Curved canals revisited

Occasionally, I will encounter extremely curved canals in my practice. These canals were treated with a lot of patience, perplexity and gentleness. Procedural errors like canal blockage and instrument separation are more likely to occur in these difficult canals. More flexible nickel-titanium files are recommended for shaping curved canals compared to stainless steel files which are more stiff, hence may lead to canal ledging and transportation. However, nickel titanium files are more prone to separation in very curved canals even in the hands of very experienced and skillful operator because of straining of the metal at the curvature. In other words, nickel-titanium files are useful in shaping curved canal but these are also easy to break.

Warm vertical condensation

The warm vertical condensation technique is my obturation technique of choice now because it is a more superior technique than the more commonly used lateral condensation technique. The warm gutta percha fills the root canal system three dimensionally, including the lateral and accessory canals. The inter-canal communications and lateral fins and slits are inaccessible to root canal instrumentation. After chemical debridement, warm gutta percha techniques predictably seal these areas and entomb residual bacteria. However the warm technique is more technique sensitive and the lateral condensation has got better apical control.

I used the lateral condensation technique for years because I was taught to do that during my undergraduate training. Subsequently I learned to master the warm vertical technique at Penn. We are still teaching our dental undergraduate students the lateral condensation and the single cone techniques, simply because the two techniques are easier to carry out but I think the warm vertical condensation is by far the best obturation technique.  

Improving smiles

The before and after photos above belong to a patient with protruding and elongated upper left lateral incisor. A one-visit prophylactic root canal treatment was performed on this lateral incisor prior to crown preparation because the extra reduction on the labial surface would most likely cause an injury to the pulp. The patient was beaming with happiness after the crowns were issued and I, of course, was satisfied with the results.

A happy and satisfied patient never fails to put a smile on my face. I love this quote, "If you are happy, tell someone, if not, tell us" simply because it has a positive meaning. When we solve a patient's dental problem and he/she is happy with the results, it will do us a great favor if the patient shares his/her pleasant experience with a friend or family. However, if a patient is not too happy, it will do us a greater favor by giving us a feedback, so that we can reaccess and improve on our services.

We aim to do our very best to solve our patients' dental problems, with most minimal pain associated with dental procedures. Root canal treatment, for example, sounds painful and scary, but it has a very high success or healing rate, ranging from 85-95%. In most cases, root treated teeth are symptom-free and remain functional in the oral cavity.  However, there is still 5-15% of unresolved problems even after treatment. The tooth may already be in a very compromised state and a predictable outcome may not always be possible. Some complications associated with the procedure, although unlikely, may happen and this may affect the outcome of the treatment. It is important that the patient understands each dental procedure. Hence, communication between doctor and patient is critical.

How far do we go to save a tooth?

Teeth should only be extracted when they are non- restorable or beyond salvage. Implants are good but should not be used to replace teeth that can be saved.  Endodontic retreatment should always be considered as an option, as illustrated on these radiographs.

Endodontics "Gangnam Style"

Ann yeong haseyo!!!!!

It was my first visit to Seoul. The Asia Pacific Endodontic Confederation was held on the 23th and 24th March, 2013. Took a five-day tour around South Korea before the conference. Although it was spring, the temperature was generally less than 5 degrees Celsius and we had snow at Mt. Sorak and the east coast.

The conference was held at the COEX located at Gangnam itself. I would recommend Hotel The Designer because it is walking distance to COEX and this boutique hotel has a very unique concept and rooms are clean and cozy. I love the heated toilet seat.

The conference was well organized, with lectures by some prominent people in endodontics. I have heard some of these presentations before but no harm in refreshing my memory. These are some wise words and take home messages from the presenters:

Dr James Gutmann, our grandfather of endodontics, during his lecture on The Impact of New Endodontic Technology on Predictable Outcomes, mentioned:
 "When confronted with a new technology, whether its a cellular phone or high definition TV or the internet, we should ask ourselves the question 'What is the problem/challenge to which this technology is the solution?'"
 "Has the technology achieved its intended purpose/s?"
 "In this age of new technology, some things work and others do not!!"
 "To continue emphasis on research and development and tissue engineering"
 "Do not resign ourselves to the wholesale extraction of teeth seen a century ago in favor of the perception that implants are better!" (I especially like this one)

Dr Syngcuk Kim, my teacher at Penn, during his lecture, Modern clinical dilemma: Endo vs implant, highlighted:
 "The purpose of endodontics is to save teeth"
 "Preservation of function and esthetics of a patient's dentition is our obligation"
 "Implants are inferior to natural dentition in terms of function and esthetics on a long term basis"
 "Implants should be replacing missing teeth, not teeth"

Dr Martin Trope, my favourite endodontic lecturer, during his presentation on Controlling intra-canal infection with mechanical instrumentation, pointed out that
 "With the wide variety of file systems in the market and the new one file system, our aim in root canal preparation is to make it better and not quicker. Ideally, a new file system should clean and shape canal better and quicker, but the main focus is to prepared these canal better, not quicker "
Dr Trope's words always make perfect sense to me...

Long roots

This is my first post of the year and it's already March! Sorry for not being consistent in updating my blog. Time passes very quickly when one is busy. Now that the New Years are over, I can focus on planning for the rest of the year.

I had to perform this RCT on a very long second mandibular molar. The mesial root is 24mm, which is equivalent to the length of a canine. Not to mention the canals were fine and curved. Quite a difficult task!

The work of an endodontist is somewhat  like a plumber. We clean and shape, negotiate and unblock canals. We work carefully not to obstruct these canals, which may hinder disinfection. Hence, the longer and more curve the canal is, the harder it is to work on.

So, what makes us different from plumbers and technicians? For starters, we are trained for at least five years at a dental school to qualify at doing this plumbing work. What we are really doing here: we are treating a disease and healing a dental condition, our aim is to eliminate infection. We understand the biological basis of treatment we carried out and our work is supported with scientific evidences, based on many decades of researches.

In conclusion, skill and knowledge are two important components that makes a good clinician!