Endodontic Sequence

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Re: Endodontic Sequence

Postby BarryMusikant on Mon Jan 30, 2012 9:37 pm

sald112 wrote:Thank You for your response.I will most likely refer out most the retreatments as I can use my time more efficiently and with more predictable results doing other dental procedures.
Austin


Austin,

That's the response most endodontists love to hear. However, I will tell you that teaching dentists how to perform endodontics both better and more efficiently has been a boon to our practice. It seems that the more we educate with the express purpose of dentists doing more endodontics, the more work we have referred to us, not necessarily from the people we teach. Under any circumstances, as a teacher I feel I am being true to my father who was what would today be called a prosthodontist telling me it was my duty to teach. I follow his advice and have never regretted it.

Regards, Barry
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Re: Endodontic Sequence

Postby daatoon on Wed Feb 01, 2012 4:20 am

Hello Barry Sir,
                   In India, it is commonly said that knowledge will only increase if you share it (so does happiness, whereas sorrows will decrease by sharing).
                   Hat's off to you for all the efforts you put in to teach many of us here & elsewhere.      
                   Will always be indebted to you for many things.

Thank You,
Amar.
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Re: Endodontic Sequence

Postby BarryMusikant on Wed Feb 01, 2012 4:34 pm

sald112 wrote:Thank You for your response.I will most likely refer out most the retreatments as I can use my time more efficiently and with more predictable results doing other dental procedures.
Austin


Austin,

Alas that is the dilemma of the specialist. I have no one to send the difficult cases out to.

Warm regards, Barry
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Re: Endodontic Sequence

Postby drdoug2 on Wed Mar 21, 2012 7:38 pm

Speaking of teaching: THANKS! Years ago I used SafeSiders but for some reason got away from it.
Two years ago took a rotary workshop out in CA. Great course. But never used myself once I got home. Seems like there was always more expensive stuff to buy! And so unsure about breakage. So just referred everything out. But with more than half a dozen new offices opening very near me in recent years, I felt like I just had to do some endo in house. With the help of the info on EDS but more importantly the info contained in this board, have gotten back to safesiders and EZ fill. What a joy! A 75yo pt of mine was going to have RPD abutment #31 extracted. I asked if he would let me use him as a teaching case. He agreed. Finished the endo this morning. While not quite perfect, the radiograph looked great. And last week whipped out endo on a lower bi in just an hours! Now I have a whole new appreciation for irrigation technique and sequence thanks to Barry and all on these boards. So excited to do more. And scheduled myself for the 2 day course this May. Can't wait.
Just a big Thanks to all who contribute to these boards. Can't wait for the next toothache! ;)
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Re: Endodontic Sequence

Postby BarryMusikant on Thu Mar 22, 2012 7:30 am

Doug,

Thanks for the upbeat appraisal. It does not go unnoticed and it is entirely appreciated. When I get such great feedback it makes me want to help all the more.

Warm regards and thanks again, Barry
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Re: Endodontic Sequence

Postby dndiaz10 on Sun Apr 22, 2012 11:14 pm

Hola!
This is Diana and took your course in Jan. of this year.  My life in endo. is so much less stressed for many reasons after taking your course...it is fun to do endo!  Last week, on a lower 2nd molar, mb root,
I ledged the canal that had been patent when I used the pleezer reamer to try to get depth 6mm short
of the constriction.  I filled the distal canal and hope to finish mb and ml canals this week, but I had to
stop due to length of time, frustration and reamers I tried, even those w/ a bend were doubling up on me.  How do I correct this issue to finish? (I did not perforate)
Thanks, Diana
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Re: Endodontic Sequence

Postby BarryMusikant on Mon Apr 23, 2012 9:36 am

dndiaz10 wrote:Hola!
This is Diana and took your course in Jan. of this year.  My life in endo. is so much less stressed for many reasons after taking your course...it is fun to do endo!  Last week, on a lower 2nd molar, mb root,
I ledged the canal that had been patent when I used the pleezer reamer to try to get depth 6mm short
of the constriction.  I filled the distal canal and hope to finish mb and ml canals this week, but I had to
stop due to length of time, frustration and reamers I tried, even those w/ a bend were doubling up on me.  How do I correct this issue to finish? (I did not perforate)
Thanks, Diana


Diana,

Yes, too much apically directed pressure on the tapered peeso can lead to either blockage of the pathway with debris or a slight ledging which can quickly make our lives more complicated. I clearly remember creating these problems myself. The best technique  I applied to get around the blockage is to go back to a 10 or 15 with a lot of 17% EDTA in the canal. Place anywhere from a 45- 75º angle on the last mm of the instrument and then using a light twist and peck motion attempt to find a patent pathway. You don't want to apply a lot of apical pressure. It will only aggravate the situation. Assuming you finally get around the blockage, don't remove the instrument. Rather attach it while it is in the canal at the newly acquired depth to the reciprocating handpiece and use a series of short vertical strokes while it is oscillating to further open the canal space and then after these strokes elongate your strokes to make sure the glidepath is intact the whole distance. Once this happens, you should be able to complete the shaping.

For the future, the most cautious step you can take is to simply stop attempting to go deeper when significant resistance is encountered. If you don't apply increasing apical pressure you will not impact debris apically or create a ledge, the two factors that can make you come up short when going back to instrumentation. You will be surprised how easy it is to longer with the peeso once the canals have been opened to a 35. So, if you are short at 20, just continue with the sequence of reamers until you reach 35 and then try the peeso again. You will most likely see that gaining the extra depth now is far less challenging.

Please let me know if this a sufficient explanation.

Regards, Barry
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Re: Endodontic Sequence

Postby stevebenke on Wed Oct 17, 2012 8:47 am

Hi Barry,

I have been using the EndoVac system of irrigation for a number of years now and I think it does a great job of cleansing canals but now I'm ready to give it up and do it your way. The EndoVac is expensive and time consuming and with the results you get with your system, it seems to be overkill. Would you be so kind as to pick up the endo sequence from the irrigation step through to obturation. Some specific questions are; during irrigation what type and size of needle do you use? How do you avoid irrigant  going past the apex? How do you rinse before using chlorhexidine? How do you dry the canal, fit the gutta percha, and use the sealer?

Thanks so much.

Sincerely,
Steve
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Re: Endodontic Sequence

Postby BarryMusikant on Wed Oct 17, 2012 10:55 am

sald112 wrote:Thank You for your response.I will most likely refer out most the retreatments as I can use my time more efficiently and with more predictable results doing other dental procedures.
Austin


Austin,

I know you are not the only one who thinks that way considering the fact that at least 50% of my cases are retreats, thankfully most of them not my own.

Regards, Barry
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Re: Endodontic Sequence

Postby bfinch383 on Mon Nov 05, 2012 10:12 pm

Barry,
I am having trouble with seating my gutta percha points.  In all cases,  I've cleaned and shaped canals to the constriction but, Med fine gp  buckle and med gp will not go to length.  Per your suggestion in one of your earlier sequences, I've been using Dentsply points. Would the fitting be easier, if I used a size 40 GP?


Thank you,
Bernard
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Re: Endodontic Sequence

Postby BarryMusikant on Tue Nov 06, 2012 8:47 am

bfinch383 wrote:Barry,
I am having trouble with seating my gutta percha points.  In all cases,  I've cleaned and shaped canals to the constriction but, Med fine gp  buckle and med gp will not go to length.  Per your suggestion in one of your earlier sequences, I've been using Dentsply points. Would the fitting be easier, if I used a size 40 GP?


Thank you,
Bernard


Bernard,

First I would say, make sure that thru a 25 you have instrumented 0.5 mm beyond the constriction. This prevents the buildup of debris at this juncture. You don't want it wider than a 25 in most cases, but you definitely want patency.If you have this situation, then the only thing that would keep a medium point from going to length is if the coronal taper of the point exceeds the coronal taper of the canal. By straightening the coronal curve with the tapered peeso, sufficient taper is generally accomplished allowing the point to go to length. In canals that are over 22 mm in length you may want to go into the canal again with the tapered peeso and give a few swipes mesio-distally in the coronal third so this site does not become a binding point for the medium point. I rarely use a fine medium which is the next size down. A medium fine is way to thin a point to use. I think if you try the two suggestions of opening 0.5 mm beyond the constriction thru a 25 and then widening the coronal portion of the canal slightly mesio-distally when the canals are over 22 mm in length you will solve the binding problem with the gutta percha points.

Please let me know if these suggestions help.

Regards, Barry
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Re: Endodontic Sequence

Postby sald112 on Thu Nov 22, 2012 10:45 pm


Very calcified canals,  Root Canal Treatment completed using the Safesided system from EDS on the 21November 2012.

file://localhost/Users/austinsaldanha/D ... en%201.jpg
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Re: Endodontic Sequence

Postby BarryMusikant on Fri Nov 23, 2012 11:34 am

sald112 wrote:
Very calcified canals,  Root Canal Treatment completed using the Safesided system from EDS on the 21November 2012.

file://localhost/Users/austinsaldanha/D ... en%201.jpg


Said,

As of now, I can't open the images. Perhaps, my computer Dave will know how to open the image, but that won't be until next Friday when I see him at EDS unless by chance I see him on Monday at the GNYDM when i give a lecture there. In the meantime, try uploading the images. They have to be sized to no more than 755 and you use the 5th option on the lower right to upload.

Regards, Barry

PS. I had the same problem with some maxillary anterior teeth the other day. I did find them, but I had to drill several mm to get to them. One in particular, No. 7 showed no signs of a canal on x-ray until the last few apical mms. By next week I'll post those x-rays and give a discussion on how I use the color of dentin in tracking these hard to find canals to the point where with a little luck they become patent.

Regards, Barry
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Re: Endodontic Sequence

Postby steph27 on Sat Jan 26, 2013 10:22 am

both NaOCl and EDTA as a final rinse?  
--how long will you aggitate?  
--you use both of those irrigants as final rinses on both vital & non vital?


just curious, Thank you!
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Re: Endodontic Sequence

Postby BarryMusikant on Mon Jan 28, 2013 9:44 am

steph27 wrote:both NaOCl and EDTA as a final rinse?  
--how long will you aggitate?  
--you use both of those irrigants as final rinses on both vital & non vital?


just curious, Thank you!


Stephanie,

In a vital case, I will do a final rinse that includes active agitation of the irrigants with both 17% EDTA and 6% NaOCl for about 30 seconds each in each canal. In non-vital teeth in addition to this irrigation sequence I add 30 seconds of agitation in each canal with 2% CHX with the clear precaution that all traces of the former irrigants must be removed from the canal system prior to introducing the CHX. If there is either residual EDTA or NaOCl remaining a precipitate will form when the CHX comes into contact with either of these irrigants, something we want to avoid. It is the better part of caution, therefore, to wash out all remnants of the prior irrigants with copious amounts of water or saline.

Regards, Barry
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Re: Endodontic Sequence

Postby dcthor on Tue Jun 04, 2013 10:56 am

Hello Barry,
     I am using the air powered handpiece as opposed to the electric handpiece.  In my experience it seems to take several more strokes to feel comfortable before going on  to the next size.  
Am I just overworking the canal, or is my handpiece underpowered compared to the electric.  When you state that you can accomplish getting to a size 40 in 3 minutes, I don't know if I'm underpowered or just over working the canals.  It takes me a good half hour or more to accomplish that size.
Any thoughts.

David
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Re: Endodontic Sequence

Postby BarryMusikant on Wed Jun 05, 2013 9:04 am

dcthor wrote:Hello Barry,
     I am using the air powered handpiece as opposed to the electric handpiece.  In my experience it seems to take several more strokes to feel comfortable before going on  to the next size.  
Am I just overworking the canal, or is my handpiece underpowered compared to the electric.  When you state that you can accomplish getting to a size 40 in 3 minutes, I don't know if I'm underpowered or just over working the canals.  It takes me a good half hour or more to accomplish that size.
Any thoughts.

David


David,

I also use an air driven reciprocating handpiece. There is no question that an electric handpiece will more consistently deliver the 3000-4000 cycles per minute than the air driven one. And yes, I can see where that would lower the procedural speed. I have not personally had a problem with the lower speeds, but that may be because the canals we treat are often so difficult in terms of curves and calcifications that speed is rarely my first concern. My main concern is the maintenance of patency and ability to shape the apical third without any obvious distortions.

You could increase the air pressure that in turn would increase the cycles per minute. The fact is that we treat a variety of cases. Give me a fairly straight-forward case with minimum curvatures, not an excessively long root and a reasonably sized initial internal diameter along length and there is no question that the case can be taken to a 40 and larger within 3 minutes. The challenges arise when we have to shape more complex anatomy that has suffered the ravages of time leading to more calcifications that reduce and at times impede apical progress. I have had cases where it can take me a half hour to get an 06 reamer to the apex let alone finish the case. I just shaped a lower molar with significantly curved 25 mm length canals where the canals were barely apparent on x-ray. I must have gone thru 2 boxes of 06 K-reamers just to finally get to the apex in the ml and mb canals. This case would have been impossible if I had used K-files.

So, yes we can increase our productivity by increasing the air pressure for the reciprocating handpiece, but what we must realize is that endo, sometimes is just hard, and getting that initial instrument to the apex without distortion is first a manual procedure and secondly can take a long time. That's where we have to persevere.

I don't know if I exactly answered your question, but I think it is important to realize that each tooth presents its own specific challenges. Some are mild and some are mindbending. I look forward to your response.

Regards, Barry
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Re: Endodontic Sequence

Postby klpete5560 on Tue Jul 02, 2013 8:18 pm

Hello Barry-

I've been using SafeSiders for years and it's raised my endodontic confidence enormously. I follow the regimen you posted above with the addition of irrigating with Lidocaine and then Chlorhexidine at the very end before filling. I fill with MF GP and the EDS sealer.

Every so often, more often than I'd like of course, the patient reports moderate to severe post op pain lasting 2-3 days after which it calms down and all is fine. What are the most common mistakes that lead to post op pain like this?

Thanks in advance,

Kirk
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Re: Endodontic Sequence

Postby BarryMusikant on Wed Jul 03, 2013 6:17 am

sald112 wrote:Thank You for your response.I will most likely refer out most the retreatments as I can use my time more efficiently and with more predictable results doing other dental procedures.
Austin


Austin,

Your response is always music to an endodontist. I guess that is what being a specialist is all about. Having no choice in what and what not to do forces us to maximize our skills in our chosen area of specialization.

Regards, Barry
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Re: Endodontic Sequence

Postby bfinch383 on Tue Jan 14, 2014 5:40 pm

Barry,
I don't see how you can shape a canal in 3 minutes. I generally start with a 10 and have to start all over when I get to 25 because the reamer won't shape to the constriction.  In the process I change out safesiders, thinking the particular one I'm using is dull.  Is it taking me 20 minutes per canal because my reamers are not sharp? I really get jealous when I hear about these systems that only require three files to shape.  The only reason I don't switch to the newer files is because I broke so many ntis' as an early adopter that I am gun shy.

Bernard
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