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A Potpourri of Endodontic Topics Drs. Kenneth Koch and Dennis Brave

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


The dog days of summer are coming to end, which means you should take the little bit of summer left to put your feet up and relax; the perfect time to have some fun with endodontics! For this reason, we've put together a "potpourri" of various endodontic topics – not heavy research information, but light and interesting tips to achieve better results with endo. So, go to the fridge, get a cold beverage, put your feet up and let's get started.

New, Less Expensive Rotary Files
Yes, it appears there will be a number of new nickel titanium rotary files introduced into the endodontic marketplace. Some will come from Asia, some from Europe and there might even be one or two from North America. Therefore, it should come as no surprise that the price range for these instruments will vary greatly. It also should be noted that the quality will also vary greatly. So, what should the clinician do?

Our advice is to be careful and go with proven brands such as Brasseler USA, Dentsply Tulsa or SybronEndo. More importantly, the dentist must think in terms of endodontic systems, rather than just files. It makes more sense to have an obturation technique and post system that will precisely match the shape created by the rotary files. This is where endodontics is headed. Once you have endodontic synchronicity, the entire aim of melding endodontics into restorative dentistry becomes that much easier. We particularly like the EndoSequence system (Brasseler USA) because it allows you (through its constant taper preparation and bioceramic obturation) to achieve such synchronicity.

CBCT's Role in Endodontics
This is an area that has been receiving a lot of attention in endodontics. Therefore, we have referred this question to Dr. Jerry Cymerman a Real World endodontist in Stony Brook, New York who routinely uses this technology. He says:

"Evaluation with intra-oral periapical radiographs, clinical exam and pulp testing are the standard diagnostic modalities for the evaluation of pulpal and periapical pathology. However, two-dimensional radiographs present limitations in assessing root anatomy, root canal morphology, bone and root resorption and superimposition of overlying structures. CBCT has been shown to be significantly more sensitive in detecting periapical lesions, root resorption, root and bone fractures and additional canals. I also utilize CBCT to evaluate traumatic injuries of the teeth, for implant evaluation and pre-surgical planning for endodontic surgery (apicoectomy). The advantage of having three-dimensional images for challenging surgical and non-surgical endodontics and diagnosis allows a higher level of patient care."

Anesthesia
To consistently perform successful endodontics, the patient must be numb. Therefore, a good block technique is important. If you are having challenges getting good results with your mandibular blocks, try the following suggestions.

The first tip involves the pKa of your anesthetic solution. For profound, long-acting blocks (for endodontics or quadrant dentistry) try first administering a carpule of 3% mepivacaine (without a vasoconstrictor) then follow that with a carpule of regular 1/100,00-epi lidocaine. You will get deeper, more profound blocks. This is not anecdotal, but rather a technique based on science. It works because of the difference in pKa values. Remember that you give the 3% mepivacaine first because it is more comfortable to the patient. (This is a result of the pH of the mepivacaine.) After the mepivacaine has been delivered, then follow that with a carpule of your regular lidocaine. This technique works great.

But what happens if you give a patient two blocks and the patient seems very numb yet when you touch the tooth with your round bur, the patient seemingly comes out of the chair? What do you do? "Immediate referral to the endodontist" is not the answer we're looking for! The nerve that causes this excruciating pain (when seemingly everything else is numb) is the mylohyoid. In order to sufficiently anesthetize the mylohyoid, you must locate it first. There are two locations where the mylohyoid can be found. One is up at the condyle and the other is on the lingual side of the mandible, at a level equal to the apices of the lower second molar.

The easiest way to anesthetize the mylohyoid is through the Gow Gates injection technique. When using this technique, the patient is placed supine in the chair. With his or her mouth wide open, the syringe is directed on a line from across the corner of the mouth to the tragus of the ear. Entry is made (with a long needle) at approximately the level of the MGJ (muco-gingival junction) of the maxillary second molar and is advanced until it contacts bone. This is the condyle. The contents of the carpule are deposited in the region of the condyle, thereby soaking the mylohyoid nerve. This soaking contributes to the effectiveness of the technique. When properly performed, the Gow Gates is more effective than a traditional block.

What about the mylohyoid at the lingual level of apices of the lower second molar? This is an old oral surgery trick and you can simply infiltrate in this area and generally not more than half a carpule is needed. Inject slowly because this area is very vascular. A quick injection here can give the patient an unwarranted "rush." It is because of these concerns that we much prefer the supplemental mylohyoid injection to be in the vicinity of the condyle (Gow Gates technique).

We also recommend all dentists who want to learn the Gow Gates technique do research on the Web or in textbooks, and obtain further information concerning the technique.

Rubber Dam Clamps
Our thoughts and recommendations concerning clamps:

Anterior teeth: 9 N or 211 clamps will do. Bow clamps work well not only on anterior teeth but also on premolars, particularly those teeth prepared for crowns. The 211 is the most popular bow clamp.

Premolars: 00, 209s are small clamps that work well on all premolars.

Molars: 12A/13A are clamps with serrated beaks, sort of like tiger clamps. These are great for molars and will grab on to anything. 12A/13A work UL, LR and UR, LL. You definitely need to have these clamps! The Hu-Friedy and Aseptico clamps both work very well.

Optional clamps: W8A is a standard molar clamp that can be modified; W3A is another molar clamp that works well on maxillary second molars and can make your life a lot easier.

Also, it should be noted that many times when working on anterior teeth (especially those with crowns) you do not need clamps. Instead, simply cut a piece of rubber dam and run it through the contacts on the adjacent teeth. You can also use "widgets." The rubber placed in the contact area will hold the rubber dam in place. This is a nice trick because you do not have to place a clamp on the porcelain.

Safety Glasses
We are still amazed (even in dental schools) at the lack of safety glasses on patients. This should be a no-brainer! Did you ever get acrylic in your eye when adjusting a temporary or denture? It can be very irritating. Now, think about this – you should be using bleach as your endodontic irrigant and, if you get some bleach in the patient's eye by accident, it will be bad for both you and the patient. Please have your patients wear safety glasses or some kind of eye protection. Don't wait until an accident happens.

Coming Up Short
If you are using a Bioceramic sealer, such as BC Sealer, with a Hydraulic Technique and find you are coming up short (after a confirmed trial fill), you are probably using to much sealer in the canal.

Another problem could be what gutta percha cones are being employed with the technique. The use of the wrong cones can result in the final insertion coming up 1mm short. Consequently, we strongly recommend the use of the BC coated cones when using the bioceramic technique. The bioceramic cones are stiffer and will not collapse under the hydraulic pressure. If one is using the BC coated cones, and still coming up 1mm short, then the answer is definitely too much sealer…

We have found that dentists beginning this technique have a tendency to place too much sealer into the canal, even when they limit it to the coronal third. Therefore, we recommend that you do a few cases using the sealer in the same manner as you did with the old conventional sealers (lightly coating the cone and taking it down into the canal and coating the walls). By doing such, you will get a sense of how the material flows in your hands. Then, as you get comfortable with the flow rate you can start to inject a little bit of sealer into the coronal third only and then seat your cone through the sealer.

There are multiple videos of this technique on the Internet but one thing is generally not mentioned – a number of the specialists using this technique (after they inject the sealer) take the last rotary file employed and use it by hand in a counterclockwise motion. They proceed to take this file all the way to the established working length and then make a counterclockwise motion with the file and remove it from the canal. This process will remove any excess sealer that exists in the flutes of the rotary file. It is a very clever technique and one that works well, but we believe that it can be avoided by simply using less sealer.

Instrumenting Narrow, Tight Canals
We have often talked about proper access and good lubrication helping the clinician instrument difficult canals. Additionally, we have talked about the crown down method and using .04 taper rotary files. However, there has been a new instrument recently introduced by Brasseler USA, that has us very excited – the Scout RaCe file.

The Scout RaCe comes in a number of sizes but the ones we really like are the #10, #15 and #20, all in a .02 taper. While these instruments are extremely well-made and flexible, we also like their ability to cut. Even though they have a non-cutting tip, the Scout RaCe files are great at gaining length (and shaping) in those difficult canals.

One clinician who has extensive use with these files is Dr. Ali Nasseh in Boston, Massachusettes. Here is what Ali has to say about them:

"The Scout RaCe Files offer the same predictability in efficient cutting of dentin that I've come to expect from their sister files, the 'EndoSequence' File Series. These files have the additional benefit of being very useful in thinner, more curved roots found in most molars. With these small sizes, the clinician can bypass the tedious work of hand instrumentation in smaller sizes and can benefit from the super-elasticity of the NiTi metal with the efficiency of rotary instrumentation vs. hand filing.

"Following the use of a size 6 or 8 hand file, and some coronal enlargement (as recommended in all crown down techniques), the size 10-20 (or merely 10 and 15) Scout RaCe files can rapidly enlarge the canals and create a patent canal that can then be instrumented predictably and safely with the EndoSequence Files or your rotary instruments of choice."

One other thing that needs to be mentioned is that we believe the use of .02 taper rotary files (whatever system) should be limited to those dentists with considerable experience with rotary files. If one's endodontic clinical experience is somewhat limited, the clinician is best served using hand files (which are also .02 taper) in these challenging narrow canals.
Author Bios
Dr. Dennis Brave is a diplomate 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 Odontologic 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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