How do you obturate yours? When I have had the equipment (and training) I have used warm vertical compaction – no doubt that IS the gold standard. However, what is the humble GDP using all over the world? I would argue that not only are we using cold lateral compaction with sealer, but in many cases, we are sticking a big, fat, tapered GP cone in the canal with a splodge of sealer around it. Is that legit?
Obviously the landscape is changing with the popularity of bioceramic sealers in Endodontics – I use this time to ask Dr Ammar Al-Hourani about this too.
Is single point obturation cheating?
Should GDPs start using bioceramic sealers?
Does it even matter?
I hope you enjoy this group function – you can follow Dr Al-Hourani on Instagram via @theendoguys
If you enjoyed this, you might also like my episode with another talented Endodontist, Kreena Patel, on why we hate cracked teeth!
Click below for full episode transcript:Opening Snippet: Hello, Protruserati, I'm Jaz Gulati and welcome to this group function where we answer one burning question. Today's burning question has been sent in by someone it is regarding endodontics, is single point obturation good enough?...
Jaz’s Introduction: What i mean by that is you prepare your chemo mechanically prepare your canal and now when you come to the obturation stage you just stick one of those fat master gp cones in there potentially a matching size to a rotary file you just used and then you just fill up the rest with the sealer is that good enough? See i think this is what GDPs all of the world are doing. We’re not doing warm vertical compaction, we can be doing cold lateral compaction as a whole but a lot of times you stick the fat gp cone in and it fits well enough and there’s not enough space for cold lateral compaction. So is this technique of obturation up to the mark? So that’s what i’m gonna find out today from from Ammar Al-Hourani, who’s a specialist endodontist and we’re gonna jump straight away just one thing to say is the splint course is now just under two weeks away i’m looking to launch it march 12th. It’s the first time i’m revealing this. So march 12th it should be a launching online this splint course is 100% online. it’s packed full of videos like my resin bonded bridge course i thought i’m really proud of it. It’s got loads of rave reviews but it lacked video so i took that several notches further with the splint course and you’re basically like watching me like you’re like over the shoulder kind of training while i’m adjusting splints, while i’m going through diagnostic process. It very much teaches you the very basis basics of an anatomy as a gdp and building up to a diagnosis and how to choose which splint will help your patient the most. Sometimes we’re looking just use a protective splint but also with that protective splint to protect your restorative work or prevent the patient from pathologically destroying their teeth, there’s a bit of a decision-making tree as to which splint why and when and what are the risks of certain splints. So i’m going to go through eight or seven of that including the delivery from a stabilization splint to AMPSAs, the whole lot in between. So i’m so excited to share that if you’re interested why don’t you download one of my flow charts i’ve got a free flow chart for you to download which pretty much even if you don’t do the course you’re going to find it valuable because it’s going to show you when i prescribe certain appliances. Now just a disclaimer i made a flowchart and really it’s a guide but you should be deviating away from guide any sort of guideline you should always be happy to deviate away from a guideline because there’s no such thing as a cookie cutter approach to occlusion. So just read it with caution is there just to help my students of the course get an idea as a generalization and if you don’t understand anything on that it’s because it’s very much there to accompany the course but feel free to that’s www.protrusive.co.uk/flowchart you can download that straight away.
Main Interview: So let’s join Ammar Al-Hourani to answer the question, is single point obturation good enough. Hello everyone and welcome to this group function, today we’ve got Ammar Al-Hourani, okay? He’s a specialist endodontist, he works two days a week, teaching undergraduates in Plymouth, he’s three days a week in private practice in London and he’s part of the endo guys and this episode is where we answer one burning question and the burning question today thanks to Ammar’s gonna join us for this, is single point obturation okay? So i’m gonna spend just one minute here i’m also gonna check to make sure that we definitely are live but spend one minute just set the scene about how this question came to be and basically when i was a student we got taught and though in our endoclinics and we first you know we started with k files then we moved on to sort of hand.. hand protaper actually in dental school and then we moved on to rotary eventually which was cool but initially we started cold lateral compaction with the like iso files and iso gp points and then eventually we got taught how to use the the matching gp cones or the pro taper and when it filled that canal so beautifully i realized actually there’s not much space in there for the your cold lateral compaction and then eventually what happens is that you accept some compromises and practically you know you want to be quick so eventually i had a gp cone with a lot of sealer around the edges and if there was a bit of space i try and jam in a little you know accessory point. So my first question Ammar is okay so thanks for joining me on my first question is as a gdp let’s forget about bioceramic seeders for a moment as a gdp is that acceptable that scenario i just described yeah i mean that’s the scenario that’s probably going all the way through the UK and i’ve got a lot of my own colleagues i work with that probably do the same thing with h plus i think let’s take a step back i think we just need to understand the fundamentals first about why we’re doing what we’re doing. Endodontics is relatively straightforward you know it’s really broken down to three parts, get the necrotic tissue out, create a taper in the canal and wash it and then obturate. So obturation is the very last thing. Opening up, remove the decay, remove the leaking restoration and then you know once you taper it, the cleaning part is the most important element of the whole project okay? Now why do we obtain it? hat’s the point of obturation? Obturation really just fills up your space that you’ve created once you’ve cleaned and you’re happy with everything. Now we obturate, the reason why we obturate is a number of reasons you want to fill up the dead space you want to clog up the dentinal tubules from the bugs and you want to seal them all off so they can’t suffocate them from nutrients and then you want to stop any percolation of fluid back in from the apex or from the lateral canals okay? Now if you use gp you know we use gp and we use sealers for that traditionally and we still do okay nothing’s really changed over the last 40 50 years really. Now if you use gp on its own the problem with it is if used as a warm vertical compaction technique it will shrink by about seven percent and it doesn’t really have a hermitic seal towards the dentine so you’re going to have a gap between the dentine and your gp and that in itself forms a void and that void creates areas in which bacteria hasn’t been sufficient you know you can’t entomb that bacteria and that’s it there’s a biofilm that is going to regrow, spore, release their you know their toxins and they’re gonna then affect the outcome okay? So then you have to produce something like a sealer okay to prevent or close that gap. Now the sealer does a few things for you it’s antimicrobial, it fills all the gaps in turns the bacteria as much as possible or goes into the dentin tubules and it gets into the nooks and crannies that your you know your gp can’t get into okay? Don’t forget you’re preparing a circle within an ovoid you know and all we’re trying to do is disinfect the canal as best as possible and reduce the bugs as you know to a point in which your body then starts to clean things up. You’re not going to sterilize the tooth, you’re going to just disinfect it okay? Now traditionally the sealer that we use is tubular seal or more recently AH plus. Problem with tubular seal which is antioxidant, the eugenol itself is quite an irritant it goes through the apex it’s really uncomfortable, it sort of dissolves over time, it doesn’t really have a good bond to your canals and then if you want to put a post in there you’ve got oil and you can’t really bond to it very very well you know the whole thing becomes an oily mess. Some people still use it i’ve not used it for a very long time probably since i was a gdp five six seven years ago. AH plus came along a nicer material, resin-based sealer you know it’s a bit thinner, it bonded a little bit better to the dentine but it’s still hydrophobic it’s a resin it’s antimicrobial has got a nice high ph the cytoskeleton sorry it’s great on a radiograph especially the new stuff AH plus jet, it’s like you know it’s like putting an ir core in the canal and then you know but the problem with it again if you used a warm vertical you know if you use gp, the single cone add AH plus, AH plus itself as a resin shrinks by 6.5% So why am i talking about shrinkage why shrink is a big deal for me? Well if you look at Angutal studies which came out a few years back she talked about voids. Voids is an issue for us because that’s areas within the root canal system don’t forget we go back to the original position which is you’re creating a circle with your file within an ovoid canal so you’ve got areas which are not being touched by your file and that’s it is therefore which only the arrogant can to and then hopefully your sealing material and if your ceiling material is shrinking then that’s areas where you can then have repopulation of the microorganisms bacteria and these are voids where things can regrow again and cause failure in the future. So a single cone with those materials a good idea. I’ll go to the next point which is i think personally as the most important element with both of these things is the irrigation and your coronal seal, if you’ve got a mark that’s a given okay i’m going to take control because that’s a given okay? So we have to have a clean canal i’m totally with you but i want to really twist your arm here i’m trying to really twist your arm and try and get the the answer in terms of the gp cone right? So basically but here’s the situation you’ve mentioned about warm vertical compaction but you know most of the audience here we’re gdps right we’re using cold lateral compaction okay and a lot of time like whether you can get an accessory point and extra gp cones in it depends on what kind of a canal you start out with right? So that scenario where you know you can’t get another accessory point in there but the gp cone let’s say an f2 f3 the pro taper system and again f3 matching cone and you stick it in there there’s not enough space to put an accessory cone in there but you still see that it’s not as snug as you want in the coronal portion. So that all the tubules that you’re using whatever sealer AH plus is all around okay? What should we do in that scenario with cold lateral compaction or is that pro taper system is not, it wasn’t it was never designed for cold lateral. Well the new matching systems have obviously been designed for the single cone technique in the sense that you want to use it as a warm vertical compaction technique okay? So you’re cutting it back you’re getting that really nice tug back at the last five millimeters where the you know most file systems now are not a progressive taper they’re available taper. S o the first four five millimeters off the canal you know the apical part of the file is really what the gp is fitting into and then the rest of it should be technically warm vertical compacted but we don’t have these materials these are very expensive materials they’re technic sensitive you can put a lot of pressure on the root so from that point of view as long as you’ve got in my opinion a clean canal dried well you know you don’t have any fluid going back in there because you’ve got inflammation or inflammatory acidity and you’ve got a really good coronal seal i think you should be absolutely fine i think it would be okay yes okay i’m so glad you said that i was actually really worried because when i did that i felt guilty i have to say no it’s not guilty but you need to understand that there’s still limitations from the sealer material. So the sealers haven’t really truly been designed for this purpose but as long as you’ve got good coronal seal if you’ve looked at ray and drop studies if you’ve got good coronal seal even with a root canal treatment that seemed to do fine so maybe we’re looking at the finer technicalities of things and at the end of the day let’s be honest let’s be honest we’re always judging the outcome of root canal treatment by the white line and if the white line looks great then we all assume everything’s good on a two-dimensional x-ray don’t forget it’s not that’s not from a three-dimensional point of view. So that’s why i think that bioceramic sealers in my opinion now sort of take over you know. I think they are the future because.. So i mean i want to come to the bioceramic sealers i want to come back i just want to say at this point because we’ve got some people live right now so i want to encourage at this stage that if anyone’s got any questions send them over because then, So nicola hi nicole and nicolas are based in italy he’s saying hello he’s talking about bioceramic hydraulic sealers which you’re going to come on to now so if anyone’s any questions okay you can send it here we have had one question from instagram already which we’re going to come on to at the end. So in the first half this group function which we’re doing amazingly for timing you’re really good that you know you really answered my question beautifully, Ammar thank you so much i’m not just saying that because you’ve given me the wink right answer but no it makes you feel good that all those observations i did where i thought you know i don’t have a warm vertical compaction system i’m just cold lateral compacting and there isn’t much space so i’m relying on my sealer but you’re right as long as the disinfection was good and the coronal seal the rayon trope studies 1985 i think it was, classic studies you probably know that the date but i will but that’s amazing. So now with the bioceramic sealers give us a flavor of what most endodontists you think are doing now with the bioceramic sealers and how as gdps we can implement that for our more simple endos? Okay well we have to understand the science of the bioceramic sealer if you give you a few minutes just to you know discuss that with your colleague some people don’t really understand what up bios don’t understand that we’ve not really gone into the technicalities of bioceramic it’s not something we’ve been taught relatively. It’s not new, it’s been out since 2007 but bioceramic sealers are really derivatives of mta. MTA was obviously you know discovered by mahmoud turbine quite a few years back and we took some of the active materials from that so the tri-calcium silicate, dicalcium silicate, calcium phosphate okay and they put that into sealer and the nice thing about that is that the you know if you look at all the studies from bioceramic you know with bioceramics it showed that it was by you know bioactive so it was osteoconductive in a sense it created healing or it stimulated the bone to heal, it’s a stable material it doesn’t shrink it actually expands by 0.2 percent so you know expanded so therefore it’s a stable material, it’s hydrophilic, it actually bonds to dentine through alkaline etching, it’s a high ph of about 12.8 an initial setting which is highly antimicrobial and it releases calcium hydroxide as a byproduct so as a material if you were to have asked me as a gdp many many years ago, create me a sealer that would do everything for you this is the closest we have to a sealer that sort of overcame all the limitations of the past don’t forget what we were doing before and the technique of obturation before, was our technique was sort of being guided by the sealer that we had because we had limitations to the sealer. Now that sealer does is actually pretty good and the gp really only does one thing for us it’s a vehicle to push that sealer to where we want it within the zero two millimeters that is what we’re aiming for because if we do that then that means we have cleaned to zero two millimeters and that apical third is where we have most of the ramifications the lateral canals where we have most bugs are difficult to clean especially with you know big lesions with vital cases you can get away with it, with a non-vital case with a chronic implant on that you need to clean that area very very well. So now i have a material that’s really stable it does everything i want it stays where i want it to be sets nicely but where’s the problems with it? The problems with it is retweeting it is going to be a nightmare okay because it’s attached well don’t forget we go back to the original thing you’ve created a circle with an ovoid canal, that ovoid part on the sides you’re never going to really remove 100% and if you’ve not prepared it to the zero to two millimeters it’s going to make my life extremely difficult trying to get patency. If you look some of the studies patency was very very difficult to re-ascertain because this material is rock-solid you can’t dissolve it, you can’t wick it out, you can’t use chloroform on it you can’t use anything on it you have to literally either drill it out or it’s going to stay there because it has high affinity.. -That begs a really interesting question then so we obviously know that a lot of endodontists i know are using bio ceramic sealers with a warm vertical compaction system with gp obviously as a vehicle as you say you put it so nicely there. So that’s great so that’s what endo guys are using, gdps, what do you want us to use? Do you want us to use like imagine we’ve done everything to a high standard we’ve used sodium hypochlorite at least three percent heated and whatever we can go into in that whether it’s necessary or not we’ve used edta 17%, we’ve done a a good sort of chemo mechanical cleaning and then we come to obturation and we may not have warm vertical compaction but we’ve got a bioceramic sealer and we can squirt inside or place inside a nicely fitting gp cone that’s going to be snug in the apical few millimeters. Should we use the bioceramic sealer which may make a make it difficult for you, if you’re going to see it for re-treatment in the future or should we just stick to using the tube seals and the AH pluses because of that scenario that we just discussed? Ultimately at the center of all of this discussion is the patient? Okay so the patient really needs to get the best outcome out of all of this if you are sure that you have located all the canals you’ve gained patency which improves your outcome by doubling it you’ve done a really good chemo mechanical preparation you’ve really cleaned that tooth well you’ve done it edta red to remove the smear layer and you’re happy with your working length pa and you know you’re within zero to two millimeters then go ahead and put your biceramic in there i have no problem with that because it’s not going to be difficult for me that gp is going to act as a quasi glide path i’m going to get back in there and be able to get to the apical two millimeters and the apical 2 millimeters is the most important element for me because that’s why i need to i need to clean that area very very well. So if you have achieved all of these areas and you’ve ticked all those boxes then by all means go ahead and use bioceramic sealer. It’s as simple as that but if you think you have it… -If you yeah if you meet all those objectives you’re probably not going to get to see it because it’s probably going to be a success…- It’s going to be a success it’s going to be great, it’s going to look great on an x-ray, it’s gonna be it’s technique you know the technical sensitivity is nothing it’s easy to learn it looks great on a pa you’re gonna fist pump your nurse in the end of it you’re gonna look you’re gonna feel like a hero and so why not use it if it’s there and you know it’s gonna do a great job and we know the science is really good behind it use it you know but if you don’t get to those points then please don’t because that’s when it’s going to be very difficult for someone like myself or a dentist specialist or even other dentists to retreat that and therefore. that might be pushing us towards surgery straight away rather than a retreat and that’s you know that makes it more difficult then you’ve sort of for any root canal treatment we need to remember one thing, if you do any treatment in dentistry you need to always think about what am i going to do when it fails not when it’s going great. Always think about failure, what do i do next? If you think about it this way it makes things a little bit easier to plan and us endodontists are like that we do the endo but then i’m always thinking if this fails what am i going to do next? Am i going to do surgery or am going to get back to do i’m going to do? So i use bioceramic sealers but actually, Jaz, you’re going to be surprised by this not all Endodontist used bioceramic sealers i would say it’s still a 50-50 mix okay i like it because i like the science i enjoy i like what it does it makes me feel and i’m i’m a little bit lazy so i like it you know whereas others like to make their life you know they want to use the AH plus that’s what they’ve been trained with, they like warm vertical compaction they like it you know how it looks in a pa, they like the skill set involved with it you know different people like different things but for me it just works. It works in my hands and i’m getting really good outcomes and that lesion that i’ve got is disappearing or getting smaller over time. So for me it works but will it work in the long run you know we just need to wait also for the long term studies as well we still have to wait. – Well i really like those answers and i think you summed up very nicely as a closing summary of this segment if you like is that as a gdp now this is as a gdp perspective based on what i’ve just learned from you, if you’re.. everything’s going well use the bioceramic sealer use gp give your nurse the fist bump as you said but if you have any doubts that the root canal which you’re approaching from you know the best intentions and maybe you just feel that you know one or two elements are not you know you haven’t got patency but it’s not bad enough that you want to refer it or you need to refer it because now you’re sort of you’re invested into that root canal right? Maybe in that scenario you should be using the tubule seal or the AH. plus or whatever to make a potential re-treatment easier. Do you think that’s a fair way to put it? – Yeah fair analysis because even then you know don’t forget the coronal part we’re going to you know most dentists are going to probably flare with the gates so it’s going to be overly flared a little bit so you’re going to have enough space to still put you know a few accessory cones and give yourself some good lateral compaction so i think it’s fair to say yeah if you think you’ve cleaned it very well but you just can’t get to the very don’t forget patency is still one of those things, it’s debatable concept you know some people think you know some scholars believe in it and some scholars still don’t you know some of the big scholars still don’t push for it you know so as long as you’re… – But you’re able that gut feelings i’m all right? gdps we all have that gut feeling that okay we know that this is going to be going well so i think i like it let’s leave it that gut feeling and then base your sealer on that but then let’s not get into the fact that bioceramic sealers are expensive so is there use it that kind of stuff but i think you’ve covered it really well, Ammar about ‘is single point obturation acceptable’ so i think you’ve given you’ve done this group function justice so in the in the latter bit now we’re gonna take some questions because i have got some questions so we’ll take that out.. -One last thing what i’m trying to say is that the obturation part is just one element of the whole thing. If everything’s being done well it’s just one element you can’t put down your whole success or survival of a tooth or things going well on the obturation it’s all about everything else fitting together so there’s a lot of animal elements and you can’t ever do a study to say it’s definitely the obturation system or the sealer is what caused the whole thing to work. So if you’ve got a dirty canal and a poor coronal seal no matter what you’re going to put in there it’s just not going to work it’s eventually going to come and blow up, you don’t put rubber down you get you know saliva leaking in there it’s not going to work you know and it’s just common sense as long as you’ve got really you’ve done a really good job if you obturate it relatively well you should get a good outcome your body really heals very very well you know the healing potential of the body is phenomenal and you’ve seen a lot of terrible root canal treatments i’m sure that are still surviving 10 15 years down the line if not longer. So it just shows you that as long as we reduce in the the bottom line is reduce enough bacteria in that canal and tilt the balance towards your body and your body will clean up everything up hopefully. Has anyone ever told you that as you get as you get more passionate you become more scottish i just thought i’d let you know in case anyone hasn’t told you that? Thanks so much tuning in but he’s asking can i ask about restoration of the pulp chamber, is it better to place gic barrier or can we directly etch and bond over the orifice before placing a composite core and then the second part of that question is who should place the core restoration to gdp or the endodontist? So the first part was restoring on the pulp chamber over your gp gic barrier versus composite and then the second one was who should be doing the the core? Okay so first thing first question i think the most important thing is that you need to cut back the gp to the cej don’t leave it hanging in the pulp chamber because if your coronal seal starts to leak that’s going to leak very very quickly so make sure that at least you’ve cut it to the cej okay first and foremost. Secondly two schools sort of thought really here some people like the the the gic because there’s been some leakage studies that showed that if the filling came out it gave you about 30 days worth of protection against saliva others you know are saying put the composite straight away the likelihood if you’ve got a really nice MOD or MO or occlusal restoration the likelihood of that composite popping off just in one piece and just leaving the gic is highly unlikely okay so i think if you can get you can cut the gp to the to the cej get your you know clean the pulp chamber really well make sure it’s nice and clean etch it and bond it should be absolutely fine that’s not a problem you don’t have to have the gic. I like putting gic because i’m i’ve read the books and i just feel happier and more warmer inside me that it’s i’ve done a better job but am i doing a better job i don’t know you know that’s the reality of probably costing the principal more money. Second question you were saying about who does the core? I personally think if the you know the the patient’s already in the chair you know they’re taking time off just get the you know put the core in there , put the rubber dam on how long’s how long is going to put you know i use sdr or or bulk fill it’s going to take me how long ten minutes maybe five minutes saving the patient another appointment, another journey more time off and then i think the dentist is going to be a bit annoyed if i put gic in there drilling out gic is a bloody nightmare you know that there’s more than anyone else. So why not just leave us do everything for you and then you just you take the the glory shot get the crown on there it looks all nice people remember you for having a nice crown and that’s it you know just so make your life easy, make our life easy. You know I 100% agree with you on both counts with the composite and with the fact that whoever does the root canal just do the core at the same time and with good bonding protocols. Two more questions now one is my question actually which is, what’s your secret to getting a lovely clean looking sort of pulp chamber so once you’ve done your obturation quite often i look at it and it’s a mess you see these three orange heads and then you see all this like white sealer mess and debris and stuff like that so what’s i mean i do air abrade and then try and clean it but it never looks as good as you endo guys like it’s almost glistening and shiny like as if you guys have got like baby oil on it like what do you guys use? – So first thing i use an LN bur just to really clean you know literally cut the gp point to the cej, secondly if i use AH plus i use alcohol, rub alcohol ethanol isoprophyl alcohol will dissolve the whole thing out that gives you everything to the surface just no not percentage you could just buy it from qed i don’t know what percentage is isoprophyl the whole alcohol’s up the whole probably 100% or 70% that’ll dissolve everything out ultrasonic tip is really good just the cavitron and your three and one just you know use that just give it a really good rinse and a clean and then just that acid etch really really brush your bond onto the canals you know and on the floor on the walls brushing is the most important bit not just a little bit of a dot here and there and everywhere literally brush it until it’s glistening then like here it glistens it shines back at you and then you know everything’s well and then that’s when you go for it. That’s it there’s nothing you know it’s so good you said that because with the bond you get a better wet ability for your actual resin that goes on as well so that’s wonderful. Next question from Mohammed Adam is solubility of bioceramics? Do they meet the iso standards i hadn’t even thought about that but there we are. Is there a question mark over the solubility of bioceramics do they meet the iso standards? The bioceramic sealers don’t are not as are not as soluble as say zinc oxide eugenol but they’re actually very very stable and they set in moisture so they’re not you know that’s why they you know the more dry the canal is in fact the irony is it takes much longer for it to actually set so solubility you know it’s a stable material it actually expands a little bit so it’s actually pretty stable as material it won’t just the ones that are very soluble like zinc oxide and the calcium hydroxide based sealers those ones will dissolve really you know these are the ones you should be worried about but this one no brilliance is stable fine. We’re going to take two more questions before the end of this group function. So the next one is from Jack hope you doing well buddy. He says okay we got one more from jean-marc like i never i hate letting him down he always has good questions anyway, Jagdeep says bioceramic sealers for open apa apex cases versus your traditional mta plug? Any opinion on that? I think it’s really difficult to manipulate a gp to open apex so it’s just a lot easier to use something like mta or biodentin and i find biodentin to be an exceptionally brilliant material for it compared to other materials out there is actually quite inexpensive so using that as a barrier is much easier to do and it’s much more predictable to do and plus don’t forget that down the line that patient’s endo fails you’ve pretty much done the retro prep you just do the surgery and just shave off a little you don’t have to shave anything off you just have to clean it all off and you’ve already got the retro prep ready so with an open apex it’s just a lot easier to do that way manipulating gp by time you put that in and down pack it you might push some through it just isn’t this the same so yeah mta is the way to go correct mta or bioceramic putty you can biodentin these are i think the way to go brilliant. I’m going to ask one from we’ve got quite a few now so quick follow round questions for the last six minutes. For a young patient 17 years old irreversible pulpitis doesn’t say which tooth with fully, with apex fully formed, is there any special risk for gdps take into account or shall i refer to an endo specialist? So i don’t understand that maybe even sound better 17 year old patients irreversible okay yeah. -If they’ve got irreversible pulpitis you’ve got two options here if you think you’ve you know you can open it clean it and do a pulpotomy and use something like bulk you know biodentine and and you know basically a vital pulp therapy case yeah if you’ve got the protocol but you need the magnification to know whether or not you truly have you know the pulp stumps are actually not bleeding because you don’t really know one could bleed, one could be vital, one could be non-vital so yeah with that if you could send, if you want to save the tooth or do pulp, you know vital pulp out send it to specialist if it’s a relatively straightforward root canal treatment i think you know you should you should give a pretty good goal because you also need to learn right you need to learn somehow. Good man allowing gdps have some cases as well thank you. Next question is from Channel says what’s your method i hope she’s Shannon patel, not shannon not shannon. He’s definitely trolling you no it’s not it’s not shannon patel i know shannon. What’s your method of sealer placement put it on the gp or squirt it in first and then place the cone? Is that for bioceramic or is that for AH plus? That’s a very different thing why don’t you answer for both okay so let’s go for AH plus and then for bioceramic if it’s different. Okay i have AH plus i usually will put a little bit over the orifice and just a little bit at the very tip of the gp point and i’ll just put it in slowly okay not quickly slowly to the working length and that should be pretty much all you need you don’t need that much don’t put too much because then AH plus is quite runny you’ll just get a massive sealer puff and it’s it’s quite uncomfortable for the first eight to ten hours it’s all by sealers. Bioceramic or otherwise are cytotoxic at the beginning okay some less solar so bioceramic not as much as the AH plus or zinc oxide eugenol. So yeah not a lot you just need a little bit not a lot you should be fine and if you use the AH plus jet you don’t need any at all it just literally lights up on your pa. Bioceramics a little bit different i usually will fill up the first third so the coronal third and then i’ll unscrew the top and i’ll put the gp point into that and then i’ll put it into the canal and that gives me a little bit more control of the bioceramic okay and i’ll use less material. That’s also very important, economical. Let’s see, Wajiha wants you to repeat the name of the bur you use for the removal of gp? – Well you can get a few it’s called the LN bur or you can get the comet endo bur just call the comet wrap they know which one it is it comes in either 29 millimeters or 31 millimeters these burs can be reused over and over again because they’re tungsten carbide and they’re great because you can actually physically see what you’re doing they come in different diameters so it makes it much much easier to look at they’re about 150 pounds they’re not very expensive. – I mean i’ll tell you what i do and most of the time this isn’t successful but tell me what you think of this technique i get a gooseneck fat rosehead bur right? So a gooseneck being extra long in the neck of it so it can reach down to the the apex and i’ll just put it on really high rev no water and just you know melt stroke a ablate or cut away the gp exactly what I want. Is that slightly risky method? It should be fine but just the only worry is you you could be stripping away a lot of the paste on cervical dentine that’s the dent a few millimeters above the cej and a couple of millimeters below and that we know from new studies now coming through for the last maybe a few years you remove a lot of that dentine and then that’s the dentine that you can never really replace and that really weakens a multi-rooted tooth okay and no material can replace the strength of that area so you know if you want use something like an alarm bear or use a smaller head and do the same thing not a big fat head something a bit in the middle like maybe a size 120 should do the trick. I mean if anyone’s going to be doing this you know tomorrow morning just make sure you’ve got you know you should do anyway but make sure you’ve got decent tug back on your on your gp and it’s not like just otherwise they’ll just fly at your face there you go don’t ask me how i know that one. Okay the last question which we haven’t addressed yet which is from the instagram which is what do you do and such a common scenario am i right we prep to let’s say f2 f3 pro taper other brands are available and you get your gp cone and but it’s you know your file has been there your f2 f3 file has been there to the apex to the working length but your gp cone is just not going it’s a couple of millimeters shy, what should you do? So a couple of things we need to first let’s just give you a quick science lesson very quick 130 seconds all files that we use now are a bit more martensitic than they are austin citic what does that mean they’re a softer file they bend they’re not straight and rot you know like rigid as before so what that means is that the file itself will create that shape of an f2 or a waveone primary but it doesn’t create a hundred percent because it’s a softer file okay and your gp point will always have a little bit of discrepancy as well okay so it doesn’t fit a hundred percent so you might have an 07 taper, a 2506 or 2507 but it’s not a hundred percent 2506, percent, not 100% 2507 okay? So to correct this problems two things one you might have a you know the older style gp where it’s fitting at the top so it’s a bit fat at the top thin at the bottom so it’s basically wedging itself at the top so that’s coronal tugback okay so check for that buy the newer gp points that’s tops you have in that okay second thing is you might have a lot of smear layer in there and dentine shavings and debris so you might need to wash that out so activate the arrogant or gp pump which is really cheap and just liberate all that gunk that’s in there get some edta it removes the smear layer dissolves the dentine and that might be stopping it’s a bit like turkish coffee i don’t know if everyone’s anyone’s had greek or turkish coffee coffee’s at the bottom you know the bit at the top that you drink and that is your dentist that bit at the bottom that mud you can’t need to get rid of that okay so that’s the second point. Third point is your gp point is sometimes not fitting bang on because it’s just not been designed 100% perfectly so if you’re using an 06 taper by 04 taper gps and that stops you that means you’ve got good apical tug back and it’s not tugging back on the actual taper okay on the sides it’s tugging back only at apex and therefore it really fits beautifully at the very very tip you will not get that problem so go a taper shorter not a size charter a taper shorter so if it’s 046 buy some o4 tapers you can get that from any shop you know any distributor in the uk we’ll get you that and they’re not they’re not very expensive another thing i love that analogy of the turkish coffee actually that was genius i love that very much. Okay we’ve come to the end episode just tell us a little bit about how we can learn more from you i really like your sort of style today i like your down to her style and i just love the fact that you actually i think you you understand us as gdps obviously you’ve got the endo guys but tell us about love about because i sort of did your intro for you i’d like to know for those listening a little bit about yourself and what you get up to and how can we learn more from you so basically i really didn’t enjoy endo, as an undergrad i absolutely hated it, i actually had to go and supervise our shadow an endodontist to actually understand the principles and from that point on i’ve always thought you know i never understood it maybe i was just a bit thick i don’t know maybe other people understood it better than me but the long and short of it is i never wanted anyone to feel like that again you know i wanted people to get you know education which is relatively cheapish you know i don’t want people to pay over the odds for courses i wanted to be accessible for everyone and me and my friend always had that dream that you know we wanted everyone to be able to have you know if they want education they should be able to afford it you know i came up with horrendous amounts of debts like everyone else which had to pay back so the endo guys really is a simple concept we show you our cases we tell you what went well what didn’t go well, learning points. We’ve also got the endo guys academy that we do with coltin again it’s you know we do it for a relatively cheap fees 250 to 295 pounds of course and we go through a principle, a protocol. So we do access cavities canal location and one principle on how to get a good coronal you know coronal, middle and apical prep with glide path files and we just want to show you how you do it well so that in practice you could do you could use any file system you want and as long as you understand the principle you should use anything and anything should potentially work okay and that’s what we’ve wanted to do and that’s what the Endo guys stands for you know being there for everyone, being accessible for everyone and being you know if you want to text us, phone us, email us whatever we’ll always get back to you. You know because we felt the pain that you guys have gone through you know we never understood it till I. became a specialist and even until now i’m sometimes going to work and i’m like it’s damaged limitation i still make mistakes it’s just a matter of you know i make maybe last mistakes or i pick the right winners you know i don’t take every case on i’m comfortable to say no. Once you learn how to say no or this tooth is goosed then things become a little bit more liberating and and maybe that just comes with experience more than just just training you know and that’s what Endo guys is all about they’re for everyone basically. I really appreciate that what’s your instagram handle? – It’s just called the endo guys really easy let’s just type that up. -Fine find it you can follow the endo guys, Ammar thanks so much for covering that really well honestly, I always worry about doing these short episodes because the answer is usually to any of these complex questions the answer is usually it depends right? I’m so glad you didn’t say those two words together you never said once, it depends so thank you for not saying it depends but one last thing because Daz has just asked a really quick cheeky question for the LN burr slow hand piece or endo motor slow hand piece? Slow hand piece and use the middle always start with the middle because the middle of the size is not too big not too small if you find it’s too small go one big if it’s too big go on small simple as that keep it simple.
Jaz’s Outro: Okay amazing Ammar thank you so much for for coming on the show today. It will be on the proper podcast very soon and it was an absolute pleasure thanks so much. – Oh my pleasure thanks so much for inviting me.