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The Postpandemic Upside in Endo by Dr. Manor Haas

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Categories: Endodontics;
The Postpandemic Upside in Endo 

Best practices rise to the top after a stressful year

by Dr. Manor Haas

Dentaltown has always been about “real dentistry for real dentists.” In line with that slogan, this article looks at our profession as wet-fingered dentists with a frontline perspective to demonstrate how patients in need of endodontic treatments, along with our practices, can permanently benefit from what we’ve learned during the pandemic. As the saying goes, with every tragedy, opportunities arise. This pandemic is no exception. It has forced us to adjust our practices to adapt to pandemic-minded ADA guidelines.1

Remember the days of bringing patients in for consultations, then back again for multiple and lengthy root canal appointments, only to be followed up with more appointments to restore the endo-treated teeth? That’s a lot of wasted time and effort that would be deemed unnecessary during a pandemic—and should be deemed unnecessary after one, too. The future of endo could and should entail more efficient and more productive treatments.

During the pandemic, we’ve been encouraged to enhance our triage of potential endodontic and emergency cases before patients step into our practices and weed out any unnecessary visits. And while patients are in our chairs, we’ve had to work more efficiently by providing as much treatment as possible during every visit. This safeguards patients from potential exposure as they leave their safe bubbles. And, in the process, it enhances a practice’s efficiency and production.

The trick is good triage

The pandemic-minded tweaks that could and should become common practice start with the following: Front desk staff and dentists should better assess and triage patients calling in with dental pain. Doing so would help ensure that patients are scheduled and seen accordingly.

It is important that non-endo-related symptoms such as sinus, parafunction or neuromuscular-related cases aren’t scheduled to be seen for endodontic treatment. For instance, what if a patient says they have pain that is not localized to a tooth and wakes them up at night, or is present upon waking up in the morning?

In such cases, they may not need to be seen for a lengthy appointment that would otherwise be set aside for possible treatment.

Not triaging these patients accurately could result in waste of office time and resources. On the flipside, a FaceTime communication with such patients, or an emailed photo taken by patients of their problem (e.g., swelling) would help tremendously.

So asking the right and specific questions and possibly incorporating teledentistry could help triage patients’ dental issues and help the office schedule accordingly. This could mean reducing wasted appointment times for non-endo-related issues.

Perfecting protocols

Making the most of every visit can also be accomplished by having systems in place and the necessary instruments to enable fast and efficient root canal treatments. By no means does it mean rushing or cutting corners. It means working more efficiently with up-to-date science and tools.

It’s been shown that single-step root canal treatments can be as successful as two-appointment treatments.2 In fact, the chance of post-treatment flare-ups might also be equal between one- and two-appointment treatments.3 This could mean fewer patient follow-up visits.

Certainly, there are some key protocols if one was to complete endo treatment in one appointment, especially of necrotic teeth. This includes, at least in part, the following:

1. Locating all of the canals, including calcified canals and MB2 canals in maxillary molars.

2. Ensuring there are no internal fractures that may lead to mechanical failure of the tooth.

3. Instrumenting large enough apically to mechanically remove as much of the (necrotic) pulp tissues as possible, and to enable intracanal medications to reach the apical third of the canals.

4. Use of copious amounts of intracanal medicaments (e.g., NaOCl).

5. Removal of the smear layer with EDTA (e.g., QMix by Dentsply Sirona) to enable penetration of a medicament (e.g., QMix, which has EDTA and chlorhexidine) into the contaminated dentin tubules.

6. Intracanal passive activation with an endodontic ultrasonic or sonic activator.4

Importance of instrumentation

The use of instruments that enable faster treatment is paramount. This includes enhanced magnification (e.g., loupes with light, or a dental microscope) to help locate canals, diagnose microfractures and enable faster endo access preparations.

The incorporation of an accurate and new generation apex locator is also crucial. It helps reduce the treatment time by requiring fewer (but not necessarily the elimination of) midtreatment radiographs for working lengths. It also helps improve treatment quality, because instrumentation and obturation lengths are obviously crucial for success and patient comfort.

For instance, a short endodontic fill may leave necrotic or inflamed pulp tissues in the canal, while overinstrumentation or overfill may reduce treatment success and increase postoperative symptoms.

The third key instrument to consider using is a NiTi file system that is efficient in canal shaping and debriding, and may require fewer files. Fewer files translate into fewer steps required to fully instrument a canal. Examples include reciprocating NiTi files by Dentsply Sirona (WaveOne Gold) or Brasseler (ESR).

Furthermore, while a patient is already in the chair and rubber dam isolation is still in place, one should consider permanently restoring the endodontic access—at least with a core. It’s been shown that doing so increases the treatment success of the endo-treated tooth.5

So, without compromising the quality of care, it comes down to better diagnostics and case selection and more efficient endodontic treatments. This is what the pandemic has shown us to be a best practice. So why not invest in setting up systems with your staff and clinical protocols permanently? And why not invest in the necessary dental instruments? The return on investment could be significant for your practice and patients as you look beyond the pandemic.

Conclusion

All in all, better diagnosis and time allotment (thanks to previsit triaging), with enhanced treatment efficiency (thanks to advanced endodontic instruments) can and should be the common mindset in providing endodontic treatments. Doing so is a win–win, for patients and for dental practices. That’s “real-world dentistry.”

So, after a roller coaster of a year, enhanced endodontic-related protocols are emerging from this pandemic for our patients and our practices.

Don’t just tweak your practice so as to meet the pandemic-related guidelines. Instead, use those tweaks to enhance your practice moving forward and have them become permanent changes. If you do so, only good will come out of this, whether you’re in a pandemic or beyond it.

References
1. American Dental Association online. Covid-19 Center. www.ada.org
2. Penesis VA, et. al., Outcome of one visit and two visit endodontic treatment of necrotic teeth with apical periodontitis: a randomized controlled trial with one-year evaluation. J Endod Mar;34(3):251-7, 2008.
3. Kalhoro F, Mirza A, A study of flare-ups following single-visit root canal treatment in endodontic patients. J Coll Physicians Surg Pak. Jul;19(7):410-2, 2009.
4. Kurt M., Caliskan M, Efficacy of chlorhexidine as a final irrigant in one visit root canal treatment: a prospective comparative study, Int Endod J. Oct;51(10):1069-76, 2018.
5. Goldfein J et al, Rubber dam use during post placement influences the success of root canal-treated teeth. J Endod, 39(12), 2013.

More endo courses from Dr. Manor Haas online!

Click here to see Dr. Manor Haas' four CE courses that bring an endodontic expert right to your computer, tablet or smartphone. Topics include everything from a survey of endo basics to the exploration of advanced techniques.

Author Bio
Manor Haas Dr. Manor Haas, a certified specialist in endodontics, is extensively involved in providing continuing education to dentists and has lectured and conducted workshops and webinars internationally. Haas maintains a full-time practice limited to endodontics and microsurgery in Toronto, and is on staff at the University of Toronto and The Hospital for Sick Children. A regular contributor to dental journals, websites and blogs, he may be reached via haasendoeducation.com.
 

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