Wednesday, November 19, 2014

Avoiding Endo

In dental school, I really enjoyed performing root canals. We had a wonderful endodontist on the clinic floor that helped me through some difficult cases, and pretty soon, I was starting to feel like an endo expert. (Dental students are so naïve!) I think I graduated with maybe 10 or 15 cases under my belt, a little more than our requirements asked from us. I even considered specialty training in endodontics at one point but, like most of us, I was eager to be done with school. Besides, what more did I need to know?

Endos in private practice are not like the ones I completed in dental school. As you all are well aware, time is a precious commodity when you are self-employed, and sitting there trying to search for canals in a second molar for hours was just not something I had the patience—or chair time—for. In addition, some of my earlier employment stints were in offices where other doctors actually laughed at me for trying to use a rubber dam (!!) or for worrying about filling all the canals properly. I realized I did not have the skills to complete root canals correctly in a short period of time. To make matters worse, the materials in some of these offices were so terrible that the rotary files—reused an infinite amount of times, of course—would have a tendency to separate, giving me minor panic attacks every time I picked up an instrument.

When I started working at my current office, I was able to decide how I wanted to proceed when my patients needed root canals. I wanted to do what was best for them and cause them the least amount of pain and discomfort. That is when I decided to refer all of my patients to an endodontist. I knew that a specialist would be able to perform the procedure in a fraction of the time, making the experience a lot more pleasant and tolerable for my patient, while yielding more predictable result. Sure, I probably could have invested some time in continuing education courses and gained more proficiency in this area, but it just so happened that I was not seeing a ton of endo in my practice anyway. Many of my patients are young with healthy teeth; for those who do need an endo, it’s usually to retreat an old poorly done root canal. I rarely saw “fresh” teeth that needed root canals.

Now, I know what you are thinking: How can none of my patients need root canals? I have thought about this as well. I try to be extremely conservative when restoring teeth. I know some dentists may tend to take a more proactive approach, since they do not want their patients calling them in the middle of the night, complaining of post-op pain. I always explain to my patients the pros and cons of trying to save the tooth and avoiding a root canal. There are many different kinds of patients. If you have a patient who would rather jump off the Brooklyn Bridge than experience post-op sensitivity, sure, you can offer them a preventative endo. However, I like to present my patients with every option. If it were up to me, I would prefer to do everything possible to avoid a root canal. This may be why so few of my patients actually need fresh endos, since I try to have that be my absolute last resort.

This is a patient I had a few weeks ago. This seemingly simple Class II case turned into an exposure, as the patient had ground down the tooth so much and there was extrusion. I do all of my restorative under isolation, either with a rubber dam or Isolite, to help prevent any contamination from saliva. I placed my favorite liner on the exposure and proceeded with the filling. I explained the situation to the patient and even gave her the information of my endodontist. She called me the next day complaining of pain, but she said that it was bearable. I advised her to try to wait it out. Either the tooth will heal itself, or the nerve will die, but isn’t it better to try to avoid having a root canal? Most patients agree with this philosophy. She ended up feeling better after a few days, and I continue to monitor this tooth at her recall visits.

These radiographs were taken one year apart. The patient had a mouth full of decay when I first saw him. A few teeth received permanent fillings, but some, like the one shown in the picture, were filled with glass ionomer (GI). There was too much decay to place the fillings right away, and I was not yet ready to create a more definitive treatment plan. Since he lived in a different state, I did not see him for over a year. When he returned, I removed the GI filling and placed a liner with a permanent restoration. We are still working on restoring his entire mouth, but so far so good with that tooth. Sure, he had to have that filling redone a few times—and still may need a root canal in the future—but I think he appreciates that I am doing everything I can to try to avoid it for as long as possible.

Hope everyone has a great week!

Lilya Horowitz, DDS 


Unknown said...

I think that this approach is very conservative and thoughtful, I support this philosophy, too. For deeper restorations, I use peridex to rinse out the restoration. What liners do you recommend or any other techniques for deeper restorations? Thank you.


R.Kashefi, DMD

Lilya Horowitz DDS said...

Hi Dr. Kashefi

Thanks for reading! I also like to use Peridex, then I like to use Theracal liner from Bisco I love it!


Eric Boyd DDS said...

I'm an avid supporter of doing whatever possible to avoid endo. In a case like this I'd do a few things differently. 1) I wouldn't excavate all the deep decay close to pulp. 2) I'd use a glass ionomer restoration and leave it in place for a year or two. 3) If I do pulp cap it's using sodium hypochlorite scrub and a Durelon cap. Calcium Hydroxide is about the worst thing you can put close to the pulp. I'd also use a rubber dam.

Great topic.

Adam said...

You can't always avoid endo. Normally the patients get back to the office with great pain.

But if you inform the patient about the risk then you can maybe save the pulp.

Best regards.

Rita Diana P said...

Great article, first of its kind that I've read.

I've struggled with disliking Endo but feeling I'm not an adequate dentist if I don't do it.

Dr Rita Philip


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