Best practices rise to the top
after a stressful year
by Dr. Manor Haas
Dentaltown has always been about “real dentistry for real dentists.” In line with
that slogan, this article looks at our profession as wet-fingered dentists with a frontline
perspective to demonstrate how patients in need of endodontic treatments, along with
our practices, can permanently benefit from what we’ve learned during the pandemic.
As the saying goes, with every tragedy, opportunities arise. This pandemic is
no exception. It has forced us to adjust our practices to adapt to pandemic-minded
ADA guidelines.1
Remember the days of bringing patients in for consultations, then back again
for multiple and lengthy root canal appointments, only to be followed up with more
appointments to restore the endo-treated teeth? That’s a lot of wasted time and effort
that would be deemed unnecessary during a pandemic—and should be deemed
unnecessary after one, too. The future of endo could and should entail more efficient
and more productive treatments.
During the pandemic, we’ve been encouraged to enhance our triage of potential
endodontic and emergency cases before patients step into our practices and weed
out any unnecessary visits. And while patients are in our chairs, we’ve had to work
more efficiently by providing as much treatment as possible during every visit. This
safeguards patients from potential exposure as they leave their safe bubbles. And, in
the process, it enhances a practice’s efficiency and production.
The trick is good triage
The pandemic-minded tweaks that could and should become common practice
start with the following: Front desk staff and dentists should better assess and triage
patients calling in with dental pain. Doing so would help ensure that patients are
scheduled and seen accordingly.
It is important that non-endo-related symptoms such as sinus, parafunction or
neuromuscular-related cases aren’t scheduled to be seen for endodontic treatment.
For instance, what if a patient says they have pain that is not localized to a tooth and
wakes them up at night, or is present upon waking up in the morning?
In such cases, they may not need to be
seen for a lengthy appointment that would
otherwise be set aside for possible treatment.
Not triaging these patients accurately
could result in waste of office time and
resources. On the flipside, a FaceTime
communication with such patients, or
an emailed photo taken by patients of
their problem (e.g., swelling) would help
tremendously.
So asking the right and specific questions
and possibly incorporating teledentistry
could help triage patients’ dental issues and
help the office schedule accordingly. This
could mean reducing wasted appointment
times for non-endo-related issues.
Perfecting protocols
Making the most of every visit can also
be accomplished by having systems in place
and the necessary instruments to enable
fast and efficient root canal treatments. By
no means does it mean rushing or cutting
corners. It means working more efficiently
with up-to-date science and tools.
It’s been shown that single-step root
canal treatments can be as successful as
two-appointment treatments.2 In fact, the
chance of post-treatment flare-ups might also
be equal between one- and two-appointment
treatments.3 This could mean fewer patient
follow-up visits.
Certainly, there are some key protocols
if one was to complete endo treatment in
one appointment, especially of necrotic
teeth. This includes, at least in part, the
following:
1. Locating all of the canals, including
calcified canals and MB2 canals in
maxillary molars.
2. Ensuring there are no internal
fractures that may lead to mechanical
failure of the tooth.
3. Instrumenting large enough apically
to mechanically remove as much of
the (necrotic) pulp tissues as possible,
and to enable intracanal medications
to reach the apical third of the canals.
4. Use of copious amounts of intracanal
medicaments (e.g., NaOCl).
5. Removal of the smear layer with
EDTA (e.g., QMix by Dentsply
Sirona) to enable penetration of a
medicament (e.g., QMix, which has
EDTA and chlorhexidine) into the
contaminated dentin tubules.
6. Intracanal passive activation with
an endodontic ultrasonic or sonic
activator.4
Importance of instrumentation
The use of instruments that enable
faster treatment is paramount. This includes
enhanced magnification (e.g., loupes with
light, or a dental microscope) to help locate
canals, diagnose microfractures and enable
faster endo access preparations.
The incorporation of an accurate and
new generation apex locator is also crucial.
It helps reduce the treatment time by
requiring fewer (but not necessarily the
elimination of) midtreatment radiographs
for working lengths. It also helps improve
treatment quality, because instrumentation
and obturation lengths are obviously crucial
for success and patient comfort.
For instance, a short endodontic fill
may leave necrotic or inflamed pulp tissues
in the canal, while overinstrumentation or
overfill may reduce treatment success and
increase postoperative symptoms.
The third key instrument to consider
using is a NiTi file system that is efficient
in canal shaping and debriding, and may
require fewer files. Fewer files translate into
fewer steps required to fully instrument a
canal. Examples include reciprocating NiTi
files by Dentsply Sirona (WaveOne Gold)
or Brasseler (ESR).
Furthermore, while a patient is already
in the chair and rubber dam isolation is still
in place, one should consider permanently
restoring the endodontic access—at least with a
core. It’s been shown that doing so increases the
treatment success of the endo-treated tooth.5
So, without compromising the quality of
care, it comes down to better diagnostics and
case selection and more efficient endodontic
treatments. This is what the pandemic has
shown us to be a best practice. So why
not invest in setting up systems with your
staff and clinical protocols permanently?
And why not invest in the necessary dental
instruments? The return on investment
could be significant for your practice and
patients as you look beyond the pandemic.
Conclusion
All in all, better diagnosis and time
allotment (thanks to previsit triaging),
with enhanced treatment efficiency (thanks
to advanced endodontic instruments) can
and should be the common mindset in
providing endodontic treatments. Doing
so is a win–win, for patients and for dental
practices. That’s “real-world dentistry.”
So, after a roller coaster of a year,
enhanced endodontic-related protocols
are emerging from this pandemic for our
patients and our practices.
Don’t just tweak your practice so as
to meet the pandemic-related guidelines.
Instead, use those tweaks to enhance your
practice moving forward and have them
become permanent changes. If you do so,
only good will come out of this, whether
you’re in a pandemic or beyond it.
References
1. American Dental Association online. Covid-19 Center.
www.ada.org
2. Penesis VA, et. al., Outcome of one visit and two visit
endodontic treatment of necrotic teeth with apical
periodontitis: a randomized controlled trial with one-year
evaluation. J Endod Mar;34(3):251-7, 2008.
3. Kalhoro F, Mirza A, A study of flare-ups following
single-visit root canal treatment in endodontic patients.
J Coll Physicians Surg Pak. Jul;19(7):410-2, 2009.
4. Kurt M., Caliskan M, Efficacy of chlorhexidine as a final
irrigant in one visit root canal treatment: a prospective
comparative study, Int Endod J. Oct;51(10):1069-76, 2018.
5. Goldfein J et al, Rubber dam use during post placement
influences the success of root canal-treated teeth. J Endod,
39(12), 2013.
More endo courses from Dr. Manor Haas online!
Click here to see Dr. Manor Haas' four CE courses that
bring an endodontic expert right to your computer, tablet or smartphone. Topics include everything from a survey of endo
basics to the exploration of advanced techniques.
Dr. Manor Haas, a certified
specialist in endodontics, is
extensively involved in providing
continuing education to dentists
and has lectured and conducted
workshops and webinars
internationally. Haas maintains
a full-time practice limited to
endodontics and microsurgery
in Toronto, and is on staff at the
University of Toronto and The Hospital for Sick Children. A
regular contributor to dental journals, websites and blogs, he
may be reached via haasendoeducation.com.