The problem I found with endodontics was that the more you learn, the less you can cut corners, and the longer it ends up taking!
I was keen to learn how to be more efficient with endodontics so I brought on Dr Omar Ikram to talk us through his sequencing and protocols for RCTS.
Turn those challenging appointments into seamless, lunchtime-friendly successes.
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Click below for full episode transcript:Jaz's Introduction: When I qualified from dental school, I was really into restorative, but the part of restorative I was most into was actually endodontics. In fact, I actually did quite a lot of root canals when I was a dental student.
And the funny story is that because of orthodontics, I actually lost vitality of my four lower incisors.I had root canals from specialists for all my lower four incisors. So I actually experienced root canal treatment as a patient while I was a dental student. And also having really inspirational tutor and someone called Dr. Stephen Godfrey at dental school meant that I was actually really looking at these postgraduate options for specializing in endodontics as one of my serious career considerations.
I went on to win the Tom Pitt-Ford prize, which is given to like one student per dental school every year. And I also won like this runner up prize in the Julian Webber Harley Street prize. And I was basically about submitting a case. And I did an MTA case back when I was a DCT in Sheffield. That was pretty cool.
Using a scope, learning how to do simple retreatments. So I was on the path to really consider endodontics. Now fast forward 10 years. And my favorite type of endodontics is the referral pad. Okay, I’m joking but I’m kind of not joking because it’s not my favorite thing to do anymore. I do TMD, I do restorative, I do occlusal stuff, tooth wear, and I get a lot of joy from that.
Root canals is low down in my pecking order and one of the reasons I’m so keen to refer to my specialist colleagues is how long it takes me and I’m thinking if this tooth is going to take two hours with me and it’s going to take one hour and 15 minutes with the specialist and they’ll probably do a better job than I will.
Then it just makes sense to see a specialist, right? If the patient can afford it, great. And also, in terms of an hourly rate, like GDPs doing endodontics that are particularly tricky and pushing boundaries and spending longer on it, it just doesn’t make sense as a financial point of view. Because if your patient is paying for your time, then they may end up paying you more than the endodontist.
And that just is bizarre. That should never happen, right? So I’m more than happy to rely on my endodontic colleagues. The way that this ties in to the superstar guest that we have today, Dr. Omar Ikram, who I’m sure many of you know of. He’s very prolific on social media. He puts out such good stuff to the world in terms of being helpful in our endodontic treatments.
He’s very giving with his time and knowledge. So it’s a great pleasure to have on Dr. Omar Ikram today. And I was thinking, what could I ask him? There’s so many different topics that we could ask him. There’s some topics I’ve already covered on the show when it comes to endodontics. And I thought it’d be a really good one about how to make root canals more efficient.
Because my own personal struggles is that it can take a long time. In fact, as a dental student, do you remember how long it used to take for root canals? I remember patients being there for two to three hours per visit. And on the first visit, because you’re so slow, you’re so new to everything, The only thing you achieve is removing the amalgam, moving the caries and putting a core in and by the time you start your access, oh, time’s up and then a few weeks later, the patient comes again for another three hour appointment.
This time you do access, you struggle, you start scouting, you maybe do a little bit of your chemo mechanical preparation and then a few weeks later. They come in again for another three hour appointment. And then you start struggling with obituation. You just about finished and maybe just about run out of time again.
And then the patient comes back for a fourth visit to finish your root canal. I mean, that is ridiculous, but it’s also understandable. It’s understandable because as a dental student, you’re so new to it. Root canals are extremely steep learning curve. You have to keep getting every stage checked by your tutor.
And the most bizarre thing of all is that a dental student usually is not using very high magnification, if any magnification at all, and I think that’s absolutely a sin. Like, it should be illegal to do root canals without loops, and I think a lot of endodontists would say that it should be illegal to do RCTs without scopes.
But anyway, I wanted to tackle this theme of becoming more efficient. Where are we? And namely me, where am I going wrong in terms of why it takes me so much time? Like one tip I previously learned is that try and do a root canal whereby you’re not taking your eyes off the tooth. Like you’re literally communicating with your assistant, your nurse in a way that they’re handing you over the instruments and you’re just keeping your eyes either in the scope or on the tooth via your loops.
And you’re just not having to move your eyes away, which slows you down. Or every time you have to move your body or every time you have to change something in your hand piece. That’s what slows you down. So top tip I was given was try and develop a system where you’re not having to change things very much.
And I think one thing that perhaps we didn’t give enough love or enough emphasis on this episode is having a slick team. Like having a really well trained DA or dental nurse can make a huge difference in your efficiency and think about it. Is your practice really set up perfectly for efficient root canals?
Like, I worked in practices before where if they see a root canal treatment on the list on the day, they start panicking, the nurses and DAs start talking to each other, Oh, where’s the hypochlorite? Where’s the apex locator? Oh no, this apex locator stopped working in 2012. We need the other one. Where is that one kept?
Oh, let’s look in all the different surgeries. Oh, no, we’re missing this GP system and we’re missing these paper points. And it’s not really set up for high quality, efficient root canal, whereas specialist clinics endodontist, like that’s all they do. And so they have such slick systems in place.
And that makes a huge difference to your efficiency. In this episode, I actually asked Omar Ikram how long he spends on each stage, e. g. the access cavity, the file sequence protocols, the obturation. And I didn’t actually directly ask him entirely how long a typical appointment takes, but I calculated around about an hour and 15.
So let’s say it’s a lower first molar, an hour and 15 to dismantle the old amalgam, for example, build up a new core, access, preparation of your canals, obturation, and build back up, an hour and 15. That’s pretty good going. And so the whole episode is focused on breaking it down into each section, like access cavity and file sequences and talking about what are the different things that we should be doing to be more efficient.
The advice he shares and the way I encourage him is to make it quite generic because it’s so difficult to be specific about specific scenarios. So we assumed a very standard, basic lower molar with three or four canals that would be suitable for a general dentist. We’re just about to join the main episode now, but I just thought I’d introduce myself for any newcomers to the podcast.
My name is Jaz Gulati. If you’re an avid listener of the podcast, you know that you’re already called a Protruserati. So the way I like to introduce myself is hello, Protruserati. I’m Jaz Gulati and welcome back to your favorite dental podcast. Every PDP episode, I give you a Protrusive Dental Pearl.
So just before you join the main interview, my pearl today is how to find out if two canals are joined together, apically. So sometimes let’s say you’re doing a premolar or or a molar and you wanna find out if the distal canals of a molar, for example, are joined together. And so one way to do this is when you are irrigating and you are putting your sodium hypochlorite in, if you put it in one canal, are you also seeing the other canal fill up?
And actually we can do then is actually retract and, and try and pull out the hypochlorite and see do they both drain, in which case, the canals are connected or does just one canal drain and the other one stays full of hypochlorite and then we know they’re two separate canals. The other way that was taught to me and the way I’m speaking like this was taught to me rather than being very authoritative and what I’m saying is because I’m no endodontist these are just things that I’ve picked up over time from other clever people and just sharing to you and so the other way was when you put your GP cone in one canal, and then if you suspect that they may be joined, because maybe the other GP is not going fully to length, if you get a K file and you take it to as far as it goes, when you take out the GP cone, do you see an impression of that K file in the GP cone?
So, for example, did the K file take a little bite out of the GP cone? And then usually you’ll see it as a little scratch or some damage, and then you know that the canals were connected. So number one, using hypochlorite or your irrigation system. And number two is putting two different things in. So this could be two K files and seeing the other one shake, or it’s just easier to see when you put a GP cone in and then a K file and you see a scratch on the GP.
So that’s a couple of ways, but if you know another way that’s more efficient or better, please comment below. I love to learn from you guys and love to share all that with everyone else. Let’s join the main episode now and I’ll catch you guys in the outro.
Dr. Omar Ikram, as we all know you as at Specialist Endo, welcome to the Protrusive Dental Podcast. How are you?
Very good. Thanks for having me along. It’s great to finally meet you.
I’m so excited to have you on the show. I’ve been following your work for the longest time, years, I mean, dental student wise, like it must be 12, 13 years. You’ve been very active, very good on social media. I first got exposed to you when you were in the UK through Dental Tubules.
And so I just want to start off by just saying, I’m a huge fan of everything you do. I’m a huge fan of all the stuff you put out. You pump out good stuff, real world stuff. And so from the dental community, thank you, firstly, for those very few people who don’t know who you are, tell us a little about yourself and your endo practice and how it all began.
[Omar] Well, basically I I’m actually from New Zealand, Christchurch. I lived there, obviously did my university in Dunedin, which is in the far south of New Zealand. New Zealand has one dental school, so everyone goes through that, if you’re doing dentistry in New Zealand. And then once I graduated, I went back to Christchurch to live with my parents and do a year as a general practitioner.
And then I decided that London was the place I wanted to be. So I went to London and had some of the best times ever and some of the best 11 years of my life were in London. And then sort of, I realized that I needed to do something, get some more advantages out of being in the UK and the contacts that I had, and I decided to do specialist training in endo.
At, well it was Guy’s Hospital, KCL, basically there with Francesco Mannocci, Shanon Patel, and the other guys there. And when I finished that course, I went to Sydney. And set up my own practice called Specialist Endo Crow’s Nest, which is in a suburb called Crow’s Nest. And I also worked at the dental hospital there treating the public waiting list, which is like a state waiting list. NHS is very different in Australia. It’s in these facilities like teaching hospitals rather than practices.
One question that springs to mind is, why did you choose Sydney? Why not go back to New Zealand? Was it family reasons, life reasons? Why Sydney?
There’s a few reasons. I mean, I loved Australia as a kid. We used to come here for holidays. We could see that lifestyle wise, it was fun. It’s a very diverse, large country. It’s as big as the USA in land size. But it has a population of around 25, 26 million people. There’s also good opportunities in Endo, especially in Sydney, because we didn’t have a training course, so most Endodontists were from outside of Sydney.
They either trained in Australia, New Zealand, or some in the States. But there wasn’t really a course in Sydney. Well, there wasn’t a course. There is one starting up possibly in the near future. But when I arrived 13 years ago, there was no training course. So as an outsider, I thought Sydney was good.
New Zealand, I really love. I like to go back there and visit my parents every now and again, but I just wanted a different change of scene. I’ve been living in New Zealand for 24 years and wanted to try something else out. I’m one of these people who loves to try new things in life and live different places and had the opportunity because of my New Zealand passport. To be able to move to Australia easily, which is really helpful. And also the degree-
Specializing, well, you specialize here, obviously in the UK, but did you fancy perhaps staying as a, and practicing your specialist analytics within the UK?
Well, I did actually specialize in the UK and then practice for around, must’ve been around eight, seven, six, seven months as a specialist on the register there. But like the plans were always in place for me to move to Australia, mainly from a lifestyle point of view, I just felt that was somewhere that was close to the home. Obviously, my parents are in New Zealand. I’ve got a brother in New Zealand and his family. And I just felt that moving that side of the world was something that I really wanted to do.
And Australia is such a great place to be a dentist, honestly. There’s a huge need for specialists. There’s a huge need for dentists. Perhaps not in the cities as much as people would like to live in the cities, but there are sort of quite a few dentists in the cities, but rurally. And I had a really great time when I first came over here working rurally as well.
I worked one day to two days a month in a place called Tamworth, which is a short 45 minute flight on a propeller plane. And used to go in there. Because there’s a huge need, obviously, just the patients build up and I just used to treat them. And then come back to Sydney and build up the practice there and work in the dental hospital.
And basically that was a fun part of the early stages of my career here. For around four and a half years I was making the trips to Tamworth and seeing full days of patients and it was really fun. Like, just coming back with the Harbour bridge, with the plane and the Harbour bridge in view when you come back to Sydney. It was really fun. Part of the job when I first came here, but now I’m fully in Sydney, just working in my practice that I established 13 years ago, basically.
When you were qualified and you were thinking, okay, how do I navigate the rest of my career? Like, it’s so clear in everything that you put out to the world and social media and all the cases you post that you are so in love with Endo and, you’ve been an active learner throughout it and a great sharer.
How did you know that endo was your calling and why was it not perhaps prostho or a different specialty or why specialize in the first place? What’s your own story when it comes to that?
Oh, this is a really interesting one. I actually really liked endo at dental school, but the problem is being good at something at dental school, you get exposed. So you don’t really get exposed to these things enough to really work out if you like it or not. You sort of do a couple of root canal treatments and think you’re doing well, but at the end of the day, it’s not about the easy ones. It’s about the hard ones and the difficult cases you’re going to face.
Because I get a lot of students contact me and say, like, I’m good at endo. How do I specialize? And I say, look, wait till your patient comes back in pain. Wait till they have flare ups. Wait till they accuse you of this. Wait till you perforate, accuse you of perforating or whatever, or accuse you of causing pain when they had no pain before.
Well, all those things that everyone’s going to face, fracturing instruments. So when I graduated, I had all those things happen to me. And you know what, I thought to myself, it’s a bit of a mystery this endo, it’s kind of sometimes good, sometimes it’s obviously difficult, sometimes you have complications, and I just wanted to get really, really good at endo because I thought that was the thing in dentistry that was very, very difficult to do, and everyone that I know used to hate it.
And especially when I came to the UK, everyone said, oh, NHS endo is so difficult. Let’s refer and the usual things you hear. And I started building up a interesting crown and bridge, funnily enough. And one of the things that I did, which I sort of subsequently realized that I was doing, I was basically targeting my weaknesses.
So, I developed as a clinician in the UK as a general dentist and all the way through tried to avoid endo. It’s a hard thing to do as I mentioned, and I was doing a lot of crown and bridge. And as I got better and better at crown and bridge, I thought to myself, what’s the one thing that is stopping me from doing more crown and bridge?
It’s those endos that need to go to the endodontist that the patients never go for. It’s those cases that I don’t feel confident. It’s those simple re treatments that I feel because there’s a bit of GP floating around the canal I can’t treat. What if I just decided to do NHS re treatments for a bit and see if I can do them, the ones I can treat.
So I started off with simple stuff and pluck out a GP cone and then treat the case as a normal case basically. And they were going well and I was doing more crown and bridge. And then as I got better and better, my colleagues referred me cases. And all of a sudden these NHS cases turned into private referrals.
All of a sudden I started getting interest in the technology involved in endo. You get your loops, you get your hand pieces with the motor. You get your rotary files. All of a sudden you start to get an interest in that and I started building this interest. And I went to a guy’s course called Julian Webber.
That was the first time that I went, right, I want to go and see someone who teaches endo because I’m starting to enjoy this. Wonder what he will say about it. He looked so happy with his position in life and his career. And he was such a great teacher and [unclear] was also there. And I had such a great time watching them basically unravel cases and show what they were doing.
And I thought, these guys really love endo. It’s pretty obvious. And then I decided I needed to go and specialize at some point. I had to sit the fellowship exams, the second part that I’d started in Australia, and I sat the second part the next year. And then basically I was in specialist training, 2005 was my first year.
So yeah, I really the journey was quite long and took a lot of toll on me as everyone finds. It’s all about working consistently, building up your skills, facing your nightmares and trying to deal with them, facing up to reality. I was listening to an audio book the other day by David Goggins and he talks about callusing your mind basically.
Can’t hurt me, can’t hurt me.
Yeah, exactly. And that’s pretty much what I was doing. I didn’t, when I listened to this book, I thought to myself, that’s pretty much what I did all the way through my dental career was like. Something was in my way. I decided to focus on it, not run from it. I focused, as I said, on endo because it was stopping me doing crown and bridge.
I was tripling down. He says triple down on your weaknesses. Triple down. People say triple down on your strengths. Triple down on your weaknesses and realize what makes you weak and change that. And the only way you’re going to change that is do more of that. And that’s basically what I was doing all the way through.
Unknowingly, when I heard this in the book, I thought, I was pretty much doing that the whole time I’ve done endo, and when I was a general dentist and everything, I was just learning, learning, learning. But the good thing about the NHS environment is it gives you the opportunity to use your skills to help other people, and also a lot of people. You get help, you get-
High volume dentistry.
Yeah, high volume dentistry and also, to be fair, I mean, people go on about the NHS and how the work isn’t good or whatever, but most of the cases done, the patient still keeps their tooth for some time, and it’s low cost dentistry, but if, even if the treatment isn’t ideal, the patient still has the tooth a lot of the time and this is what we’re seeing filter through again.
The exposure of this to this in my early part of my career really set the stage for what I do now with this concept of minimally invasive endodontics or how would I say using technology to do less. You don’t have to be keep doing endo, you can watch things, you can monitor. We have technology on our side now.
We know that we focus on patient centered outcomes, keeping the tooth as a priority. There’s a few things that I learned in the NHS and saw in the NHS that have trickled into my private practice in Australia and make me think. And, the things that you hear on podcasts, and I was listening to the AAE podcast the other day, the Endo Voices with John Khademi talking about this.
And I thought, some of the stuff he’s saying is, rings true with me. Patient centered outcome first, and obviously we want to treat disease if we can and heal that, but you’re not going to get healing in every case because some patients don’t heal well, some teeth aren’t easy to treat, and just because there’s a little dark area under the tooth doesn’t mean the patient’s going to have a massive abscess. There’s a difference between a full blown abscess and a little bit of apical periodontitis. We do have to aim to treat the case as well as we can, of course, but preservation of the teeth should always come first.
I’m just going to highlight a few themes for the listeners and watchers where we tackle the main theme of the episode, which is getting more efficient at endodontics. And I’ll share some of my own struggles, but a few highlights I just want to highlight for those listening and watching to what Omar said is when he was doing lots of crown and bridge common theme.
When I speak to amazing guests I have on the show is that they’re always on their, the edge in terms of their comfort zone. So, trying to do that first re RCT and just, you know, being a safe practitioner, just slightly outside your comfort zone. And eventually, you are doing these cases.
And you weren’t being fairly remunerated at the time, but you were doing it anyway for the sake of getting better and learning. And it also reminds me of another thing that Dr. Raj Rattan taught me when I was at DF1 about 10 years ago. He said, if you want to get better at Endo, do more Endo. People say, I want to get better at Endo.
Which specialist program should I do? Well, the first stage of getting, I hope you agree, Omar, is getting better at anything is just do more of it. And so those themes were definitely very apparent of when you were talking. Before we tackle the main things that will help us become faster, faster is probably a wrong word, more efficient endodontics.
And when we really focus on that, if you just do me a favor and for the young dentists, the students, can you just describe a root canal to a dental student, basically in just a few minutes, just the main principles of endodontics as we know it in 2023.
So basically when we do root canal treatment we’re trying to either treat apical periodontitis or prevent apical periodontitis and also preserve the natural tooth. The three aims of root canal treatment basically, the three situations where we try to preserve the tooth. Apical periodontitis is just a swelling under the root. I’ve recently thought about this a lot and done some posts on this on social media. Basically all that happens is the bacteria get into the root canal.
The level of bacteria exceeds some threshold level that your body is unhappy with and then you develop swelling under the tooth. And basically the swelling under the tooth is painful because it’s compressing the bone. When you get compression of the bone, you can’t touch the tooth very easily.
You feel sore. Swelling sometimes occurs if it’s a lot of bacteria in the root canal system. If the bacteria exit the root canal and enter the tissues, then you end up with a full on abscess and then you get pus formation. And that’s more painful because pus is obviously more pressure. It can spread.
Your body can’t create space, can’t create the apical lesion quickly enough, and it can shoot off and spread, and that’s the danger of it. When we try to talk about preserving the natural tooth, we talk about minimizing hard tissue loss essentially and restoring the tooth correctly. So there’s heaps and heaps and heaps of studies that show that root canal treatment is fairly successful, but success also depends on restoration and longevity definitely depends on. restoration.
In fact, most studies show that root canal treatment is kind of an important stage, but the restoration is way more important for longevity and also for success of the root canal treatment. For example, teeth that are temporized will leak, eventually fail, and obviously they break down.
And if you don’t have cuspal coverage, then occasionally in molar teeth, obviously you can get fractures. So we are trying to do more restorative dentistry and endo now as well and think more restoratively. In fact, my heart sinks every time I see a beautifully done root canal treatment with a cotton pellet or a Teflon tape in the, over the gp because basically we are trying to prevent that.
We know that the bacteria come from coronal and get into the root canals, and that’s what causes root canal disease. That’s been studied multiple times, so if that’s the case, then why not seal the access? But there is a movement to do this, although some people still insist on placing temporaries.
What is your, I mean, we can ask these little micro questions as we go along. What is your coronal seal of choice nowadays? So once you’ve obturated, what do you like to place? There was a previous school of thought about GIC being superior because of the chemical union, if you like, and avoiding resin. But a lot of people, mostly androgynous I speak to now, will, they have the rubber dam on, they’re just gonna do the adhesive protocol and place composite. Do you have any preference of materials?
Yeah, yeah, I use adhesive composite most of the time. The only time why I wouldn’t maybe use adhesive composite would be if I’ve got an occlusal cavity and I can just put some GIC in there, it’s not going to receive a, receive a crown. GIC’s been shown to be a fairly, fairly poor core material, so you want to be using resin.
I mean, some people use amalgam, but that’s something that I don’t use in my practice, but amalgam is obviously a good core material if you’re used to using it and your patient won’t let you place it, but no, I don’t use amalgam. So I’m using at the moment SDR, which is smart dentine replacement.
I was just going to say endos love SDR. Is that you as well? I was going to say that next.
Yeah. Yeah. I like it because you can inject it down the root canals easily. There’s different types. You can use the, I actually use the syringe and I put an etch tip on the end, which is the smaller than the black tip that you use. Yeah.
I really like SDR. I haven’t really used many other products for this. And then I just use a regular composite, whatever I got. I do have a liking for the corex material or paracore or like core materials and fiber posts in some teeth, but I’m trying to do less and less posts. I’m just finding I don’t really need to do posts these days.
I think with sufficient ferrule, and sufficient SDR down the root canals, you can bond the restoration. You don’t really need many, many posts.
Post after all is to help retain a core and if you can rely on your adhesive dentistry and you’ve got enough residual tooth structure to bond to, then yeah, surely it negates the need for a post.
Yes, well, the other thing that we found in my master’s thesis was that preparation of a post space actually weakens or removes 1. 4 percent of the total heart tissue of the tooth. It was in pre molars, so an extra 1. 4%, you can avoid that by not placing the post. So, in fact, on our smartphone app, EndoPrep app, William and I created this smartphone app where you can see a calculator and see how much tooth tissue you’re removing.
If you prepare the canal to like a 30/06, for example, and then you look at where you can take the post drill down to, so it says how big is the post drill if it’s one millimeter, it’ll tell you when you’re going to get beyond a 30/06. As far as tooth tissue removal goes and you’re removing more dentine than you did for the root canal preparation of that root canal.
So that’s a handy little tool just to say, look, you’re removing some and it might be okay to do that, but like you have to be mindful if you’re doing micro preps that you don’t stick a big post down the distal route just because you feel like that’s the post drill of choice. Think more logically.
So what I tend to do with posts now is I tend to prep a bit bigger in the canal that I’m preparing, I’m going to put posts in if I am doing that. And then I’d rather that than prep a post space with a post drill.
So using a larger, like using a 30/06 for example rather than a 25/03 or whatever you might be doing.
Yeah, like maybe 30/06 over, over 25/06 and then cutting the post down. So, I’ll actually cut the post down so that it’s tapered and then trial fitted and then-
Just like with a fast hand piece and diamond, but just you’re basically like you would adjust your wooden wedge. You’re just removing away a fiber material that you don’t need to allow a passive fit.
Yes, exactly. So and then I just place it with like a core material as the cement. So there’s a composite core material. Yeah, so that’s pretty much how I place posts when I need to, but I just, I’m trying to avoid. Right.
We’re going to now tackle the main reason I got you on because when I liaised with you, I thought, okay, great. Almost I’m going to show. And I was like, had a headache. Like, hey, there’s so much he could talk about so much we could talk about. It’s such a fun topic. But one thing that’s close to my heart is that I also enjoy Endo. I enjoyed Endo a lot in my earlier days. I’m doing more and more referrals now just because I’ve got other interests now, TMD, restorative, that kind of stuff.
And so my biggest struggles initially was, okay, let me get good at root canal. Good at root canals, good quality irrigation, good quality preparation, focus on doing the pre endo buildup really nicely. And sometimes they’re restorative to get these matrixing, getting a good seal, that takes a lot of time and effort to do.
And then the actual root canal. And we’re doing molars, multiple curves, tiny canals, and so negotiating those and try to get good at that. But all that takes so long, especially when you’re a beginner, when you’re a learner. So eventually when I got more experience, I was like, okay, I’m getting more consistent results, but a molar root canal is still taking me two and a half, three hours.
And that’s no good at that point. I could do it much faster now, but still nowhere near as you guys do the specialist endos do. So I was thinking, what are GDPs doing who are taking as long as I am? And what are the mistakes we’re making? I think maybe one potential mistake we could discuss. And I think if we break it up into access cavity mistakes and then how you can be more efficient access cavity and maybe the chemo mechanical prep and the obturation, different little stages maybe that might make it easier to break down the episode in terms of where I might be losing that time.
For example, irrigation, for example, sodium hypochlorite at what point. Would you actually introduce that? So previously, I was introducing quite early on, thinking that the earlier the better. But then also, I was thinking that I haven’t even done much of the canal prep yet, and it’s not actually getting to the places I need it to be.
So perhaps I should delay that. So I’d like to learn that from you as well. So maybe if you start from the access cavity bit and isolation, any things that you’ve learned over time that makes you more efficient with that?
Okay, okay, I’m going to take a step back and say that diagnosis is super important for like, assessing the case like, as in like, planning the case, whether it’s going to be a slam dunk case, easy to do, like a pulpitis case, you’re going to get big canals, that’s why it’s pulpitic, I mean, patients have symptoms and sensitivity because the pulp is big, but then the tooth can be hard to anesthetize.
Necrotic pulp, you won’t have difficulty with anesthesia, but you may end up having calcifications there. The pulp may have necrosed after years of micro leakage. There’s things like this that can really help your thinking with regards to planning the case. So I’ll skip through that, but like that’s really important.
Then the access, for example, you have to be thinking like depth of access. I really feel that, I know I’m gonna mention microscopes, of course, but they really, when you get good with a microscope, like seeing the CEJ, the different shades of dentine, you get good at finding canals. And even in the last like five to 10 years, I’ve improved my canal location through using microscopes and different ones not all microscopes are equal.
That’s the other thing I’m learning. Is that like, I’ve upgraded to a new microscope recently, which has been so much better than the old microscopes I used just because it allows you-
Give a plug. Is it Zeiss Extaro? Is it the CJ-Optik?
You knew, you knew already. It’s a very good scope. It’s an amazing piece of kit and there are more expensive microscopes out there. So it’s not, I mean, it’s a middle of Zeiss’s range, but I find it amazing just the ability. I mean, I’m using a microscope all day, so it’s for posture and stuff. It’s fantastic. You can move the tube any position you like basically to suit the patient’s positioning.
Because basically we have to remember that. We’re treating a patient who wants to sit in a funny position, they’re conscious most of the time. And we’re treating the patient and we have to be comfortable as well. So the patient has to be comfortable and we have to be comfortable and that makes it difficult because us being comfortable is always the second priority it seems in dentistry and our backs will suffer.
And then if you’re doing it all day then you can’t work long term in endo because it’s painful, it’s tiring and it’s more strain on your body. And we all get strain but like it’s less strain. So, I mean, just the optics are amazing. They allow you to find canals that, I mean, I remember finding my first calcified canal with a Zeiss Extaro and I thought, is that large, like, canal in the tooth the calcified canal?
That just looks too easy to find. It actually surprised me how easy that was. I was like, that looks calcified and it’s so obvious. It is actually amazing, the lighting and stuff. You can do all these crazy things like turn the eyepieces around. Bring the patient closer to the light, the light goes down and through crowns, like when you’re treating through crowns, the light is going in more, you can see micro leakage, you can remove the micro leakage and tell the patient, you can take a photo, go look, crowns leaking, you need a new one.
There’s the photo. You can do so much with those. These are things that you just think are finding the canals is where you have a microscope. They’ve really improved this with that model and the features. So that’s a wonderful thing I found. And also obviously finding canals and access.
It allows you to do smaller accesses if you can see better. That’s one thing that I found with when I was at GDP is access was difficult because depth of access and also finding canals. That’s the obviously the big one for GDP is because if you don’t have good magnification or illumination. You tend to do everything by tactile feel and it was only until I started using a microscope during specialist training regularly that I realized how much we do do by tactile feel.
Where I was stabbing around with the DG16 or a micro opener or something to try and find the canal, all of a sudden I was seeing and stabbing. So you see and then you probe and then it’s like it catches, that’s the canal. You can find so much. So magnification, illumination, depth of access, I think it’s good to plan. So finding the canals for anyone.
Before we get to finding the canals, I mean, just actually just the initial access, a few questions on that, which I think will be helpful for everyone is. How many minutes do you think, because you’re obviously slick at what you do now, so something to aspire to, how many minutes would a typical, I mean, obviously every case is different in terms of the coronal restoration, etc.
But on average, what percentage of the appointment or how many minutes are you dedicating towards getting the access and to actually be able to scout the canals?
To be able to get down to the pulp chamber and visualize the canals?
Yeah, I would say you’re probably looking at about 15 minutes.
And does that include dismantling any previous restorative and rebuilding that kind of stuff? Because that can take a lot of time itself. And do you leave that to other colleagues before you get a referral? How do you do that?
No, generally I would do that myself. And then pre build, if I need to, I build up with SDR, that’s a good material to quickly build up with. I’ve recently found a little trick you can use with the fluorescence light on the Zeiss microscope.
You just hit the fluorescence button and it becomes a curing light. And you can build up distal walls and stuff, and you can just cure, like, with the light of the scope. It’s not a perfect cure, I mean, it’s, you need to back that up with something, but you know that part of the build up where you’re fixing up a distal ridge on a lower seven, for example, or lower six, sorry.
And you need the dam back to build up, and then you need the curing, and you have to hold the dam back while the nurse shoves the light in, curing light in, and that’s always the annoying part. So I just now hit the fluorescence light, pull the dam back, and then place the SDR or composite material, whatever I’m using, in the distal margin, and then it will cure.
It has to be fairly direct vision, but then you can get some sort of curing going, and then you can put the light on from the curing light. So there’s a couple of little tricks there, but I’ll do that myself. That makes your life so much easier.
Is that 15 minutes? Like, let’s say you’ve got an MOD amalgam, classic lower first molar, you’ve removed the amalgam, you’ve removed any carries, and then now you’re going to continue the access because part of the access is removing the old amalgam. And so then building up, is that all 15 minutes? Or are you going to suggest more time to actually do a restorative as well?
If you’re doing restorative, you’re going to extend to about 25 minutes, I’d say. It’s going to be a good 10 more minutes. The cases that I need to pre build, they’ll take. Sometimes I’m using an orthodontic band around the tooth.
That takes a lot longer. You remove the restoration, you realize you’ve got some gingival margins. So what I’ll do is I’ll do like a deep marginal elevation of the box, and then I’ll do the band. The band I usually just cement with some GIC, Fuji 9 is what I use, and then just cement it in, and then leave it to cure, and then I’ll just go back through the middle.
I put the clamp on the tooth with the band on it then, and then I can just go back through. And you know you’ve cleared all the caries, you know you’ve bonded the box with SDR, and then the band is just holding the tooth all together. So those are those really difficult ones, and sometimes you even need to do a post at the end, obviously with those cases, because they’re sort of limited ferrule and things like that.
But I would tend to build up at the start. It really makes your life easier if you don’t have to worry about hypochlorite going down the patient’s mouth and all those things that you have during the endodontic procedure. You want to be not worried about that.
I think it’s fair to say that if anyone’s spending too much time on the axis cavity part, it’s just to revise your anatomy and use magnification. And then from there, we can then talk about scouting. Is there anything else you want to add in terms of access cavity specifically?
Well, I would say with access cavity, it’s very important that you practice on extracted teeth. It’s really important to have that. The dentine map has helped me immensely with, which is basically the CEJ and on the floor, you have this green gray colored dentine and laterally you have the yellow brown kind of dentine.
And after a while you get good at reading it and I teach this in my courses. I’m teaching these calcified canal courses. They seem to be really popular all around the place. In fact, we had the first one in London. Would you believe it?
A few months ago I was planning to do one to in Sydney this year which we had the last we had the first one last week and then I was contacted to do a course in London and we did the first calcified canal course there in near Watford in Stan-, we’re near Stanmore. So some, we had 14 people come along and we practiced it.
So that’s the kind of thing you need to be doing regularly. Practice on extracted teeth, see the dentine map and just locate the canals like that.
Excellent. So when you’re coming on to scouting, I’m thinking you’re going to be mentioning about the use of ultrasonics that could speed things up here. Is that part of a top tip that you had in terms of improving efficiency and?
You can use ultrasonics, but I tend to not use ultrasonics that much for this kind of thing. I tend to use burs. Again, as part of my old school, I guess, upbringing in dentistry was that we didn’t have ultrasonics. We didn’t have access to these at the start of my career, so it’s something that I didn’t use a lot of, but I do use it occasionally.
Start-X #2 being the one that I use a lot for the MB2. I’ve got the Start-X tips and they’re quite handy for finding canals, but I really find that they scratch the floor. So, as you trough, they scratch the floor, then if you want to create debris, then you get lines in funny places, you scratch the floor. So, I prefer using a burr, something like an LN bur, shorter, it’s a short handled, small gooseneck burr, long neck, it’s called LN bur. It’s a gooseneck, basically steel round burr, and they come in different sizes.
Especially in the UK, I know that they have different sizes. We use the very small one here in Sydney. Then you’ve got the endotracer burrs and the pulp burrs, which are the Komet burs. So I just trough and find the white dot, then I’ll use a micro opener and just probe, and then if I find that it catches and that’s the canal, I’ll open it with usually an XA or an orifice opener, and that’s how I would find the canals that way. But I like using the burrs, because to me the burs don’t scratch the floor, they’re at hand usually, and they’re something that most practitioners would be used to using. Ultrasonics are handy, but you need a specialized endo ultrasonic unit for that, because if you don’t have that, it’s not powerful enough.
I also love using the long neck, gooseneck burs, that you mentioned, the rose head type, right? With a long stem, long neck.
They’re brilliant. So, so once you’ve used your opener, you mentioned a specific type of opener. Is that like a pro taper thing or is that, what file system is that?
So the opener that I was talking about was the XA orifice opener, which is the ProTaper Next file. It’s a 19 millimeter long. They’ve got a 19mm tip and the idea is just to open the canal and just widen the orifice so that you then can just get your hand files out or scouting files or whatever you want to do there.
So that would be my choice. They have other ones like SX which is the gold wire version of that same file.
That’s the one I’ve seen.
Yep, and there’s the true anatomy orifice modifier. I have to say the true anatomy orifice modifier is pretty interesting. It’s a 20 size tip. It’s got a passive tip. That’s probably why it’s called a modifier rather than an orifice opener.
And it’s very difficult to break because it’s very passive and it’s very handy for cases where you’re unsure about. Snagging or because the tip is passive, it literally won’t go into a canal unless there is one there. It’s also 0. 8mm wide, so you can’t really over prepare a root canal very easily at all using that orifice modifier, so that’s quite a nifty file to use.
The 15 minutes that you said, was that including the use of an orifice opener in all the, let’s say, low molar, all three to four or five canals? Or are you spending a bit of additional time to just locate open up each canal?
I would say, I would say that includes that opening of the orifices. Yeah, around 15 minutes as well. I’m just talking about a, a simple case here. Not a difficult calcified one, of course. Sometimes it takes me 45 minutes to link out the root canal. Sometimes we’ve had these cases where they calcified halfway down the roots and everything like that. But this is a simple case.
I’m just talking about GDP cases because this is mostly going out to GDP. So once you’ve used your orifice opener, what is the recommended or not recommended? Which is this kind of file sequence that you’re using? And how soon, back to that question I asked initially, how soon are you actually introducing the hypochlorite?
Did you see what I mean about introducing it too early and wasting time? Is it actually doing anything? Was I perhaps wasting time by introducing it early?
No, no, you’re doing the right thing here because what you’re doing by introducing hypochlorite is there’s a few things. First of all, the most bacteria that you’ll find in a root canal are actually coronal.
But it’s also the easiest, easiest part to clean. So that’s why it gets sort of overlooked a little bit, but like you don’t want to inoculate the bacteria from the coronal region all the way to the apical tissues. So by flushing the area, you’re doing a bit of cleaning initially. The other thing is that you’ll, by flooding the chamber with hypochlorite, you’ll reduce the attraction of debris to the file and increase the debris is in solution.
If you have debris on the file, you’ll slow down the cutting efficiency or reduce the cutting efficiency of the file because it’s basically blunting the file if you’re filling up with debris. And also you will end up possibly packing debris apically. You need debris out of the root canal and the best way to do that is to keep the hypochlorite in the chamber. You’ll probably see in some of the videos on social media, I don’t have this, and the reason why is I’m trying to demonstrate something.
But you should always flood the chamber with hypochlorite and use it. You will have to, when you use an apex decoder, of course you will have to wash out the hypochlorite, because it doesn’t work well with hypochlorite in the canal.
So from there, what’s your standard file protocol? Because I think sometimes one of the tips I picked up a while ago, is one of the things that slow us down, is doing too many changes, going and having to turn your back too much.
And obviously, I mean, one thing we haven’t touched on, which I’m thinking we’ll definitely touch on is having a really slick assistant. I’m sure it makes a huge difference. I’m sure I’m going to come to, but in terms of file sequencing, is there a way that we could be smarter about the way we use our files to be more efficient?
Well, actually, yes, because I came up with this concept a few months ago with patency filing. If you might’ve seen this, I posted on social media, this idea of scouting using variable tapered hand files. So there are some variable tabled hand files. I don’t know if everyone knows this, that there’s the C+ files.
So these can be very handy if you have a canal. Let’s say you’re treating a fairly simple case and you just want to not have to use too many hand files. One of the techniques you can use is basically a size 6 C+ file or even a size 8. And if you get to the apex with this variable tapered hand file, there is a technique to using it, which again is a quarter turn and pull, rather than the watch winding technique.
If you’re able to slide the file through a millimeter through the apex, then you’ll increase the diameter of the apical foramen from say a size eight to a 12.5. And then you’ve done your glide path. So sometimes just using that one file will double, it’d be like two files in one. Rather than having to pick up the eight, ten, fifteen, you’ve gone eight, twelve and a half, and then you’re ready to go with a rotary file.
So this is a little tip you can do. The other thing if you’re unsure is you can use, say, a size 6 or 8 K file or a C pilot file, which is what I like to use, and they have the same dimensions as K files. The C pilot files, they’re just stiffened K files. And so you can prepare them to the apex and then take your C plus file down and then through by a millimetre, and that again will save you going 6, 8, 10.
Because the 6 8 10 is a very difficult, long winded technique. And also you can ledge or you can end up getting frustrated with a case like that. You need that stiffened K file, C pilot file. It won’t crumple. Especially the 6 is not good to use. I don’t actually use size 6 K files and not size 8 either. I pretty much just use C pilot or some kind of stiffened stainless steel for those sizes. And in tens, I would use a K file occasionally.
Okay. So use the C plus pilot file and then you can happy to go straight to the rotary then?
So you could use the C pilot file to get patency because it’s a safer ended file. And then you can get the C plus file, which is like got the active tip, but it’s got variable taper passes through the apex.
And then you can use your rotary files straight away. So you just need two files to get down rather than 6, 8, 10, which is what a lot of people do.
Yeah, that’s exactly what I was looking for.
Yeah, you can get into trouble with a 6, 8, 10 because you can when you’ve got a ledge, you go around with a six.
Then you’ve got to unledger with the 8, then you’ve got to unledger with the 10. Well with this technique you go in with the 6 and then you get the 6 C+ and just go through and then you’ve gone it’s an 11 now at the apex. It’s 6, it’s a 5 percent taper file so it’s 6 and 11 I have all this stuff on Instagram, it’s quite helpful and I use it a lot myself.
Perfect, I’ll put all that in the show notes as well as a reference, a visual reference as well, which is great. Now, when you’re going to the Apex, this is all based on an estimated working length on the radiograph, is that correct?
No, I use the Apex Locator throughout this. I would estimate the working length.
So the Apex Locator is already connected to your size 6C+, am I getting that terminology correct?
Correct. What I do is I go in, obviously I’ve got an estimate working length, you can tell when you’re not at the apex. If the canal looks long and you’re at 20 millimeters, you probably aren’t at the apex.
But I do clip on the apex, I get it every now and again just to check what’s going on because if you’ve got resorption and things like this, it can tell you you’re at the apex or through the apex. If you’re perforating, you will find out that you’re through the apex quite early.
Things like that. But when you have a microscope you’ll perforate way less because you’ll know what a hole in the tooth looks like versus a root canal different things. So basically I would clip on the apex to get it every now and again and just check as I go down the root canal. So I’ll put that on at the start when I start getting the glide path or getting close to where the length is going to be.
The size 6 C Pilot file for example or maybe an eight pilot file whatever I’ve chosen and then once I got the length go through by half a millimeter pull back and then take the reading then that becomes the reading for the root canal and then I can get my C+ file if I need to and I just set that one or half of even half a mil or a mil long and then try and pass that through the apical framing, as long as you’re not near any nerves, of course and then you get patency and then you can go for your rotary.
I always check as well, the working length with the Apex locator again. I take a radiograph as well, of course, to just to verify the machine readings. Because one thing you don’t want to do is say. In your notes, the Apex Decoder is correct. And then you say, oh, that’s completely not correct. You need to be backing up your notes with, and you took the radiograph and it shows it’s good or whatever. You need to write your radiograph.
What file is inside the canal when you’re taking the radiograph?
Again, the good thing about the C plus files is you can actually use them for working length. You can use probably, even a 6 is an 11, one millimeter back. So you can possibly use that, but an 8 is a 12.
So. That’s very okay for taking working length radiographs. And I tend to use like the glide path file in the root canal as well to take a radiograph. So I tend to do the preps up to the glide path. And then I tend to take the working length radiograph, ’cause I know I’m, my apex locator will be good.
If there’s anything unusual going on, I’ll take one earlier, obviously. If it says I’m through the apex, like three millimeters and then it probably perforation or there could be some lateral resorption or something, then I’ll just take a really wide file. and I wind it down to the length that it says that the reading is and take a radiograph.
So it’s wedged in the root canal at that length. One thing you don’t want to do is have a small file and it’s dropping through the apex or it’s dropping through the resorption or it’s, it’s just moving around because then you don’t know if it moved from the patient which had the radiograph taken.
You need to find something that’s quite stiff and wedges itself in the root canal at the length that it’s telling you and then you can sometimes see oh yes there’s a lateral canal there that’s what the reading will give be giving and then you can just advance the file and take another radiograph and see if it looks correct.
Just going back to basics for for the dental students and younger dentists who will be the slowest to start out with when you’re taking that radiograph once you’ve got your sort of lens from the apex locator and you’re verifying with the radiograph, and you’ve got, let’s say, a lower molar with four canals.
You’re going to have four of these files in, and you take a radiograph, and just to confirm you’re happy with each canal.
Well, actually, funnily enough, I don’t generally put in so many files. I tend to put, like, if it’s two distal canals, I tend to put one file in the distal, because in reality, it’s really unusual, unless you can see something really unusual.
You tend to get, say, the same length root canal in the distal, if it’s got one root. Of course, distals generally, you have one root on a lower molar. Sometimes you have a radix or whatever, that’s different, you need a file in a separate root. But if it’s the same one root with two root canals, I tend to put one file in and just take the working length.
For me, the working length radiograph is all about just showing what I’ve found on the apex locator. I don’t sort of overanalyze the reading and if it’s telling me that I’m at the apex and it looks like I’m at the apex, then I’m at the apex. Because the apical foramen is often short of the radiographic apex by one and a half to two millimeters, sometimes even more.
And what you don’t want to do is be obsessed with looking at the radiograph and go, I’m short, I’m long, I’m short. It’s like, if the machine tells you, You’re at the apex, then you’re through the apex, and then you’re back in the tooth. And you take a radiograph, and it looks like you’re at the apex. You’re at the apex.
So, what I don’t do, which is probably what we used to do back in the days before apexicators, before they were reliable, is actually obsess about the radiograph and how far you are from the radiographic apex, when in actual fact we shouldn’t be doing this. We want to basically prepare the root canal up to the apical foramen and not through.
So if you take a radiograph and your file is maybe two, three millimeters away from the radiographic apex, but you felt confident with your apex locator reading and you can’t see any unfilled canal beyond it on the radiograph, that’s a fairly good green light signal, right?
I think so, yes, and especially what I do is I wind the file through the apex, a millimeter, and then it tells you, obviously, on the apex, yeah, you’re through, and then you wind it back, and it keeps giving you that reading.
That is the apex. That would be the, that would be some sort of different anatomical apex to the radiographic apex, and that’s fine. This is where cone beam is a beautiful thing, of course, and we’ll get talking about that in a few minutes, but cone beam can really help you with these cases.
Absolutely. Now, what is your typical file protocol? And also just I want to get in your head about sequencing, like, are you the kind of guy who would do one canal, do it all to finish and then move to the next now? Or are you going to use the same file of your sequence and then do all the canals and then change the file and do all the canals? What’s the most efficient way? What’s the better way?
Oh, I like to use one file through all the canals. So I get all the glide path preparation with hand files done, as I mentioned, and then I’ll get the rotary glide path file a lot. I’m using it more and more. ProGlider, Slider from ProTaper Ultimate, the TruNatomy Glider, which is an amazing file, I love the TruNatomy Glider.
Then you’ve got the other one, which is the Wave 1 Gold Glider, if people are using this. But I tend to use this more and more now, because it just does more work than a handfile. And it goes places that a handfile can’t go. in that situation. You’ll save time using these files. I mean, yes, it’s another file, but it’s saving you time.
And time at the end of the day is also going to affect your ability to see more patients. So, if you can get those treatments done more efficiently, then you will see more patients and that’s good, you can help more people. Basically the glide path file is becoming more and more part of what I do.
I like to run them a little bit slow because I’m a little bit concerned about them binding somewhere. They are tend to be a 1502 with a variable taper around this sort of size of 1602 or 1702, depending on what you’re using. Because they’re an early file, I don’t want to be using them very fast.
Although the only one that I don’t mind using fast is the wave on gold glider. I find that that works. It’s quite brilliantly at a fast pace, something to do with the wire and the floating action and it’s 0. 8 millimeters. I was also, I’ll probably mention this later, but the fact that these files don’t bind coronally really speeds up the preparation time.
Really does. So, that’s my favorite one. I’ll do the preparation with one file of in all the canals, and then I’ll move to the next file and do and treat them. I won’t be preparing the whole canal to a finish and then. Another another starting again. If you like, I prefer that technique.
Although it makes sense to the less times you change the files, it just makes sense, right? You the one file user for all. And so on that note a lot of people think that using reciprocating just makes sense. Once you’ve done your glider using a wave one gold, for example, and then that’s one file using only canals.
Wham bam, thank you ma’am. This is how you do efficient endodontics. But obviously, I mean, one thing we can’t get into because probably a whole episode itself is when to choose which type of file system for which canals. But generally speaking, for the general dentist who’s not doing cases that are too tricky and that’s probably referring those ones.
Do you think that is right that we’re relying so much on reciprocating systems to improve our efficiency?
Well reciprocating systems, that’s certainly a good way to go when it comes to efficiency. I have to say that they’re reducing the wire on the rotary files and that’s helping them keep pace with the reciprocating files.
For example, as I mentioned, TruNatomy has a 0. 8mm wire. And Wave 1 Gold has a 1.2mm wire for the primary. And so you’re going to get binding coronally with Wave 1 Gold, and find when you get to long cases, that you’re going to find it binds coronally too much, and that’s where TruNatomy is such a brilliant system.
It doesn’t bind coronally in these cases, and it preps apical mainly. It’s like a kind of reverse protaper, TruNatomy. It’s like you get the apical prep and no coronal prep at all, so that speeds up prep. The reciprocating file systems are very good for general practitioners. They minimize your files, you can treat lots of cases with them.
That’s why they were designed, they were designed with that efficiency in mind for people who were doing standard or moderate cases, I would say, moderate difficult cases to obviously easy and moderate cases, which I also love. I mean, Wave 1 Gold is a system I use. Almost on a daily basis, just to let you know about your question about file systems, we actually have got a feature in our smartphone app, which is endo prep app to show dentists based on the length and the size of the root canal, what system they should use.
That sounds brilliant.
Yeah, just a kind of guide of like what we would use in certain situations.
I’ll definitely put a link link to that because that’s something I’m going to download straight away. I think it’s very, very helpful to have that kind of a guide to on this topic of efficiency. One thing I was taught.
And I feel it’s carried through with me that I feel slows me down. Omar is when I’ve used, let’s say we use ProTaper Next, for example, and I’m using like a X1, then I’ll use the X2. Once I’ve used the X1, I’m getting a bit of binding. I’m going to come out. I’m going to use some sodium hypochlorite.
I’m then going to put my size 10 K file and go all the way. Ensure I’ve still got patency, but then having to do those changes and do those motions. It takes so much time. Is it correct that I’m doing this because that’s the way to do it, or am I perhaps, if I’m doing it every time there’s binding, I’m doing it too frequently and that’s slowing me down? Any advice on that?
Yeah, so with this situation, you’ve got a 1704 variable tapered X1, which has got a high coronal taper because it’s a shaping file. It’s the only shaping file. It’s making space for the 2506, which is the X2. That would be my normal protocol. A few years ago, I used to start every case with an X1 and then decide where to go from there.
So what I would actually do, if you are finding it’s binding with X1, your X2 is gonna be a real difficult file to follow that. So then I’ll tend to change to either a, a TruNatomy or maybe wave one gold small because it’s not, it’s a 20/07 and it actually, the wave one gold small file is quite neat because it has a one millimeter maximum flute diameter.
So it’s a one millimeter file in a system that’s 1.2 millimeters for all of other files. So the Wave one gold small is actually a pretty nifty little file to have in your kit. It just gives you that bridge between X1 and X2, which is lacking in ProTaper Next, so that’s one of the things I have found with Protaper Next.
I’m generally trying to move on to Protaper Ultimate now because it has more diversity in the system. So I taught Protaper Next for about four or five years when it first came out and all the courses were full and we had a wonderful time with it. But I think that I feel that now that it’s good to move on to a narrow wire system like Protaper Ultimate. And it will give you more efficiency and make your treatments more efficient, basically.
But is it right that I was recapitulating the whole flushing out the debris and going back into size 10 just to check for patency? And I did that a lot. And I feel as though that was slowing me down. If I could just eliminate that from a protocol, I’d be much more efficient. But is it a necessary evil?
Yes, you have to make sure you’re not blocking the canal. But like I said, you will find that if the file is more efficient, is a narrow wire, you won’t have to do that nearly as much. You won’t clog the blades as much because you’ll get less coronal binding. With an X1 you’ll get a lot of coronal binding, that’s what it does, it prepares the middle and coronal sections.
The apical tip of the X1 is really not doing a lot, it’s just to create a bit of space. It’s almost like a glide path file if you think of it the size 1704, it’s really small. But the middle and coronal sections are high taper. So that’s why you’re getting that binding, because it’s the only shaping file in the system.
So, unfortunately, you are correct in the sense that it will get binding and flutes filled with debris. And, as I said, the way to minimize that is to flood the chamber with hypochlorite, and that will prevent clogging in the blades. Don’t use the viscous chelator, the Glyde and EDTA gels. They attract debris to the file. They slow down your preparation. And they also reduce cutting efficiency.
Okay, now that’s a top tip right there. Not to use that, very good. Happy to be more minimalist and exclude things. How long, for like a standard lower molar, that perhaps a GDP would do, so a relatively straightforward case for you, how long would you be spending in the chemo mechanical preparation, using, running through all the file sequence of whichever file system you’re using? How much time do you dedicate to that?
Well, let’s just say, if you use TrueAnatomy, you can do the prep of four canals in about, 15 minutes. It’s a very, very quick process. But then the flip side of that is that now you need to spend a lot of time irrigating because the prep was so quick and you didn’t debride much.
So you’re going to have to remove the pulp tissue somehow and you’re going to have to spend time activating and irrigating with those specialized plastic needles. You’re not going to be able to use a stock needle with TruNatomy at all. The other thing you can basically do is prepare with ProTaper Ultimate, for example, that’s a one millimeter wire.
That’s going to be a bit slower, but it’s going to allow you to do a bit more with the file, so that you don’t need to rely on so much irrigation, although you will irrigate and activate and everything. You spend a lot of time with TrueAnatomy fiddling with the irrigation, fiddling with the cones. Because it’s such a micro system, but the prep is very quick.
So I probably, if it was Protaper Ultimate, you would need another file in there because it’s going to be Slider, Shaper, and then F1, or maybe even F2. So that would probably be up around the sort of 20, 25 minutes to prepare four canals. The other thing that occasionally you can, obviously then you can use wave 1 gold and that will also be a bit slower sometimes, but that’s not too bad.
I mean it depends on the case of course, but reciprocating systems can be fast, but I find, as I said before, the 1. 2 millimeter wire will really slow you down. So you might find 30 minutes. For the preparation of canals using most systems like ProTaper Next, WaveOne Gold. The two systems that I think are quicker are TruNatomy and ProTaper Ultimate.
As soon as you reduce the wire, you reduce the coronal binding, you improve the flexibility because you’ve reduced the flute diameter. So, in all the studies, it’s quite funny, you look at studies with like protoper gold versus protoper ultimate and you see that the, the cyclic fatigue resistance is better because it’s a smaller wire and basically the flexibility is better because it’s a smaller wire.
This is the same wire, but they’re just different, diameters. So that’s really what, what it is. It’s the different diameters that will help you. So this is another top tip for improving your efficiency for root canal treatment. Go to a narrow wire. I would recommend ProTaper Ultimate because it’s kind of that nice hybrid between 0. 8 for TruNatomy which is very small and micro, which is very quick, but there’s a lot of fiddling with irrigation activation and filling and then, WaveOne Gold or ProTaper Next, which are wider diameter files, which will get that binding. So it’s a nice in the middle kind of system.
I’m finding that at the moment. And the new cones are nice, they’re conform fit cones like all the file systems that we were mentioning. They have, so the file systems match up. I’ve actually recently trialed a new handpiece which is coming out soon, which is really quite interesting. So I’ve been trialing this handpiece that’s called XSmart Pro+, which I’ve been using a little bit.
So I was really against upgrading any of the handpieces because buying a new handpiece means buying more motors. Those little, very expensive motors. And this one has an Apex locator on it. So what you can do is you can actually get the Apex locator settings up. You can measure as you do with your regular Apex locator
take the lengths and then you can actually turn it to motor and Apex locator mode. And it’ll actually, when it hits the Apex, it’ll just spin backwards at quite a fast rate. It kind of lets go of the file slightly instead of rotating backwards. It actually just lets go and spins backwards. And then you can sort of feel when you hit the Apex, it’s got that fast different feel to it.
And the conform fit cones will then seat perfectly because of course they’re prepared to the APEX perfectly as per the APEX Cicada reading. So, so I’ve been using this. It’s called the X-Smart Pro+. It’s coming out soon, hopefully. But that’s been quite a nifty little device. So I might end up having to upgrade my motors, but I’m still kind of thinking about that.
But I’ll try it in some more cases and see how we go. I think I’ve used it in about four or five cases now, and it’s been really good. And quick. And super quick. Because you hit the APEX and it’s like, it spins you out. You’re done. You don’t need to keep worrying about was I there or not? Was I, it just does it for you.
That sounds very clever. Now the whole pillar of this is the using enough hypochlorite. So how many milliliters of hypochlorite would you use for a standard molar?
So four canals, probably use around about five syringes. So that would be around about 20 mils or so, 25 mils, something like this. Yeah. So I tend to think of active time rather than mils. Because if you keep just washing it out, that’s not very effective. If you soak it and activate, that’s much more effective. Adding small amounts and then activating is far better than just keeping on irrigating for like, I mean, the recommended time of irrigation is like 45 minutes.
Obviously, it’s that Retamozo study from Loma Linda. So in the protocol, you should spend about 40 minutes altogether irrigating from when you get into the root canal all the way to the end. Of course, the Loma Linda study didn’t activate it and prepare the canal. They weren’t preparing canals and files and things like this.
So, I mean, are you introducing it between every file change? Is that when you’re introducing your hypochlorite, flushing everything out? And then at the end, I mean, once you’ve got your nice shapes, because you’ve finished with your file sequence, whichever file you’re using, tell us about how much time you’re now spending with active irrigation and what that looks like for you.
Yeah, so I followed the Eastman study, which is the old 30 minute, 30 seconds, sorry, of hypochlorite activation in a minute of EDTA per canal. So at the end, so what I do is I’ll irrigate generally with a stock needle to start with, just to clear debris, just to flush out. I mean, if you’re not near the apex, then why use a tiny little delicate needle?
And then once I get to the apex with the last file, I’ll say to my nurse, can you refill that syringe and give me the plastic needle? I will fill up all the root canals with, with hypochlorite and fill the chamber, and I’ll take out the endoactivator, and I’ll activate for, as I said, 30 seconds for hypochlorite each canal and a minute for EDTA. Probably way more than that, but that’s the Eastman article.
You activate the EDTA as well, right?
Yeah, yeah. I’m activating the EDTA. That’s been shown to improve the tissue dissolving capacity of the, when we’re dissolving tissue, we’re trying to get rid of it. So I’ll do that as well.
I didn’t used to, but I’m doing that now. Yeah. I find that it works really well. The endoactivator, the new one’s particularly good as opposed to the older one that’s a bit slower. I used to use EDDY as well. That was quite a good tip. I don’t know if you’ve used that. That’s the EDDY sonic activation plastic tip. It’s like an endoactivator, but it’s on a-
So you got that literally will take about 30 seconds because you’ve got all the canals filled with the hyperchlorite at once. You’re going to activate for 30 seconds per canal now, so that’s two minutes there. And then you’re going to pay the points to get rid of the hyperchlorite before you introduce the EDTA.
Yep. Yep. Paper points. Oh, no, sorry, don’t drive the paper points. I just wash it out with the EDTA. I just dilute the hypochlorite.
Oh, okay, so you’re happy to put the hypochlorite? Okay, cool. That will save me some time now because I was using paper points.
Yeah, yeah, no, no, because if you put EDTA in to remove the smear layer- if you’re using hypochlorite and you’re alternating, you’re diluting the hypochlorite action by the EDTA. But if you’ve used the hypochlorite all the way through the process, and then you just use the EDTA to remove the smear layer, and then you’re going back in with the hypochlorite, it doesn’t really matter because you’re going to be going in with hypochlorite later.
So you can just wash that hypochlorite out with EDTA, and EDTA’s action is not affected by hypochlorite. If you mix the two, the action of the hypochlorite is to reduce. But if you’re gonna use some more straight after it, then well and you’ve used it way a lot at the start, then it’s fine.
It’s just not good to alternate it. ‘Cause you kind of use it, dilute it, use it, dilute it, use it, dilute it. You really want to be doing that. So I’d use the EDTA and flush out the hypochlorite and then just sit. I sometimes, what I actually do, and I’ll tell you a little tip here, is I actually, when I’ve prepared all the canals and last files in the tooth, I’ll put the EDTA in and then I’ll put the files in and take a like a master cone or a working length radiograph just to make sure that the canals are all the length that we got at the start or, maybe the, if you haven’t done one yet, you can, if you’re relying on your Apex locator, that would be the time to take the working length film after you prepared. Sometimes I’ll be doing this as well because of course we can rely on our Apex locator reading most of the time.
And if you, if it’s correct, if you get used to using your Apex locator, when it’s correct and when it’s not correct. Which is why I was a bit resistant to changing Apex locator, but this new one seems to be pretty good. So basically that’s what I’m doing. Sorry, I’m soaking the EDTA.
I’m taking the radiograph and by the time you take the radiograph, get the result and you’ve done your EDTA.
So you’ve got your GP cones in the EDTA, right?
Yeah, yeah, that’s right. Yeah, yeah. Or your files or whatever you’ve got to take the working length or your master cone. Yeah, so that’s what I’ll do. And then you don’t need to worry about EDTA for the rest of the appointment because you used your last file in the tooth. The smear layer that that’s created is removed by the EDTA and you’ve got-
But then you’re using one more flush of hypochlorite afterwards, right?
Yeah, I use a few more flushes with hypochlorite and then the activation maybe of that as well. But not always. I mean, like I’m happy to activate and then wash the EDTA out with hypochlorite and go through a couple more times with that, with the plastic needle I’ll be using at this stage. And I put the stopper on the plastic needle about one to two millimeters short so that I know that I’m not going to go through the apex and that I can just irrigate to the apex. And I’m happy with that, because once you’ve got the irrigant to the apex, then you should be good.
So it sounds like five to seven more minutes of final irrigation and getting your master length radiograph. Is that about a fair estimate?
Yes. Yeah, exactly. That’d be about right.
Now, if you talked about cause the final bit now, obturation, obviously most GDPs are using cold lateral compaction, especially so using warm vertical compaction, or maybe bioceramic sealers.
I don’t know where you’re going to suggest it, but for GDPs, it’s difficult to then compare your protocols to GDPs because they’ve got different materials. So I thought the best way to pitch it is what are the top tips for obturating for GDPs. And actually I did an episode Omar with an endontist, Ammar Al-Hourani.
And the main topic I asked him is, is it okay for general dentists to be relying on single cone obturation in this modern climate? Because if you use a system like Protaper, you won’t have much space for your accessory GP cones anyway. So really you’re using single cone obturation. And he says for GDPs, actually, that is probably the minimum standard. How do you feel about that?
I think that’s okay. If you’re using single cone and bioceramic sealer, that’s acceptable. I would tend to recommend single cone with a bioceramic sealer because of the nature of bioceramic sealer. It’s more of a cement than a sealer. And also the fact that not really exposing it to any heat is good.
I think that for the average case that I would treat, I’d probably finished all the treatments, sorry, obturate the case in about 15 to 20 minutes. It doesn’t take very long. Four canals. The cones now fit, as I said, they’re the same size as the file. They don’t, they’re not sort of something you need to work on.
They are basically the exact same size of the file. So that’s why single cone is possible now. If you have a cone the same as the file and you can just fill up the rest with bioceramic sealer, then why not? I personally think it’s okay to do that. I don’t do many single cone cases. What I actually do is I put a cone in bioceramic sealer.
I inject the bioceramic sealer 5mm short of the working length. I see it in the canal, then I put some on a pad and I’ll put that on the cone. And I’ll put the cone in and I’ll down pack like the first three to four millimeters. And what that does is it means that you’re removing the bioceramic sealer coronally, where we don’t really need it.
You want it apically in middle, but not coronally, because if you have a coronally and you have a huge wall of sealer, retreating might be a bit difficult. So then I just backfill with the backfilling unit, the guttersmart unit I have. And then that will basically mean that when-
Basically warm vertical compaction, right? With the Obtura type thing. Yeah. It’s a limited, it’s not all the way down.
No, exactly. It’s not the four to five millimeters short of the apex. Because by doing that, then you are essentially just using a one cone, single cone technique. I mean, we were probably all doing single cone techniques a little bit with the minimal prep systems like TruNatomy and small prep systems because how can you get a plugger down or down pack tip all four or five millimeters short in a 2504 prep? It is challenging curved canal. So this is where you need the bioceramic sealer to help you out with that. But I think bioceramic sealer is okay. I mean, there’s some research showing it’s satisfactory.
And to be honest, I think that filling the root canals is. It’s something that we need to do, but it’s not something that really affects our outcome filling. It’s like a surrogate outcome we’ve used for years in studies to look at quality of treatment when we don’t know what the treatment would involve.
We don’t know if the dentist used hypochlorite, we don’t know who uses dam, we didn’t know anything. So we’ve just taken a surrogate, voids or short, long and things like that and then try to relate them to outcome and really they have some relation to outcome, but filling in the root canal, we know from the Cleveland eggnog study going back to 1983 that.
We don’t need to fill root canals, get healing, but it probably acts as some kind of rudimentary barrier. I’d say. Obviously if you’ve got a restoration and it leaks and the canal’s open, it’s gonna get fully infected. Seal the root canal or filling the root canal probably helps prevent something, but it’s not very, it’s not gonna stop it from getting reinfected, as we all know.
There’s plenty of re-treatments out there to keep me busy. GP hasn’t stopped, hasn’t stopped them failing over the years.
We mentioned that you would use SDR as a protocol to restore from there. And the things we didn’t mention because we ran out of time is how much more information does CBCT can give you in terms of just knowing exactly where your canals are so you can be a little bit more confident in your access cavity, a bit more certainty about the length and also having a slick nurse that you work with and you’ve trained appropriately. That’s obviously is a huge part of it. Any other bigger picture things that you want to finish off this episode with and to help our colleagues become more efficient at Endo?
Well, the one big one I can think of, as I said before, is the CBCT is very helpful. Like just quickly, it will show you the where the canals are and I had a case today with two dystopical canals and it just showed, showed you DB1, DB2, it’s there. There was no MB2 in this case. I mean, it looked like, I mean, sometimes you can sort of see, it might be there, it might not be.
It looked like it really wasn’t there. And I did look for it and it wasn’t there. But it had a DB2 and it is just so nice to go into cases now and go, that’s what’s happening. We know that’s happening. There’s no guesswork, there’s no, that would be a lot of the-
So it is just a routine. So now, as well as a periapical, all of your RCT patients will have a CBCT? N ot all of them.
When I take a PA, if something looks strange, like the anatomy doesn’t look quite normal, and that’s what happened with this patient. It sort of looked like all the, there was three roots, but they were kind of all together. In an upper six, that’s not a very normal anatomy. Normally they’re a bit more splayed.
And I thought, something looks weird here. I’ll take a CBCT. And sure enough, there was no MB2. There was kind of a triangular shaped anatomy of the roots. And there was two, between the palatal distal buccal, there was another root canal. You could see that a slight smudge on the scan. So when something looks a little bit off, I’ll take a scan, but I won’t do it.
Because with a, say an upper mole or a lot of the time is you can work out the anatomy in the tooth because you have space to look. We have the microscope, we have our skills, we have our knowledge. I would say when it becomes really handly, something like a lower incisor where you don’t have space and you don’t have troughing is not a good idea in a lower molar, a lower incisor, sorry, a lower incisor, take a scan, and again, there’s one canal, there’s one canal, no need to trough, there’s two canals, you need to be looking. It’s right in front of you. That has been a big help for me in the last year and a half or two since we’ve got the machine at the practice.
So you wanted to ask another question about other things. Well, I would say just keep practicing. But like, also go and watch what other people do and talk to people. If you can go to, there’s a few meetings around the world which are very, very good for endocentric dentists.
There’s AAE, which is the American Association of Endodontists meeting and the exciting news is that that’s in Los Angeles next year in April 17th to 20th. It’s even in our school holidays. So Disneyland is a possibility for those wanting to go along if they’ve got kids. And then there’s the, obviously the ESE, which is a great meeting.
It’s happening tomorrow, I think in Helsinki. And they have courses. Attached to these meetings, like pre Congress courses, where you can go and meet some of the big names in Endo, talk to them, see how they do things. I remember a few years ago going to Rick Rubinstein’s surgical course, and I thought, Rick Rubinstein’s a legend of microsurgery, and he’s going to show me how to treat these plastic models that we were treating.
And it was really great to go along and see his thoughts, and hear his thoughts, and see what he did. And use the kit and everything so these are good opportunities as well as, as practicing and working hard. We need to have our fun as well and keep our motivation high enthusiasm.
Yeah. I want to echo the shadowing really helped me become more efficient in all aspects of my dentistry. Just seeing how other more experienced clinicians do things and how different that is to you. Like from you today, I picked up a few gems, including the fact that I don’t need to use the paper points after my hyperchlorite little things like that, they add up over time as the more tips you gain.
So thanks so much Omar for giving me your time and I know how busy you are and you’re going to help and impact a lot of people to improve their endodontics. I’m going to put links to your social media profiles, which have been absolutely brilliant. Everyone should, who’s even thinking about doing endo or does any sort of endo should follow Omar and also the link to your app as well, which I’m very excited to download and just wants to say, yeah, thank you so much for your time today.
Thanks a lot for having me on the podcast. It’s really great to talk to you and look forward to meeting you at one of the meetings in the future.
Absolutely. Well, there we have it, guys. Thanks so much for listening all the way to the end. Hoping your root canals are going to be a little bit more efficient now after picking up some of those tips.
I have put below in the YouTube notes or in the show notes, depending on where you’re listening. And of course, on the Protrusive Premium app, I put all his app link and his social media account is definitely worth following. He’s so brilliant with what he shares and you should definitely give him a follow.
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