The Total Endodontic Experience“Succeeding in the New Endodontics”        John West, DDS, MSD          Pacific Dental Conf...
CENTER FOR                        John D. West, DDS, MSD ENDODONTICS                          AGENDAI.     CONTEXTII.    D...
CENTER FOR                                                    John D. West, DDS, MSD ENDODONTICSI.       CONTEXT     •   I...
CENTER FOR                                                         John D. West, DDS, MSD ENDODONTICSII.      DIAGNOSIS   ...
CENTER FOR                                                    John D. West, DDS, MSDENDODONTICS  4.       Necrosis        ...
CENTER FOR                                                   John D. West, DDS, MSD ENDODONTICSIII.   RESTORABILITY       ...
CENTER FOR                                              John D. West, DDS, MSDENDODONTICS  3.   Periodontal          • Gui...
CENTER FOR                                                   John D. West, DDS, MSD ENDODONTICSIV.   SHAPING AND CLEANING ...
CENTER FOR                                                      John D. West, DDS, MSD ENDODONTICS              Carving aw...
CENTER FOR                                                        John D. West, DDS, MSD ENDODONTICSBlocks, ledges, and tr...
CENTER FOR                                                    John D. West, DDS, MSD ENDODONTICS      7.     The game and ...
CENTER FOR                                           John D. West, DDS, MSD ENDODONTICSV.   OBTURATION     What obturation...
CENTER FOR                                                 John D. West, DDS, MSD ENDODONTICSVI.   BUILDING      1.   Educ...
CENTER FOR                                                     John D. West, DDS, MSDENDODONTICS  9.    Cracked Tooth Synd...
CENTER FOR                                                                John D. West, DDS, MSDENDODONTICS  19.   Fun. Th...
CENTER FOR                                                    John D. West, DDS, MSD ENDODONTICS      21.    Stages of Den...
CENTER FOR                                                                             John D. West, DDS, MSD ENDODONTICS ...
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  1. 1. The Total Endodontic Experience“Succeeding in the New Endodontics” John West, DDS, MSD Pacific Dental Conference March 10th, 2006
  2. 2. CENTER FOR John D. West, DDS, MSD ENDODONTICS AGENDAI. CONTEXTII. DIAGNOSISIII. RESTORABILITYIV. SHAPING AND CLEANINGV. OBTURATIONVI. BUILDING 2
  3. 3. CENTER FOR John D. West, DDS, MSD ENDODONTICSI. CONTEXT • It Works (if you do it right) • Today is a Line of Demarcation • The three changes that are influencing endodontics: 1. Technology 2. Interdisciplinary 3. 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. 3
  4. 4. CENTER FOR John D. West, DDS, MSD ENDODONTICSII. 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. 4
  5. 5. CENTER FOR John D. West, DDS, MSDENDODONTICS 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.” 5
  6. 6. CENTER FOR John D. West, DDS, MSD ENDODONTICSIII. 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.” 6
  7. 7. CENTER FOR John D. West, DDS, MSDENDODONTICS 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.” 7
  8. 8. CENTER FOR John D. West, DDS, MSD ENDODONTICSIV. SHAPING AND CLEANING • Concepts • Technique • New Technologies Five Distinctions of Cleaning and Shaping 1. Vision 2. Motions 3. Sequencing 4. Language 5. 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, MSD Conclusion: 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 Taper o Cross-sectional Diameter o Flow o Never Transport POE o Nature’s POE Three Keys: 1. Delicate Radicular Foraminal Cementum 2. I Love You 3. Groundhog Philosophy of Shaping and Cleaning Four Critical Distinctions of Manuel Motions 1. Follow 2. Smooth 3. Balance 4. Envelope 8
  9. 9. 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 EinsteinWhat do the program directors, the JOE advisors and valued clinicians consider themost important determinants of endodontic success?Finishing Checklist • Mechanical Objectives • Appropriate • Smooth • Solid • “Four” DimensionalAAE Finishing Survey, 2000 – “What part of a curved, narrow MB canal of a maxillary 1stmolar is the most difficult for you to prepare? Is it the apical third, the middle third, orthe 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 itis not balanced F____________, it is actually shaping from the inside out. It isremoving everything that is not the cone fit, or as Michelango said, “As the marblewastes, 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 SixPack”What do six-time Tour de France champion Lance Armstrong and the experience ofexceptional endodontics have in common?10 in a Row30 in a RowMs. Gnarly meets Mr. CrookedGuess what time it is and, more importantly, guess the level of technical artistry. 9
  10. 10. CENTER FOR John D. West, DDS, MSD ENDODONTICSBlocks, 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 rotary 2. Never force 3. Single use 4. 220 RPM in electric slow speed 5. Remove all chamber orifi dentinal triangles 6. Use EDTA or Chemet during rotary 7. Use microscope to observe micromovement 8. Inspect & clean 9. Use progressive, passive passes to reach POE constriction 10. Float, follow, and brush away from furca with S1 & S2 11. Follow F1, F2, and F3 until they engage, then remove, clean, inspect and repeat until arrive at POE constriction 12. Never rushCorrection • 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 afraction of a millimeter short. Once we disturb the “dense dentin mud”, then the rest iseasy.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. 6. Forget clock 10
  11. 11. CENTER FOR John D. West, DDS, MSD ENDODONTICS 7. The game and the promise. 8. Randomization, not searching.Ledges. The key is to precurve a ProTaper™ file and finesse it past the ledge, usuallyan F1 (yellow) then make several rotary turns manually, remove and note ledge debrison flutes. Fit the cone.Open Apex. Make a barrier unless there is enough tooth structure to shape inside ofthe open apex and shepard warm gutta-percha vertically. If there is not enough toothstructure, create an apical barrier with calcium sulfate, or CollaCote and then backpackusing a combination of syringing warm gutta-percha with sealer, heating and furtherdistorting the gutta-percha. Another alternative would be to ultrasonic MTA to the apicalconstriction after appropriate barrier placement, place a layer of gutta-percha, and thenrepair the access with a flowable composite. The apical periradicular fluids serve asappropriate MTA hydration. 11
  12. 12. CENTER FOR John D. West, DDS, MSD ENDODONTICSV. 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 12
  13. 13. CENTER FOR John D. West, DDS, MSD ENDODONTICSVI. 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 13
  14. 14. CENTER FOR John D. West, DDS, MSDENDODONTICS 9. Cracked Tooth Syndrome Class I Incomplete Vertical Fracture Through Enamel Into Dentin, But Not Into Pulp Class II Incomplete Crown Fracture Involving the Pulp Treatment Flowchart for Cracked Tooth Syndrome Bite Remove Bite Extirpate No bite Endo + restore No bite + Endo + CTS Band Extirpate symptoms restore No bite + Restore no symptoms 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 14
  15. 15. CENTER FOR John D. West, DDS, MSDENDODONTICS 19. Fun. The relationship of performance and fulfillment. High Transition Performance Transition Low High Fulfillment 20. Kodak Study on Profitability Assuming a profit goal of 25%: 5% decrease in fees 25% increase in volume 10% decrease in fees 67% increase in volume 20% decrease in fees 400% increase in volume 5% increase in fees 83.5% of previous volume 10% increase in fees 71.5% of previous volume 20% 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. 15
  16. 16. 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. 16
  17. 17. CENTER FOR John D. West, DDS, MSD ENDODONTICS West’s Shopping ListProduct Company Toll Free NumberAccess Kit Dentsply Tulsa Dental 800.662.1202BioPure MTAD Dentsply Tulsa Dental 800.662.1202Calamus Flow, Downpack, Dual, and Manuel Dentsply Tulsa Dental 800.662.1202PluggersChemet (DMSA) Union Avenue Pharmacy 253.752.1705Coronaflex Kavo 800.323.8029Digital X-ray Trophy 800.667.1780Electric High Speed KAVO America 800.323.8029Electric Rotary Motors (DTC or ATR) Dentsply Tulsa Dental 800.662.1202Endodontic Cart ASI 800.566.9953Hand-files (K-files, C-files) Lexicon Tulsa 800.622.1202Irrigation Systems/ Endo Irrigator Vista Dental 877.418.4782JW 17 Microexplorers CK Dental 800.675.2537JW Microprobes CK Dental 800.675.2537JW Microspatulas CK Dental 800.675.2537Kerr Pulp Canal Sealer Kerr 800.521.2854Microscope Global Surgical Corp. 800.861.3585Microsurgeon Chair Global Surgical Corp. 800.861.3585MTA Dentsply Tulsa Dental 800.662.1202Narrow Posterior Heat Carrier (29001) Sybron Endo/ Local Dealer 800.346.3636ProTaper Technology Dentsply Tulsa Dental 800.662.1202 Rotary files: SX, S1, S2, F1, F2, F3, (F4, F5) gutta percha, obturators, carriers, paper pointsRoot ZX Dentsply Tulsa Dental 800.662.1202Ruddle Post Extractor Dentsply Tulsa Dental 800.662.1202Schilder Pluggers Sullivan Schein Dental 800.372.4346Single Wave Heat Pluggers Sybron Endo 800.346.3636System B Heat Source Sybron Endo 800.346.3636Tilt Bins (deflecto) Beemak Plastics 800.669.4399Ultrasonic System Dentsply Tulsa Dental 800.662.1202 Obtura/Spartan 800.344.1321Ultrasonic Tips Dentsply Tulsa Dental 800.662.1202 Obtura/Spartan 800.344.1321 17

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