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The Total Endodontic Experience

“Succeeding in the New Endodontics”

John West, DDS, MSD

Pacific Dental ConferenceMarch 10th, 2006

CENTER FOR John D. West, DDS, MSD

ENDODONTICS

AGENDA

I. CONTEXT

II. DIAGNOSIS

III. RESTORABILITY

IV. SHAPING AND CLEANING

V. OBTURATION

VI. BUILDING

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ENDODONTICS

I. CONTEXT

It Works (if you do it right)

Today is a Line of Demarcation

The three changes that are influencing endodontics:1. Technology2. Interdisciplinary3. Longevity

Key: Knowing the changes enables us to embrace and benefit from the changes.

We have a choice, and today is about those choices in the face of constant change.

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ENDODONTICS

II. DIAGNOSIS

Diagnosis is half the cure. Rendering the first aid of dental pain during a regular dental schedule. Listen, duplicate, diagnose, and treat. Patients should come in with pain and leave with peace. What are our problems in diagnosis?

Three Principles

1. Statistics Approximately 90% of all teeth requiring endodontics are or were pulp

exposures. Approximately 8% of teeth requiring endodontics have radiographic

lesions of endodontic origin. Only about 2% of all teeth needing endodontics require more

sophisticated testing.

2. Pulps die coronally → apically.

3. Pulps die multifactorially.

Six Clinical Distinctions

1. Pulp Exposure Symptoms Anything under the sun. Diagnosis Clinical or radiographic pulp exposure. Treatment Superb endodontics.

2. Hyperemia Symptoms Intense and fleeting pain to cold. Diagnosis Duplicate cold. Treatment Protect pulp and endodontics if pulp protection is

unsuccessful.

3. Pulpitis Symptoms Heat Diagnosis Duplicate heat. Treatment Endodontic treatment or pulpotomy or pulpectomy if

time does not allow.

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ENDODONTICS

4. Necrosis Symptoms No pain or sinus tract. Diagnosis Pulp tests are negative. Treatment Superb endodontics.

5. Lesion of Endodontic Origin Symptoms None or sinus tract. Diagnosis Radiographic radiolucency and pulp test is negative. Treatment Superb endodontics.

6. Acute Alveolar Abscess Symptoms Pressure, percussion (may or may not be cellulitis

and/or lesion of endodontic origin). Diagnosis Pulp tests are necrotic. Treatment Drainage (orthograde and/or surgical) and schedule

endodontics.

Pop Quiz

Using 6 clinical distinctions and 12 diagnostic aids.

“Nothing is more deceptive than the obvious.”. . . Sherlock Holmes

Bottom Line: “Diagnosis is half the cure.”

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ENDODONTICS

III. RESTORABILITY

Optimizing restorative outcomes – “the endodontic perspective.”

Considerations in diagnostic and treatment planning sequence. Biology Structure Function Esthetics Value

Treatment Sequence Biology Structure Function Esthetics Value

Treatment Plan Sequence Value Esthetics Function Structure Biology

Biology

1. Portals of Exit Guideline #1 – “Any tooth that is endodontically involved can be

predictably saved if the root canal system is sealed, either nonsurgically or surgically, the periodontal condition is healthy or can be made healthy, and the tooth is restorable.”

2. LEO Location Guideline #2 – “If the lesion of endodontic origin is confined

apically, if the previous endodontic treatment is reasonably sufficient, and if nonsurgical retreatment were to compromise structural integrity of a tooth, then surgical correction is the treatment of choice.”

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ENDODONTICS

3. Periodontal Guideline #3 – “If a pulp is necrotic and there is a precipitous

draining sinus tract (narrow or wide) that probes, then endodontics will predictably solve not only the endodontic problem, but regain periodontal health as well.”

4. Perforation Guideline #4 – “If the perforation does not include the sulcus, and it

is immediately repaired, then, like the prognosis of any tooth with a portal of exit, the prognosis is excellent.”

5. Resorption – depends on the type and whether or not the resorption is contained.

Guideline #5 – “Like a perforation, resorption can be successfully treated except when involving the gingival crevice or an advanced disease process such as extra canal invasive.”

6. Fractures – depends on horizontal vs. vertical and location of each. Guideline #6 – “Any fracture that does not involve the gingival

sulcus has a favorable prognosis.”

7. Calcific Degeneration or Calcific Metamorphosis Definition – the root canal system is calcifying at a rate faster than

the adjacent and/or contralateral tooth. Less than 10% of these pulps become necrotic and when they do

micro-endodontic technology enables the endodontic clinician to frequently discover the root canal network and successfully treat the tooth, however, there are times when these teeth cannot be successfully treated because the root canal system anatomy does not physically begin until the last few millimeters of the tooth.

Guideline #7 – “Calcific metamorphosis is a disease. Even though a limited percent of these pulps progress to eventual necrosis, clinicians should consider pre-empting this disease in order to prevent future mechanical restorative disasters.”

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ENDODONTICS

IV. SHAPING AND CLEANING

Concepts Technique New Technologies

Five Distinctions of Cleaning and Shaping

1. Vision2. Motions3. Sequencing4. Language5. Creative

WHAT IS THE EVIDENCE FOR ROOT CANAL SYSTEM SIGNIFICANCE:

“The Incidence of Undersealed Foramina in Endodontic Failures”Goldman School of Dental Medicine Thesis, 1975, John D. West, DDS, MSDConclusion: 100% of the endodontic failures had at least one undersealed foramen (POE: portal of exit).

Defining Moment – Lucille The Game of Endodontics – Playing to Win Mechanical Objectives

o Continuous Tapero Cross-sectional Diametero Flowo Never Transport POE o Nature’s POE

Three Keys:

1. Delicate Radicular Foraminal Cementum2. I Love You3. Groundhog Philosophy of Shaping and Cleaning

Four Critical Distinctions of Manuel Motions

1. Follow 2. Smooth3. Balance4. Envelope

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ENDODONTICS

Carving away restrictive dentin in order to create a path to follow. Balanced F________ technique and envelope of motion New Technologies in Shaping and Cleaning, John West’s journey and

what we can all learn from it. But Molartown, USA, we have a problem.

You cannot use the same type of thinking to solve a problem that created a problem. You must think differently.” . . . Albert Einstein

What do the program directors, the JOE advisors and valued clinicians consider the most important determinants of endodontic success?

Finishing Checklist Mechanical Objectives Appropriate Smooth Solid “Four” Dimensional

AAE Finishing Survey, 2000 – “What part of a curved, narrow MB canal of a maxillary 1st

molar is the most difficult for you to prepare? Is it the apical third, the middle third, or the coronal third?” Or, is it none of these thirds, but a portion of one of them?

State-of-the-Art shaping and cleaning is not step-back, it is stepless. It is now crown-down, the successful clinician needs to know the path and know the booby traps, and it is not balanced F____________, it is actually shaping from the inside out. It is removing everything that is not the cone fit, or as Michelango said, “As the marble wastes, the statue grows.” Of course, he is referring to his famous Statue of David.

“Shaping and cleaning is like dancing,one you’ve got the moves down it’s easy.”

. . . Westism.

New technology to improve efficiency, create simplicity, and increase safety. “The Six Pack”

What do six-time Tour de France champion Lance Armstrong and the experience of exceptional endodontics have in common?

10 in a Row30 in a RowMs. Gnarly meets Mr. Crooked

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ENDODONTICS

Guess what time it is and, more importantly, guess the level of technical artistry.

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ENDODONTICS

Blocks, ledges, and transportation (BLT) Prevention Correction

Key:1) Purple, white, yellow, red, blue.2) Always secure reproducible glide (slide) path.3) Never force.

Breakage Prevention:1. Show restraint- be 10x more delicate than other rotary2. Never force3. Single use4. 220 RPM in electric slow speed5. Remove all chamber orifi dentinal triangles6. Use EDTA or Chemet during rotary7. Use microscope to observe micromovement8. Inspect & clean9. Use progressive, passive passes to reach POE constriction10. Float, follow, and brush away from furca with S1 & S211. Follow F1, F2, and F3 until they engage, then remove, clean, inspect and

repeat until arrive at POE constriction12. Never rush

Correction If an instrument does not go, there are only four possibilities:

1. There is a presence of dentin mud.2. The instrument is simply following in the wrong direction.3. The tip of the instrument is too big for the canal it is attempting to follow.4. The shaft of the instrument is too wide for the canal it is attempting to

follow.

Dentin Mud. We think we may be several millimeters short, but in reality we are a fraction of a millimeter short. Once we disturb the “dense dentin mud”, then the rest is easy.

Steps for deblocking:1. The path is still there.2. Shake fingers loose as a goose.3. Whistle a merry tune.4. Irrigate thoroughly.5. Make believe.

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ENDODONTICS

6. Forget clock7. The game and the promise.8. Randomization, not searching.

Ledges. The key is to precurve a ProTaper™ file and finesse it past the ledge, usually an F1 (yellow) then make several rotary turns manually, remove and note ledge debris on flutes. Fit the cone.

Open Apex. Make a barrier unless there is enough tooth structure to shape inside of the open apex and shepard warm gutta-percha vertically. If there is not enough tooth structure, create an apical barrier with calcium sulfate, or CollaCote and then backpack using a combination of syringing warm gutta-percha with sealer, heating and further distorting the gutta-percha. Another alternative would be to ultrasonic MTA to the apical constriction after appropriate barrier placement, place a layer of gutta-percha, and then repair the access with a flowable composite. The apical periradicular fluids serve as appropriate MTA hydration.

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ENDODONTICS

V. OBTURATION

What obturation method is for me?

Factors Heat Source Wave Pluggers

The Cone Fit: Cut Back Considerations Length of Canal Width of Canal Curvature of Canal

KEY: Multi/single wave obturation success depends on the cone fit which depends on shape.

Vertical Reality – the Wave of the Future

Obturation Videos

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ENDODONTICS

VI. BUILDING

1. Education

KEY: An educated patient will always make the choice that is in their best interest.

KEY: The best education in the world is your own.

2. Coronaflex by Kavo

3. How do you Remove Posts?“There is a difference between a solid obturation of teeth and an obturation of solid teeth . . . the great endodontic clinicians job is not complete until there is a solid obturation of solid teeth.” . . . Westism

4. Irrigation Heated, full-strength, scented sodium hypochlorite EDTA Hydrogen peroxide 100% alcohol Water Diet Pepsi (MTAD)

5. Access – be sure to remove triangle 1 and 2 in anterior teeth and dentinal triangles in posterior teeth.

6. The Hot Tooth Stabident Local Anesthesia System Dentipatch

7. Altering the Color of Pulpless Teeth A Method to Determine the Location and Shape of Intracoronal

Bleach Barrier. Steiner, D., West, J. J. Endodon,1994;20;304-306. Pulpless Age Less Than 20 and No Barrier Transfer of Epithelial Attachment for Protective Bleach Barrier

8. Annual Electric Pulp Test

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ENDODONTICS

9. Cracked Tooth SyndromeClass I Incomplete Vertical Fracture Through Enamel Into Dentin,

But Not Into PulpClass II Incomplete Crown Fracture Involving the Pulp

Treatment Flowchart for Cracked Tooth Syndrome

10. Trophy digital radiography

11. Endodontic operator design

12. When and How to Refer?

13. Single Use

14. Call List

15. Restraint

16. Reinvent Yourself

17. Continuing Education

18. Differentiate Quality Service Attitude

Three Office Styles in the Future

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CTS Band

Bite

No bite + symptoms

No bite + no symptoms

Extirpate

Extirpate

Restore

Bite

No bite

Endo +restore

Remove

Endo +restore


ENDODONTICS

19. Fun. The relationship of performance and fulfillment.

20. Kodak Study on Profitability

Assuming a profit goal of 25%:

5% decrease in fees 25% increase in volume10% decrease in fees 67% increase in volume20% decrease in fees 400% increase in volume

5% increase in fees 83.5% of previous volume10% increase in fees 71.5% of previous volume20% increase in fees 55.5% of previous volume

Ultimately, the value-adjusted fee is determined by supply and demand. If the patient demand is high due to a high-perceived value, they will purchase. However, if you appear to be like any other endodontist, of which there is a high supply, the patient will have a low perceived value.

Key: The key to fee acceptance is establishing a high perceived value.

If fees are the obstacle to treatment acceptance:

Can treatment be phased over time? Is financing available? Are there other options?

Small quantities of the best treatment are almost always better in the long run for the patient, more energizing for the endodontist, and more profitable than converting to a compromised plan.

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Transition

TransitionP

erfo

rman

ce

FulfillmentHigh

High

Low


ENDODONTICS

21. Stages of Dental Life: Survival, growth, profit, transition, and retirement. The key in profit is to only start the patients that you can finish well. Control your practice size through differentiation.

Priorities and Profit

Patient Health Practice Health Practitioner Health

Experiencing an Intentional Future

KEY:

“Today’s signatures become today’s reputation. Today’s reputation becomes tomorrow’ legacy.” . . . Westism

“By improving your industry to make your product more valuable, you are, by an invisible hand, improving the entire profession.” . . . Adam Smith

“You should periodically check where you are going, because you are very likely to end up where you are head.”

. . . Old Chinese Proverb

My Ideal Practice Looks Like _______________________________________

I Am Not Practicing That Way Because _______________________________

What is the Answer? The answer to a deliberate future is very close to all of us.

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ENDODONTICS

West’s Shopping List

Product Company Toll Free Number

Access Kit Dentsply Tulsa Dental 800.662.1202

BioPure MTAD Dentsply Tulsa Dental 800.662.1202

Calamus Flow, Downpack, Dual, and Manuel Dentsply Tulsa Dental 800.662.1202Pluggers

Chemet (DMSA) Union Avenue Pharmacy 253.752.1705

Coronaflex Kavo 800.323.8029

Digital X-ray Trophy 800.667.1780

Electric High Speed KAVO America 800.323.8029

Electric Rotary Motors (DTC or ATR) Dentsply Tulsa Dental 800.662.1202

Endodontic Cart ASI 800.566.9953

Hand-files (K-files, C-files) Lexicon Tulsa 800.622.1202

Irrigation Systems/ Endo Irrigator Vista Dental 877.418.4782

JW 17 Microexplorers CK Dental 800.675.2537

JW Microprobes CK Dental 800.675.2537

JW Microspatulas CK Dental 800.675.2537

Kerr Pulp Canal Sealer Kerr 800.521.2854

Microscope Global Surgical Corp. 800.861.3585

Microsurgeon Chair Global Surgical Corp. 800.861.3585

MTA Dentsply Tulsa Dental 800.662.1202

Narrow Posterior Heat Carrier (29001) Sybron Endo/ Local Dealer 800.346.3636

ProTaper Technology Dentsply Tulsa Dental 800.662.1202 Rotary files: SX, S1, S2, F1, F2, F3, (F4, F5) gutta percha, obturators, carriers, paper points

Root ZX Dentsply Tulsa Dental 800.662.1202

Ruddle Post Extractor Dentsply Tulsa Dental 800.662.1202

Schilder Pluggers Sullivan Schein Dental 800.372.4346

Single Wave Heat Pluggers Sybron Endo 800.346.3636

System B Heat Source Sybron Endo 800.346.3636

Tilt Bins (deflecto) Beemak Plastics 800.669.4399

Ultrasonic System Dentsply Tulsa Dental 800.662.1202Obtura/Spartan 800.344.1321

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ENDODONTICS

Ultrasonic Tips Dentsply Tulsa Dental 800.662.1202Obtura/Spartan 800.344.1321

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