Comments on an article By Dr. West in Dentistry Today

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Comments on an article By Dr. West in Dentistry Today

Postby BarryMusikant on Wed Jun 09, 2010 10:33 am

I just read John West’s article, titled Endodontic Predictability: “Are You Making the Right Decisions?”, published in the June 2010 issue of Dentistry Today. He is an excellent endodontist and posted some beautiful cases in the article which would make one pay attention to the 10 decision making points he made in producing excellent results. Some I agreed with. Others I did not.

According to Dr. West the first decision is for the practioner to ask himself and then decide if he has the skills to produce the best endodontics possible. If the dentist cannot produce an excellent endodontic seal, I suppose Dr. West is saying don’t do the case. The question he poses is really a philosophical one. How do we measure our own skills? How do we improve if we set standards so high that we rarely get a chance to practice those skills? There is a certain sense of idealism here that does not mesh with reality. I agree with his concept as a quest for a goal that is never fully attained, but not as a realistic decision making process across the board. I believe the goal should be one of continuous improvement so we can incrementally improve taking on more challenging cases over time. If we don’t stretch ourselves we don’t grow.

His second point (decision) is to acquire the skills to use the microscope effectively. Can’t argue with that.

He then discusses the benefits of straight line access (the decision to attain it). Again, I couldn’t agree more. He even notes that straight line access is attained when the endodontic instrument sticks straight up from the orifice and is in line with that overlying cusp. In other words, if you are placing an instrument in the mb canal at an angle that extends the instrument distally, you don’t have straight line access and you need to straighten the coronal portion of that access.

The next point is all about using finesse and a light touch to follow canals to the apical terminus overcoming such obstacles as impacted pulp or necrotic tissue, the angle of the access file being different from the angle of incidence (a mildly curved instrument in an abruptly curved canal), the tip diameter of the instrument being wider than the canal and the taper of the canal being narrower than the taper of the negotiating instrument. This point could be turned into a chapter in a book and is an important area for the message board to make continuous contributions.

His fifth point is where we part ways. He states it as follows” Are You Willing to Master the GlidePath so You Can Make Rotary Endodontics Safe, Predictable and Efficient? This article started out as a generalized list for superior endodontics and has just switched to the use of a specific approach. The implication is that the only way to attain excellent results is with some form of rotary NiTi system as a given, and the important thing is to create an environment so they can be used safely. On the one hand he is saying that rotary NiTi is safe and predictable and on the other hand he is saying that it is mandatory that the glidepath at least up to a 15 must fit loosely, easily able to follow length, that the inadvertent creation of a shelf, dent or gouge in the glidepath wall can result in the breakage of a rotary NiTi instrument. Given the fact that the walls of a canal already opened to a 15 can still have ledges, tight grooves, lateral canals, bifurcations as well as a host of other anatomic anomalies, rotary NiTi is most safely used if it does little exploring of the lateral walls of a canal.

I am describing limitations to the safe use of rotary NiTi and Dr. West adds no insights to the fact that there are other approaches that can overcome the limitations imposed on rotary NiTi for the very reasons he discusses.

Give the premise of his article that implies there are no alternatives to rotary NiTi he then goes on to state that a decision must be made on which rotary NiTi system to purchase. Here he is magnanimous in stating that one should try a variety of systems and choose the one that works best for you. Magnanimity for rotary NiTi. None observed for none rotary NiTi systems some of which are clearly safer, simpler, at least as effective, can be used many times without replacement and cost 90% less.

He then goes on to discuss ways to irrigating canals encouraging the use of 6% NaOCl and 17% EDTA. His eighth decision discusses the fit of the master cone, that the dentist must master the skills of placing the initial points accurately. Can’t argue with that.

His ninth decision is to automatically employ the vertical compaction of warm gutta percha. Again, he is recommending a specific system ignoring the down sides of shrinkage, followed by gap formation associated with thermoplastic techniques. Nor does he note the ability of epoxy resin as a well documented interface to seal canals long term in three dimensions without the incorporation of heat. If he did recognize these techniques, he might mention the fact that a room temperature system expands as it warms to body temperature expanding both the cement and the gutta percha about 1.75% producing an even better seal. At a minimum, there is no evidence that the incorporation of expensive paraphernalia involving complicated thermoplastic techniques produce higher success rates.

Finally he tells us that the final coronal seal should prevent leakage and again I fully agree.

My estimation of this article is that it is a bit of puffery written to influence the greater use of rotary NiTi and thermoplastic systems and makes no attempt to be unbiased. He made some good points and they are better put in the proper perspective with the help of commentary from us. You got my viewpoint. I would be interested in hearing from others.

One final note that I found amusing. His bibliography included several self-references, plus some from Cliff Ruddle who is an advocate of the same systems that Dr. West advocates. Furthermore, most of the references were from articles written in trade magazines, and not from scientific journals. You notice these things after a while.

Regards, Barry
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