Putting on a show

THE SET-UP

“Dr. Garry Bey describes the challenges of doing a live patient demonstration. His enthusiasm for endodontics and passion for his chosen instrumentation and obturation system are contagious."
-Dr. Richard E. Mounce, team lead

When I was asked if I would perform a root canal in front of a live audience at the 2009 Greater New York Dental Meeting (GNYDM), my first inclination was, “Wow, how exciting!”

The chance to disseminate my knowledge and expertise after 30 years of practicing dentistry (27 as an endodontist), while treating a patient live in front of 300 dentists seemed like an ideal way to share my tips, techniques and philosophies.

What better way to teach than in a room full of big screen TVs showing close ups of my instruments, and microphones picking up every sound? What a great way to learn-close up through a surgical operating microscope-how I navigate, clean, shape and fill a complex root canal system. Fantastic!

Then reality set in. Where would I get the right patient? How would I set up a makeshift operatory to approximate the friendly, professional and ergonomic confines of my own office? What happens if an unexpected complication arises?

Was I thinking this through? Did I imagine it was going to be easy to do a molar root canal on a stage in unfamiliar surroundings? Every dentist knows even the simplest-looking cases can be fraught with unforeseen complications. Just like in golf, when it comes to root canal therapy, “There is no such thing as a gimme.”

Setting up

To secure the proper patient, I turned to my referral base. About one month before the GNYDM, long-standing friend and excellent dentist Dr. Ronald Herrmann sent me an x-ray and clinical history of a patient, who we’ll call “Jane,” in need of root canal treatment. Tooth No. 19 had a pulpotomy and could wait for treatment, but a tooth with an apparently complex root canal anatomy-this was certainly not a gimme!

Setting up the makeshift operatory was the next big task. I needed to have everything available to do the procedure properly while also showing the audience as many tips, tricks and “pearls” as I could in the short one hour I’d have.

If I attend a lecture and take home just one piece of knowledge I can use in my practice, I consider the time well spent. My goal was to share multiple “pearls” with my audience. Having an A-Dec chair, a Zeiss surgical operating microscope and Schick digital radiography at my disposal was a great help and I thank those companies for their support.

Three days before the event, my wonderful dental assistant for the past 12 years, Linda Cordaro, and I headed to the convention center with two boxes of instruments, many of which I knew I would need and others I thought I might. Prior to this I had never sat down to figure out how many instruments I use during a routine endodontic procedure. After going through this exercise, I know most of you would be surprised at how many there actually are.

The two most important pieces of the armamentaria were Discus Dental’s LightSpeedLSX for instrumentation and EndoVac for irrigation. I use these two systems for every patient, every canal. I believe-without a doubt-that they allow me to provide my patients the best endodontic treatment on the planet.

Tuesday, Dec. 1 – We’re live

On the big day, everyone is at the Javits Center and everything was running like clockwork as our time to go on arrives.

I anesthetized Jane with a mandibular block using two carpules of 3% mepivacaine and added an intraligamental injection using a third of a carpule of articaine with 1:100,000 epinephrine. This is my secret for achieving profound local anesthesia on even the most sensitive teeth. While that was taking effect, my pre-treatment lecture described my philosophy of root canal instrumentation calling for instrumenting to wider apical sizes.

Wider canal preparations produce cleaner canals; cleaner canals give the case a better chance of success-it’s just that simple. My talk espoused the virtues of LightSpeed files as the only non-tapered nickel-titanium rotary files, and I explained how their design allows me to instrument canals so each is prepared to its proper width based on its own anatomy, thus they are never over- or under-prepared.

Access and exploration

I continued by showing how proper access is the cornerstone of successful endodontics. Additionally, I transilluminate with a handheld fiber optic light from Welch Allyn. This is a great way to visualize even the most calcified canals.

Canal exploration followed a standard sequence, and once measurement was attained and patency established, I instrumented with a #20 K file to working length. It was now time to begin the rotary portion of instrumentation.

Broken file, no problem

As I went through the usual LightSpeed sequence, the #30 separated in the distal canal. Because LightSpeed files are designed to separate at the hub when they bind or encounter too much force rather than break at the tip, this was a non-issue. Instrument separations are rare and they also are easy to deal with. In this case, a 20 mm piece of shaft was visible in the orifice opening and easily removed with Discus’ MicroRetrieval Forceps. Six seconds later, I continued instrumentation.

I finished the mesial canals to a #45 and the distal canal to a #50. Those sizes might sound large, but because LightSpeed files are designed to only cut at the tip and not bind in the coronal third or mid-root, I know when the canal has been properly prepared. The spade blade gives excellent tactile feedback and lets me know when I’m engaging and debriding all canal walls.

Negative-pressure irrigation

With instrumentation complete, we were ready for final irrigation. For this I use the EndoVac, a ground-breaking, true apical negative-pressure irrigation system. I start with full strength sodium hypochlorite and a MacroCannula to remove gross debris from the coronal half of the system and continue with full-strength sodium hypochlorite and a MicroCannula that allows me to safely flow irrigant to the canal’s full working length. The tip design allows it to suction irrigant from the chamber all the way down to the very end of the root.

I repeat this step using 17% EDTA to remove the smear layer, then repeat the process once more with sodium hypochlorite to achieve deep cleaning into the exposed dentinal tubules. Because EndoVac uses negative pressure at working length, I’m not concerned about extruding sodium hypochlorite out of the foramen.1 Studies have convinced me I can achieve significantly better debridement and bacterial kill with EndoVac than with traditional needle irrigation.^2,3

For obturation I used Discus’ HotTip for warm vertical compaction of a master gutta percha cone and then backfilled with Discus’ HotShot cordless backfill obturation device. A cotton pellet was placed in the chamber and the access opening was filled with 3M ESPE’s Cavit™ W temporary filling material.

A priceless experience

I completed the treatment in roughly 50 minutes, and while quality is my biggest priority, I’m sure Jane appreciated the speed.

The day ended with a large round of applause. Jane, my fantastic patient, was very appreciative. Words cannot describe the gratification I felt. To have a procedure go so well, in front of so many peers, is priceless.

So, if someone ever asks you to do a live root canal, think long and hard. When you are completely comfortable with your technique and instrumentation the answer just might be yes.

Dr. Garry Bey has been in private practice limited to endodontics for 27 years, and currently practices in Pearl River, N.Y., and Woodcliff Lake, N.J. He completed his endodontics residency at NYU. Dr. Bey lectures across North America, Europe and the Middle East, training doctors from more than 30 countries in advanced endodontic techniques.

References

1. Desai P, Himel V. Comparative safety of various intracanal irrigation systems. Journal of Endod 35(4):545-549, 2009.

2. Hockett JL, Dommisch JK, Johnson JD, Cohenca N. Antimicrobial efficacy of two irrigation techniques in tapered and nontapered canal preparations: an in vitro study. Journal of Endod 34(11):1374-1377, 2008.

3. Nielsen BA, Baumgartner CJ. Comparison of the EndoVac system to needle irrigation of root canals. J Endod, 33(5):611-615, 2007.