair a perforation as soon as it happens. This applies to both large and small perforations alike. Do not reappoint the patient to further evaluate the situation. Simply seal the perforation at the time of its occurrence.

The second key element is size. This is truly a case where size matters. Obviously, the smaller the perforation, the better its long-term prognosis. There is a big difference between a perforation with a #10 hand file and a #3 Peeso Reamer.

The third factor is location – where did the perforation occur? The more apical the perforation, the better the prognosis. A perforation in the apical third with a small hand file, can be considered somewhat like an accessory canal. Make certain the canal has been cleaned and irrigated properly and then obturate like normal. This is where a bioceramic sealer can be a huge help.

Although a perforation in the coronal third of the root has a reduced prognosis, it is still quite good. However, a perforation that occurs directly at the CEJ has a reduced prognosis due to the percolation of oral fluids from the gingival sulcus. Nonetheless, the overall prognosis, if handled correctly, is also quite good.

Therefore, the next question should be “What is the best way to repair a perforation?” Fortunately, a real endodontic nightmare can be avoided thanks to the advanced repair materials available.

Historically, all kinds of materials were utilized in perforation repair. However, when mineral trioxide aggregate (MTA) was introduced, it was a significant advance in perforation repair. MTA is a calcium silicate formula (similar to Portland cement) that possesses very good sealing ability along with excellent biological tolerance. However, the challenge to some has been its handling ability (or lack thereof ). It does not come pre-mixed (and therefore must be mixed by hand), can be difficult to use, and has such a large particle size that it cannot be extruded through a small syringe. Nonetheless, it is a good material and has a number of favorable characteristics including a pH of 12.5, which is quite antibacterial. But the science of repair materials has continued to evolve to a higher level through nanotechnology. This next level is the application of true bioceramics for perforation repair.

As mentioned in previous articles, EndoSequence Root Repair Material is a true bioceramic, which comes premixed in a syringe just like BC Sealer. This is a tremendous help not just in terms of assuring a proper mix but also in terms of ease of use. Consequently, for the first time, we now have a root repair material with an easy and efficient delivery system (Fig. 2).

Actually, EndoSequence Root Repair Material has been created as a white premixed injectable paste for both permanent root canal repairs and apico retrofillings. It is insoluble, radiopaque and an aluminum-free material based on a calcium phosphate silicate composition. As a true bioceramic cement, the advantages of this repair material are (again) its high pH (pH 12.7), high resistance to washout, no-shrinkage during setting, excellent biocompatibility and superb physical properties. In fact, it has a compressive strength of 50-70 MPa, which is similar to that of current root canal repair materials, ProRoot MTA (Dentsply) and BioAggregate (Diadent). However, a significant upgrade with this material is its particle size which allows the premixed material to be extruded through a syringe rather than mixing by hand and then placement with a hand instrument.

As previously discussed, we believe the bioceramic material to use in surgical cases is the Root Repair Material (RRM). The RRM is available in two different modes. There is a syringeable RRM (very similar to the basic BC Sealer in its mode of delivery) and there is also a RRM putty that is both stronger and malleable (70- 90 MPa). The RRM in a syringe is obviously delivered by a syringe tip but the technique associated with the putty is different (Fig. 3).

When using the putty, simply remove a small amount from the room-temperature jar and knead it for a few seconds with a spatula or in your gloved hands. Then start to roll it into a hotdog-like shape. This is not unlike creating similar shapes with desiccated ZOE or SuperEBA (Bosworth). Once you have created an oblong shape, you can pick up a section of it with a sterile instrument and use this to deliver it where needed (Fig. 4). This is an easy technique for perf repairs, resorption defects and even for apico retro fills. After placing the putty into the apical preparation (or defect) simply wipe with a moist cotton ball and finish the procedure.

Protocol for Root Perforation Repair
After rubber dam isolation and the complete cleaning and shaping of the root canal system, obturate the canal apical to the site of perforation.

Place the repair material into the perforation area. If using the syringe, slowly express the material and if using the putty, slowly push the material and swipe with a moist cotton pellet.

“Ideally” place a moist cotton pellet over the perforation repair site and seal the canal for a minimum of three to four hours.

Once the repair material has hardened, obturate the remainder of the root canal with a permanent sealer (preferably EndoSequence BC Sealer) and complete the restoration.

EndoSequence Root Repair Material will remain as a permanent part of the root canal perforation repair.

The following case demonstrates the use of ESRRM as a perforation repair technique (Fig. 5).

We have discussed, in this article, some ways to avoid the occurrence of an endodontic nightmare. More specifically, we have offered suggestions as to how to handle separated instruments as well as perforations. Both events, although unpleasant by nature, can be treated in such a manner as to neither alarm the patient nor significantly decrease the long term prognosis of the tooth.
Author’s Bio
Dr. Dennis Brave is a diplomate of the American Board of the American Board of Endodontics, and a member of the College of Diplomates, Dr. Brave received his DDS degree from the Baltimore College of Dental Surgery, University of Maryland and his certificate in Endodontics from the University of Pennsylvania. He is an Omicron Kappa Upsilon Scholastic Award Winner and a Gorgas Deontologists Honor Society Member. In endodontic practice for more than 25 years, he has lectured extensively throughout the world and holds multiple patents, including the VisiFrame. Formerly an associate clinical professor at the University of Pennsylvania, Dr. Brave currently holds a staff position at The Johns Hopkins Hospital. Along with having authored numerous articles on Endodontics, Dr. Brave is a co-founder of Real World Endo.

Dr. Kenneth Koch received both his DMD and Certificate in Endodontics from the University of Pennsylvania School of Dental Medicine. He is the founder and past Director of the New Program in Postdoctoral Endodontics at the Harvard School of Dental Medicine. Prior to his Endodontic career, Dr. Koch spent 10 years in the Air Force and held, among various positions, that of Chief of Prosthodontics at Osan AFB and Chief of Prosthodontics at McGuire AFB. In addition to having maintained a private practice, limited to Endodontics, Dr. Koch has lectured extensively in both the United States and abroad. He is also the author of numerous articles on Endodontics. Dr. Koch is a co-founder of Real World Endo.
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