Clinician’s Corner – Educational Content for Clinical Directors,
Chief Dental Officers, Clinical Boards and the Entire Clinical Team.
Written by Dr. Mike Miyasaki, Chief Dental Officer, Miyasaki Dental
Sponsored by Vista Apex
John, arrived, tooth (or the crown) in hand, and he wanted the tooth put back together. We advised John that the tooth should be extracted as there were numerous missing teeth and being a cuspid this tooth was under immense occlusal loading. This is an all too familiar scenario. How would you handle this case? Your patient trusts you and would love you to treat him now! Let’s follow this case further, John was given the option that I felt would be best, to extract the root and possibly replace it with an implant or removable prosthesis. He wanted to save the tooth. We said we would do so but with caution.
Our workflow went as follows (figure 1). First, we put the fractured crown back on the tooth to scan. We then bonded some build-up material onto the tooth and prepared our margins. This rough preparation was scanned so we could begin milling the crown. Therefore, once the root canal was completed, we placed the final post and build-up, confirmed the crown fit and cemented the crown into place. This meant the root canal procedure, post and core build-up and fabrication of the crown were all done in under two hours.
Figure 1. The workflow.
I felt there were two important parts in the success of this treatment. First, we had to gain adequate ferrule on the root, and second, we had to perform a successful root canal treatment. The root canal architecture is a tortuous system (figure 2), and there are often areas beyond that which our files can reach. Yet our endodontic success depends on our thoroughly cleaning the canal system.
Figure 2. Research by Dr. Ove Peters illustrated that conventional hand instrumentation leaves approximately 35% of the canals untouched. The blue indicates the instrumented canal surfaces, and the red shows that which is uninstrumented.
Because of the complex canal system research shows that when we mechanically file a tooth’s canal system 45-65% of that system remains un-instrumented. The result can be endodontic treatment that fails to heal properly, an unhappy patient and a headache. But when a clinician can properly diagnose, perform a root canal procedure and restore the tooth the patients are very appreciative, and it can be a very productive appointment.
One problem here can be the speed at which the filing and obturation of the canal system is done today. There is significantly less time for our irrigants to dissolve the tissue and disinfect the canals. So, we must use the best, and most effective irrigants available (figure 3). Vista Apex Dental Materials has been an innovator in endodontic irrigants for decades. They manufacture pharmaceutical grade sodium hypochlorite in both 3% and 6% solutions, which are needed to predictably dissolve the tissue in the canals and disinfect. Store bought, Chlorox is designed to clean clothes and home surfaces not root canals, therefore, it can be highly variable in effectiveness and its concentration maybe up to 8% or close to zero depending on its age, how it was transported and how it was stored. Vista Apex’s 17% EDTA is more effective with a pH of 8.5 to optimize its chelation properties.
Figure 3. A line of endodontic irrigants available from Vista Apex Dental Materials.
Delivering the irrigants into the root canal system is best done with side-vented or side-port needles to avoid expressing the irrigants beyond the root apex. Vista Apex has very reasonably priced tips called the Appli-Vac and Vista-Probe tips (figure 4) that do just this, direct the irrigant flow to the side avoiding an apical extrusive pressure.
Figure 4. Side-vented and side port tips.
Activating the solutions while irrigating the canals has been shown to markedly improve the cleaning of the canals. More specifically, the use of the EndoUltra™ (figure 5) ultrasonic activation to agitate the irrigating solutions has been shown to be very effective. Once the canals have been filed to a #30 or 35 file to length the EndoUltra™ ultrasonic activator can be inserted into the canal to increase bacterial kill significantly (figure 6).
Figure 5. EndoUltra
Figure 6. Improved cleaning of the canals obtained using Ultrasonic activation of the irrigants.
Vista Apex also makes enhanced irrigants with surfactants that lower their surface tension and enhance their penetration. Chlor-XTRA™ is an enhanced 6% NaOCl that dissolves tissue twice as fast as sodium hypochlorite by itself. SmearOFF™ 2-in-1 that combines EDTA with CHX, and CHX-Plus™. Each of these products are enhanced with surfactants that increase their efficacy and your efficiency. There are also safety improvement. The more effective Chlor-XTRA offers greater safety for the patient because when mixed with the chlorhexidine in SmearOFF™ 2-in-1 it will not create the precipitate, para-chloroaniline.
Endodontics is rapidly changing and improving. Today’s new files, handpieces, apex locators and the use of CBCT is making it possible to perform endodontic procedures much more quickly. But the need to adequately remove the tissue and disinfect the canals in a speedier fashion are helped by using the improved action of enhanced irrigants, with the safer syringe tips, and ultrasonic activation.
How did our beginning story end? As John was leaving, with a anesthesia drooping smile, he commented on how happy he was since he arrived with no tooth and was leaving with a tooth.
About the author
Dr. Michael A. Miyasaki is a 1987 graduate of the University of the Southern California School of Dentistry, and has always maintained a practice focusing on comprehensive, minimally-invasive aesthetic restorative dentistry and function. With over 2 decades of clinical and teaching experience, Dr. Miyasaki has established himself as a leading figure in the world of dentistry and continues to educate his peers and patients for the optimal patient experience. His numerous accolades are a testament of his dedication and Sacramento Magazine just announced Miyasaki Dental as a “Top Dentist” and “The Face of Lifetime Dental Health.” Read Dr. Miyasaki’s other article: Steps to Ensure Your Zirconia Stays on the Tooth.
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