Making Things Easier With Endodontic Accessories

Making Things Easier With Endodontic Accessories. Image: © Anna Jurkovska - stock.adobe.com

Easier is not always best, but it is often a whole lot better. When it comes to endodontics, why make it more complicated than it needs to be? Thanks to a constantly growing suite of products, materials, technology, and accessories, these days endodontics is easier than ever—especially if you have the right tools in your arsenal.

“Perhaps the most common question [asked] during my courses is which equipment to buy for a more effective endodontic technique upgrade,” says educator Carlos Spironelli Ramos, DDS, PhD, MS. “My background as a teacher and researcher tells me that the most critical thing when adopting a new material or technique is to offer an endodontic treatment that results in greater success rates.”

But what does that mean for individual practitioners? It depends. For some tasks, there are many equipment options that will get the job done, and personal preference plays a large role. But what are the tools that every clinician should have to get the job done more easily?

Apex Locators

When it comes to tools that will get the job done effectively—with proven success—Dr Ramos immediately recommends an apex locator.

“I would start with those [tools] endorsed by evidence-based endodontic research,” he says. “The apex locator stands as my first choice. This equipment has vast scientific experimentation behind it, exponentially increasing the degree of successful results, at a reasonable cost.”

The apex locator is an important tool in determining the length of a root canal, and apical constriction positioning. Study findings have shown that all 4 generations of apex locators are accurate in measuring working length, and that they may perform better than radiographs in determining working length.^1,2 With this research behind them, apex locators are a no-brainer addition to any endodontic treatment approach.

And there are plenty to choose from, all with their own benefits. Lightweight and compact, the EndoSync A.I. from Brasseler USA can accurately identify the location of the file in the canal despite the presence of blood, saline, irrigants, or other materials. A large LCD screen, audible warnings, and automatic calibration all combine to increase ease of use.

If you are looking to go even smaller than the compact EndoSync A.I., Polaroid Healthcare has introduced NEO, an apex locator roughly the size of a smartwatch. Measuring just 46 × 43 × 16 mm, the NEO can clip onto a watchband, bib, ruler—wherever is most convenient for the clinician. Even better, the touch screen display responds to gloved fingers, so you won’t be left swiping futilely.

For clinicians who want a more prominent display, the Root ZX II (J. Morita) features an easy-to-read color LCD screen, and its ratio technique is said to deliver an accuracy of 97.5%. Other options such as the ProMark (Dentsply Sirona), CanalPro (Coltene), and EndoPilot (Komet USA) all streamline the process of determining how far instruments should go into the canal and when the preparation should end, reducing the risk of root perforation and other complications.

“Some critical devices have experienced significant technological development in simplifying usage, which in turn creates a smoother learning curve for the operator,” Dr Ramos says. “This should be the essential principle, and apparently, it is what is being taken into account [in development].”

Pulp Vitality Testing Tools

It is easy to jump to the exciting technological tools that assist in treatment, but there are also products that help before the procedure ever begins. Pulp vitality testing is critical in determining the health of dental pulp. Different testing types, including temperature/thermal, electric, percussion, and pulse oximeter, are all effective approaches to varying degrees.

When it comes to speedy, on-the-spot testing, thermal testing can be a quick and easy approach. Endodontic sprays such as Cold As Ice (Dental Creations) induce rapid pulpal response thanks to a low liquid temperature of –15.2 °F. Easy to use (and environmentally friendly) Cold As Ice produces a rapid response for instant results.

Pac-Dent’s PacEndo^™ Vital-Ice^™ Pulp Vitality Spray is another option for stimulation of nerve endings. Significantly colder than ice or ethyl chloride, PacEndo Vital-Ice tests the vitality of the tooth before a procedure ever begins.

Although thermal testing is a simple way to get results, pain-relief drugs, for example, may cause false readings as they may mask vitality issues. To avoid this, some practitioners are exploring electric testers such as the Digitest^® 3 Pulp Vitality Tester (Parkell). The Digitest 3 uses electricity to stimulate teeth and compare responses between healthy and unhealthy teeth to identify issues.

Another option in pulp vitality testing is a pulse oximeter. Recent study results have shown that pulse oximeters provide the most accurate diagnostic results when compared with thermal testing and electric pulp testers.^3,4 By comparing oxygen saturation values from a patient’s finger with pulp oxygen saturation values in these studies, researchers were able to establish pulp vitality.

Irrigants and Irrigation

As every clinician knows, irrigation is critical in endodontic procedures to disinfect and prevent reinfection—so critical, in fact, that it is a particular focus of Dr Ramos and the endodontic team at Pac-Dent.

“Many projects are under development, but the endodontic division’s primary focus is irrigation/disinfection,” Dr Ramos says. “Pac-Dent’s vocation is the development of the elements that make up irrigation in endodontics. We are working together to improve the quality of the chemicals involved in irrigation and the mechanical irrigation delivery system.”

Although there are many nonbactericidal and bactericidal irrigants available, including saline, chlorhexidine (CHX), sodium hypochlorite (NaOCl), and more, there are also some sidekicks that can make irrigation more effective. The CanalClean^™ Irrigation Kit from Vista Apex includes 2 solutions that eliminate the need for ethylenediaminetetraacetic acid (EDTA), CHX, and a rinsing agent. The kit’s Chlor-XTRA^™ 6% NaOCl formula penetrates into lateral canals, thanks to lowered surface tension. This is coupled with Smear-OFF^™ 2-in-1, an EDTA/CHX mix that optimizes smear layer removal. Chlor-XTRA and Smear-OFF 2-in-1 will not form a precipitate when used together, negating the need for an extra rinsing step and making irrigation simpler.

Dentsply Sirona’s QMix^® 2in1 Irrigating Solution is another option for final rinse smear removal. Premixed and ready to use after NaOCl, it saves time because you do not have to use EDTA and CHX sequentially. With a demonstrated bacterial kill rate of 99.99%, it is an effective solution for irrigation protocols.

Irrigants are important, but the irrigation approach is just as critical. The tools used to enlarge the root canal space are limited and cannot always conform to the intricacies of the patient’s anatomy. One method of ensuring that all of the canal is properly irrigated is through the use of ultrasonics, which can enhance the ability of irrigants to reach all portions of the canal. Ultrasonic activators such as the EndoUltra^® Cordless Ultrasonic Activator provide enhanced acoustic streaming through cavitation and better penetration into the canal (and, in the case of the EndoUltra, have the convenience of being cordless).

Dr Ramos agrees that mechanical irrigation can be of huge benefit, and believes that the iVac^™ LED Piezo Ultrasonic Scaler (Pac-Dent) represents an effective way to achieve effective irrigation.

“I have to highlight the iVac, a system that unites the 3 fundamental principles of mechanical irrigation: ultrasonic activation, negative apical pressure, and concomitant irrigation,” he says. “The next step will be to offer a complete system, with an ultrasonic unit designed and dedicated to the iVac. In this way, Pac-Dent aims to offer the best in chemical and physical irrigation approaches, and still provide a technique that, in addition to being efficient, is safe regarding apical extrusion.”

Isolation

Perhaps as important as irrigation is isolation. Isolation prevents the potential contamination of endodontic preparations, protecting both the working field and the oral cavity. The rubber dam has long been a staple of endodontic isolation and for good reason: It may be an oldie, but it’s a goodie.

For rubber dam skeptics, products such as the True^™ Dental Dam (Clinician’s Choice Dental Products Inc) may turn them into converts. True glides smoothly through contacts, easily tucking into the sulcus for confident placement. Tear resistant and extremely durable, the material can be easily stretched to create a clean, clear field. Clinicians looking for hardy tensile strength can also turn to Smart Dam dental dams (Cranberry). Powder free and with 98% less latex protein, Smart Dams come in unscented and nonlatex and latex spearmint-scented varieties.

When concerns about dental dam placement or leaks arise, products such as OraSeal^™ (Ultradent) can provide additional protection. OraSeal caulking material can be used to repair rubber dam leaks, effectively adhering to even wet rubber dams, sealing the rubber dam to protect the gingiva. Another product from Ultradent, J-Temp^™ Temporary Resin, helps support structure for isolation clamping and helps block endodontic irritants.

“J-Temp is a temporary resin to be applied to seal the interappointment cavity, creating a structure to isolate complex cases and working as a barrier so that irrigants do not leak into a patient’s mouth,” says Renato Miotto Palo, DDS, PhD, MS. “This is a multifunctional material designed to be easy to apply, resistant between sessions, and easy to remove, exactly what every professional needs when dealing with endodontic treatment.”

Building a Toolbox for the Future

There are so many other excellent tools and accessories available on the market to simplify endodontic procedures, from lasers to file systems, to burs and sponges, to obturation systems and motors, that it is hard to limit a list of accessories to just a few. Advances in endodontic handpieces, bioceramics, cone-beam computed tomography, and loupes are also pushing endodontics forward in an exciting manner. And then of course, there is the noninvasive multisonic ultracleaning technology of the GentleWave^® System, which combines irrigants with waves of broad-spectrum acoustic energy. Now it is becoming harder than ever to identify the top tools and accessories for endodontic care.

“For example, we have the new generation of endodontic motors and instruments,” Dr Ramos says. “Open motors, with the possibility of adjusting rotation and torque and angles in reciprocation, are added to intelligent preset programs with rotational and alternating movements working in synchrony with heat-treated engine-driven NiTi [nickel-titanium] instruments of better performance.”

These advances become even more thrilling when you consider how many more products and innovations there are on the horizon.

“Some non- to minimally invasive intervention proposals are on the table and will require long-term scientific proof,” Dr Ramos continues. “Innovations that present an additional improvement to what already is consolidated by research tend to succeed better among colleagues than disruptive innovations.”

Regardless of what comes down the road, clinicians can find comfort in the treasure trove of products already on the market, while ruminating positively on the innovations of the future.

“The future of endodontics appears to be well delineated today, but it needs the corroboration of clinical tests,” Dr Ramos concludes. “Once again, time reigns supreme in designing a future that perhaps we can premeditate now.”

References

1. Nasiri K, Wrbas KT. Accuracy of different generations of apex locators in determining working length: a systematic review and meta-analysis. Saudi Dent J. 2022;34(1):11-20. doi:10.1016/j.sdentj.2021.09.020
2. Martins JNR, Marques D, Mata A, Caramês J. Clinical efficacy of electronic apex locators: systematic review. J Endod. 2014;40(6):759-777. doi:10.1016/j.joen.2014.03.011
3. Patro S, Meto A, Mohanty A, et al. Diagnostic accuracy of pulp vitality tests and pulp sensibility tests for assessing pulpal health in permanent teeth: a systematic review and meta-analysis. Int J Environ Res Public Health. 2022;19(15):9599. doi:10.3390/ijerph19159599
4. Sadique M, Ravi SV, Thomas K, Dhanapal P, Simon EP, Shaheen M. Evaluation of efficacy of a pulse oximeter to assess pulp vitality. J Int Oral Health. 2014;6(3):70-72