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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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CENTER FOR John D. West, DDS, MSD
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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CENTER FOR John D. West, DDS, MSD
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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CENTER FOR John D. West, DDS, MSD
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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CENTER FOR John D. West, DDS, MSD
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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CENTER FOR John D. West, DDS, MSD
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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CENTER FOR John D. West, DDS, MSD
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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CENTER FOR John D. West, DDS, MSD
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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CENTER FOR John D. West, DDS, MSD
ENDODONTICS
Guess what time it is and, more importantly, guess the level of technical artistry.
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CENTER FOR John D. West, DDS, MSD
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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CENTER FOR John D. West, DDS, MSD
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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CENTER FOR John D. West, DDS, MSD
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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CENTER FOR John D. West, DDS, MSD
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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CENTER FOR John D. West, DDS, MSD
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
CENTER FOR John D. West, DDS, MSD
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
CENTER FOR John D. West, DDS, MSD
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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CENTER FOR John D. West, DDS, MSD
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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CENTER FOR John D. West, DDS, MSD
ENDODONTICS
Ultrasonic Tips Dentsply Tulsa Dental 800.662.1202Obtura/Spartan 800.344.1321
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