10 Endodontic Tips for a Fresher Dentist

23 years into practice and I can still recall the days when as a fresher into endodontic practice, I used to wish that it's better if i get anterior or mandibular molar root canal patients! Managing maxillary molars was something I used to find difficult. Sharing my experience and gradual learnings to make your journey a bit easier!

Tip 1 - Diagnosis

The most important aspect of performing an endodontic procedure is to first correctly diagnose the tooth. There are several tools to help you understand just what's going on with the patient's tooth: radiographs, percussion tests, pulp testers, and endo sprays. Take your time as only the right diagnosis will take you to success. My first and foremost advise will be - listen to your patient carefully. There is no doubt that radiography is one of the cornerstones of endodontics. We use radiographs to aid diagnosis, during endodontic treatment, to judge the quality of the root treatment we have just completed, and to monitor healing. In the last decade, there has been a shift from wet film radiographs to digital. Believe me RVG is worth your investment. It not only saves your time but clarity of images improves the quality of treatment. After listening to patient's chief complaint , you can always ask some leading questions or look for the sign and symptoms to decide if the tooth needs pulp capping or root canal treatment.

How will you decide if the patient requires coot canal treatment? Here are 9 clues that may help!

1. Tooth pain that doesn't go away: Many dental problems can cause tooth pain. If the patient has pain deep in the tooth, he may need root canal therapy. Discomfort may also radiate to his jaw, face or other teeth. So if a patient says that he has pain which is radiating, this is your first clue that tooth might need RCT.
2. Sensitivity to heat and cold: If his tooth hurts when he drinks hot coffee or eats ice cream, it could mean that he needs root canal treatment. This is especially true if the pain lingers for more than a few seconds. In my experience, sensitive to hot is our second clue specially which lingers for some time.
3. Swollen gums: When a tooth is infected, pus can collect in the area. This can lead to puffy, swollen or tender gums. Sometimes swelling could be related to gingiva, so we need to differentiate.
4. Pimple on the gums: Patient may develop a pimple or boil on the gums. Pus from the infected tooth may drain from this pimple, causing an unpleasant taste or smell.
5. Swollen jaw: Sometimes pus doesn't drain from the site. As a result, jaw may become visibly swollen.
6. Tooth discoloration: When the pulp of a tooth is non vital, it can cause the tooth to look darker. This occurs because of poor blood supply to the tooth. Usually, trauma is the root cause for discoloration.
7. Pain when pressure is applied: If patient has pain when he eats or touches the tooth, it could mean the nerves around the pulp are damaged and in need of a root canal treatment. This is the popular POP (pain on percussion) or TOP (tender on percussion) test that we all have performed during internship!
8. A severely chipped or cracked tooth: If patient has severely cracked a tooth in an accident, when playing sports or even by biting down on something hard, bacteria can reach all the way into the tooth pulp. It is better to verify the location and severity of the crack with an x-ray before starting the RCT.
9. Loose tooth: An infected tooth may feel looser. This is because the pus from the infected pulp can soften the bone that supports the tooth. Since this may also be a finding in severe periodontitis cases, verify with an X-ray if the mobility is of endodontic origin, periodontal origin, or the lesion is an endo-perio lesion.

Self medication is very common in India. So, if a patient has already taken analgesic for tooth pain specially during night time...it's indicative of pulpal pain. Tooth might require root canal treatment.

What if you are still unsure if the tooth requires RCT?

In few cases it's difficult to be sure. In such cases, you can go ahead with pulp capping. Pulp capping can be divided in to two categories: indirect pulp capping or direct pulp capping.

• For an indirect pulp cap (IPC), a carious lesion approaches the pulp tissue, but a pulp exposure does not occur.
• With a direct pulp cap (DPC), the pulpal tissue is slightly exposed and a medicament is placed over the pulp.

You can give temporary restoration and wait for few days and observe before making final decision regarding pulp capping or RCT.

Direct pulp capping procedures offer an alternative to root canal treatment in select patients. Dycal and Mineral Trioxide Aggregate (MTA) have been studied extensively as direct pulp capping agents. Current research indicates better results when MTA is used as the pulp capping agent.

Tip 2 - Select the right needle for LA

It is necessary to use a topical anaesthetic before injection. These are available in gel, liquid, ointment or pressurized forms. The most common ones are those containing benzocaine or lidocaine. Gels are used for effective pain relief and to alleviate pain at the point of injection of the local anaesthetic. After gel application, 30 gauge needle /insulin syringe can be used to reduce the pain of inferior alveolar nerve block. Be gentle, if patients feel that you are taking extra care to make injection painless, you win their faith.

Tip 3 - Locate the pulp chamber correctly

Any permanent tooth not worn down occlusally/incisally has a pulp chamber that is situated approximately 7 mm from a cusp tip or an incisal edge. Slowly gain depth by small degrees leading up to access.

Figure 1. The length of the bur head plus the tapered portion of the shank equals to 6.50 mm in length, which closely corresponds to a depth slightly deeper than the roof of the pulp chamber when measured from an unworn cusp tip.

Figure 2. This 6.50 mm mark on the shank of a high speed round bur can be easily marked with a colored ink, allowing the dentist to ease it up with the cusp

Use the Endo Access bur at a predetermined length (marked with a SharpieⓇ permanent marker) so as not to perforate the furcation. The design of the bur is a combination of a round and cone-shaped course diamond which allows access into the pulp chamber and preparation of the chamber walls, in one operation.

Bur with a non-cutting tip is used to taper and smoothen the access cavity preparation. Endo-Z Bur Safe End bur, with its long, tapered shape, allows widening of the pulp chamber for adequate access. The rounded, non-cutting safe-end tip prevents penetration of the pulp chamber floor or the root canal walls. Always divide your RCT into three parts:

1. First widen the access
2. Then, prepare the glide path which ensures that file easily reaches the desired working length and lastly
3. Finally, prepare the apical third .

4. Tip 4 - Access is Success!

A well-known endodontist, Dr. Frank Weine, coined the adage "Access is success." What this means is that if you get the access cavity design right, it makes the preparation of the root canals much easier. The access cavity should be large enough so that direct line access to the canals can be achieved, but small enough so that as much of the coronal tooth tissue as possible can be preserved. Once access is gained, the entire roof of the pulp chamber should be removed. At this step (deroofing), you can change but from Endo access to Endo Z safe end bur. This really helps as we don't disturb the floor of pulp chamber and only roof is removed. We should be able to see canals on floor as road map.

Finding canals is a bit easy in mandibular molars. Sharing few tips to negotiate maxillary molar canals:

LOCATING THE PALATAL CANAL Locating the palatal canal is a starting point for locating the other buccal canals as it is the biggest. It is often located at or slightly mesial to the midpoint of the palatal surface of the molar. The palatal canal is often angled at approximately a 45-60° angle relative to the molar crown long axis. We can point a 330 bur toward the mesial, at approximately a 45-60° angle. After penetrating the pulp chamber roof, irrigate the initial access opening, and attempt to locate the palatal canal with a #10 file. If the palatal canal cannot be located, we can widen the access opening in the area where we presume that the palatal canal orifice is located, try again to locate the orifice, and repeat these steps until the orifice is located. A dentist can distinguish the palatal canal visually from the other canals since the palatal canal deflects the file handle in a buccal direction. LOCATING THE MESIOBUCCAL (MB) AND DISTOBUCCAL(DB) CANALS The orifice of distobuccal(DB) canal is is at a distance of 3 to 4 mm distance from the palatal canal orifice in the distopalatal direction most cases. The mesiobuccal (MB) canal orifice is generally located at 2 mm distance from the DB canal in the majority of cases. After locating either the mesiobuccal 1 (MB1) or the distobuccal (DB) canal, we can use a #8 file to remove canal tissue that may be hemorrhaging blood, to make it easier to locate other canals. Even if there is a tiny distance between the DB, MB1 and MB2 canal orifies, the canals can be visually distinguished from one another. A file that is not in the palatal canal, and that emerges from the canal with the file handle directed toward the mesial, is in the DB canal. LOCATING THE SECOND MESIOBUCCAL (MB2) CANAL Since the MB2 canal is present in most (70-90%) of maxillary first molars, and approximately, 45% of maxillary second molars, its presence should be assumed until demonstrated otherwise.The MB2 canal may be located a fraction of a mm from the MB1 canal, and may eventually join with the MB1 canal, The MB2 canal may also be located approximately midway between the MB1 canal and the palatal canals. If an MB2 canal is extremely narrow in diameter or partly calcified, the canal may initially only be accessible using a #6 file lubricated with ethylenediaminetetraacetic acid (EDTA) chelating agent .

Another advise--- no file should go inside the canal without lubrication. EDTA gel/liquid are available for lubrication. I prefer EDTA liquid .

Tip 5 - Use an Ultrasonic!

So next tip is to use your ultrasonic scaler to it's full potential! It can make your life easier! Think of your ultrasonic as a safer slow handpiece with much better vision.

• You can use it to remove dentin when you're searching for canals and it's much better than the slow handpiece because you remove dentin in smaller increments with much more control and you can see better since the tip is very thin, whereas a slow speed handpiece blocks your view completely!
• It's also the best way to remove pulp stones and pulp tissue when used in combination with sodium hypochlorite.
• And lastly, you can use it initially to open up your canal orifice!