Two foundational endodontic requirements to move toward a ... · 2). Intraosseous anesthesia is discussed in the dental literature and a representative sample of the available articles

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endodonticsfeature

When standard anesthetic techniques are not working, youneed something more, a go to cascading series of alter-native techniques to provide profound anesthesia and visual andtactile control over the case. While opinions differ with regard tomaterials, methods and the time required to create excellent clin-ical results, the procedure must be executed efficiently.Unnecessary steps and inefficiency are a waste of time and, moreimportantly, create the environment for clinical and emotionalharm. The best clinical events are highly planned, well executedand move in a straight line from the first injection to the place-ment of the coronal seal.

Profound anesthesia and attainment of patency are the twomost vital components of modern endodontic procedures. Masterthese two foundational components, and a stable platform has beenbuilt for the rest of the procedure. Alternatively, less than profound

anesthesia leaves the patient uncomfortable, and the cliniciantwitchy. Never a good combination. A lack of patency is the har-binger of all manner of iatrogenic misadventure.

Of the local anesthetic techniques available for irreversible pul-pitis, two techniques have proven indispensible in my hands: theSTA Wand (Aseptico) and intraosseous techniques. It providesnumerous advantages over a standard syringe. First, a positive aspi-ration is more definitive with the wand and easier to confirm in thehandpiece. It is extremely rare to have an inadvertent intravascularinjection. To date, in three years of full time clinical use of the STA,no epinephrine reactions have resulted. Because the injection ismuch slower than a typical syringe injection and the tactile feelof the handpiece is more sensitive, in my experience, there havebeen no electric shock reactions where the needle has grazed thenerve bundle (Fig. 1).

Two foundational endodontic requirements to move toward a successful conclusion by Richard Mounce, DDS

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Second, the wand has three injection speeds: extremelyslow, very slow and slow. It is simply more comfortable forthe patient than a traditional syringe. There is no more-com-fortable way to administer local anesthetic. The wand tellsyou a lot about your patient. For example, if the patient hasan exaggerated response to the infiltration of local anestheticat the slowest speed (four minutes per cartridge) used for ini-tiating injections, you are treating a phobic individual thatwill be harder to get numb in any case than a patient who isless responsive. Translated, even with profound anesthesia,you are potentially in for a rougher ride than someone whotolerates the wand without a blink.

Third, another impressive feature of the wand is the abil-ity to give a PDL injection predictably and comfortably, andwithout tissue or bone necrosis. Some clinicians do theirrestorative dentistry with only the PDL injection, which is avalid technique for restorative dentistry, but not useful forthe vast majority of endodontic procedures. Having thePDL injection capability clearly reduces the number ofintraosseous injections that might otherwise subsequently berequired. Again, the tactile control of the wand to give PDLinjections is very sensitive and precise.

Fourth, the handpieces are very reasonable in price at justover $2 per cannula. For an irreversibly inflamed lowermolar, I use the 27 ga 1 1/4 inch handpiece for the inferioralveolar block, the 27 ga 1 handpiece for a buccal infiltra-tion of articaine and the 30 ga 1/2 handpiece for the PDLinjection. Generally, I will use all three injections for irre-versibly inflamed lower molar teeth.

In my practice, occasionally I need intraosseous anesthe-sia. Three methods of providing intraosseous anesthesia areclinically available: the X-tip (DENTSPLY), Stabident(Fairfax Dental) and the Anesto (W&H). In my hands, the

Fig. 1: The STA Wand (Aseptico)capable of providing infiltration,block and PDL injections.

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X-tip is the most cumbersome, but does have the advantage of aguiding sleeve for needle insertion after cortical perforation.Stabient, with no guide sleeve, is more bare bones and findingthe entry into cortical bone is slightly more challenging. TheAnesto uses the same needle for the cortical perforation as theinjection. The Anesto is simple, practical and ergonomic (Fig.2). Intraosseous anesthesia is discussed in the dental literatureand a representative sample of the available articles are refer-enced here.1-6

Regardless of which intraosseous system one uses, it is impor-tant for the clinician to be able to seamlessly move between stan-dard injections to PDL to intraosseous calmly and efficiently.

Profound anesthesia allows immediate and confident canalexploration and negotiation. The method of initial canal nego-tiation has significant implications for the treatment that fol-lows. If the wrong hand file or too large of a hand file is insertedtoo forcefully, the canal can become blocked, ledged or other-wise transported quickly and without warning. Many iatrogenicevents have, to one degree or another, their source in a lack ofstraight-line coronal access, lack of adequate canal negotiationand glide path preparation, and inaccuracy in the determinationof true working length (TWL). While a comprehensive determi-nation of each of these steps is beyond the scope of this article,using the correct stainless steel hand file, both sequentially andtactilely, is essential for both optimization of negotiation andavoidance of iatrogenic events.

I use only precurved Mani D Finders, Mani K files, andMani Safe ended K files (Mani SEC O K files) for canal negoti-ation and glide path creation. D Finders are used for curved and

calcified canals. They are stiffer than standard K files. Safe endedK files are especially valuable in canals that are highly curved,apically complex and in which the risk of blockage or iatrogenicevents is extreme. Aside from the standard ISO sizes (#6, 8, 10,15, etc.) I also commonly use medium sizes in the above filetypes (#12, 17, etc.).

It is noteworthy that stainless steel hand files are a com-modity and relatively inexpensive; there is no economy in using

them for multiple cases. They losetheir sharpness quickly, hence in my

hands these are a single use item.For an average case, even one ofmodest curvature, I will generally

use at least three to four packs of Mani hand files, in a severelycurved and calcified case, often many more. Mani (Japanese) isa global leader in the dental industry. Mani has excellent man-ufacturing quality at approximately half the cost of competitiveproducts (Fig. 3).

In vital (irreversibly inflamed) cases, in the initial presence ofEDTA gel (ChelCream, MetaBiomed) the orifice is shaped withorifice openers (for example, MounceFile .08/25 ControlledMemory). In non-vital cases,in the initial presence ofeither ChelCream or sodiumhypochlorite, the orifice issimilarly shaped. After orificeshaping, the chosen Manistainless steel hand file is pre-curved and inserted in everyorientation necessary withgentle pressure (watch wind-ing) to make apical progress.Irrigation is copious and fre-quent throughout negotia-tion. Irrespective, vital or nonvital, starting with a #6 handfile is invaluable because inmany cases, if the clinicianstarts with a larger hand file

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Fig. 3: Needle perforation to pro-vide intraosseous anesthesia.

1. Med Oral Patol Oral Cir Bucal. 2013 Jan 1;18(1) Root damage induced by intraosseous anesthesia. An in vitro investigation. Graetz C1, et al. 2. J Am Dent Assoc. 2003 Nov;134(11):1476-84. A comparison of two intraosseous anesthetic techniques in mandibular posterior teeth. Gallatin J1, et al. 3. Dent Res J (Isfahan). 2013 Mar;10(2):210-3. X-tip intraosseous injection system as a primary anesthesia for irreversible pulpitis of posterior mandibular teeth: A randomized clinical trail. Razavian H1, et al. 4. J Conserv Dent. 2013 Mar;16(2):162-6. Anesthetic efficacy of X-tip intraosseous injection using 2% lidocaine with 1:80,000 epinephrine in patients with irreversible pulpitis after inferior alveolar nerve block: A clinical

study. Verma PK1, et al. 5. J Endod. 2009 Jan;35(1):15-8. The use of intraosseous anesthesia among endodontists: results of a questionnaire. Bangerter C1, et al. 6. J Endod. 2012 Apr;38(4):421-5. A prospective randomized trial of different supplementary local anesthetic techniques after failure of inferior alveolar nerve block in patients with irreversible pulpitis in mandibular teeth.

Kanaa MD1, et al.

Fig. 2: The Anesto (W&H) systemfor instraosseous anesthesia.

A lack of patency is the harbinger of

all manner of iatrogenic misadventure.

Endo_Article_Move Rapidly2_Layout 1 5/22/14 10:30 AM Page 50

(#10 or #15, etc.) and cannot make apical progress, they willnever know if the canal might have been patent and nego-tiable with a #6 hand file, if used first.

Once the #6 reaches the estimated working length (EWL)taken from the initial radiographs, the electronic apex locatoris used (Foramatron Parkell, iRoot Meta Biomed) to deter-mine the position of the TWL. Using copious amounts ofsodium hypochlorite between each hand file, the next largerhand file (#8, #10, #12, #15, #17) is used to the TWL succes-sively until the glide path is prepared, approximately to thesize of a #15 or #20 stainless steel hand file.

One useful adjunct for glide path preparation with stain-less steel hand files is a reciprocating hand piece (ER-10NSK, MounceEndo.com). The ER-10 can save minutes percase as it replicates the manual watch winding of stainlesssteel hand files during glide path preparation. Many clini-cians reciprocate safe ended K files for reciprocation as a pre-caution, although this is an empirical preference. The ER-10has an E-type coupling that fits on any endodontic motorusing this coupling (all corded endodontic motors). I use myER-10 every tooth, every patient, every day for reciproca-tion. Along with the STA, it is an indispensible part of myarmamentarium (Figs. 4-5).

Once the glide path is created, in my hands, the canal isready for shaping with nickel titanium in the ControlledMemory (MounceFiles CM, Typhoon CM CliniciansChoice) via either a crown down, step back or hybrid tech-nique (Fig. 6).

ConclusionIve reviewed methods for obtaining profound anesthesia

and glide path creation. Emphasis has been placed on movingrapidly to a successful conclusion while avoiding iatrogenicevents using needed anesthetic techniques confidently. Onceprofound anesthesia and straight-line access are obtained, theglide path is created using an increasingly sized sequence ofstainless steel hand files starting with a precurved #6, possiblyaided by a reciprocating handpiece in the presence of copiousirrigation. I welcome your feedback.

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Fig. 4: Mani D Finders arestiff stainless steel files usedfor negotiation of curved andcalcified canals.

Fig. 5: The NSK-ER 10 usedfor reciprocation of stainlesssteel hand files(MounceEndo.com).

Fig. 6: A clinical case treatedusing the anesthesia andclinical techniques discussed.

Authors Bio

Dr. Richard Mounce is in endodontic practice in Rapid City,South Dakota. He has lectured and written globally in thespecialty. He owns MounceEndo, LLC, marketing the rotary

nickel-titanium MounceFile in Controlled Memory and StandardNiTi. He can be reached at [email protected],www.mounceendo.com or on Twitter @MounceEndo.


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Two foundational endodontic requirements to move toward a ... · 2). Intraosseous anesthesia is discussed in the dental literature and a representative sample of the available articles