Once a proper diagnosis and treatment plan is decided, talk to the patient and discuss the following:
All the operative instruments, files, airotor, burs, endomotor and everything that is being used in the treatment is thoroughly
Use airotor with LED Improved visualization increases ease and decreases effort.
For a long time, I relied on my tactile sensation and avoided this step. The logic behind it being that I would verify it with my master cone radiograph just before the obturation. I was negligent here and it took me time to realize that:
Common methods of determining the working length are:
a) Initial file:
The ideal initial file is 10k for any case. This file helps to create a glide path.
b) Pre curving the file:
Pre curving the apical part of the file before placing it in the canals helps us to explore the curvatures and respect the natural anatomy of the tooth.
c) Hand filing:
Whatever be the file system, hand filing upto minimum 20k helps to loosen up the canal and prevent stress on the root canals and also on the upcoming rotary files.
d) Orifice opening:
This step is very underestimated. Using an orifice opener to open the coronal 2/3rd of the canal decreases strain on the rotary files. The enlarged orifices appear dark in color and aid in easy location of canals during bio mechanical preparation.
e) Filing motions:
f) Apical diameter:
g) Golden rule:
If access opening is being done, then BMP has to be done on the same visit. Atleast till a minimum hand filing of 25k. Avoid using formocresol. This will relieve the patient from pain and in most cases it will avoid the necessity of local anaesthesia on the second visit.
Never compromise on irrigation. Copious irrigation should be done after each filing.
a) Choice Of Irrigant:
After experimenting with a lot of irrigants, I have realized that no irrigant is as good as sodium hypochlorite. NaOCl has tissue dissolving properties and also has a mild anti-bacterial effect. A great endodontist once said,” Doing RCT without sodium hypochlorite is like trying to cut vegetables with a
If a rubber dam is applied, then full concentration NaOCl (>6%) should be used.
In cases without rubber dam, 3% NaOCl should be used with cotton rolls on each side on the tooth and a high volume suction placed close to the tooth. The cotton rolls should be removed immediately after irrigation to avoid prolonged contact of hypo with the soft tissues.
Chlorhexidine irrigant (2%) can be used in infected cases as it has strong anti- microbial
In calcified canals and blocked chambers, EDTA irrigant (17%) will help in chelation and make our work
Saline is a good irrigant to wash out the debris. It is mild and non-toxic but it does not have any anti-microbial effect. It can be used as an adjunct with other irrigants.
a) Method Of Irrigation
Insert the irrigation needle 4-5mm away from the apex. The needle should never bind to the walls of the
Irrigation should never be forced into the canal. The deposition of irrigant has to be slow and
Use side vent needles. Irrigation with side vent needles prevents the flow of irrigants beyond the
Avoid using NaOCl, EDTA or CHX in the same tooth. This will cause a reaction and end up in formation of
Let the irrigants stay in the canal for some Studies have shown that NaOCl requires at least 20 minutes to dissolve pulp tissue.
Activation of irrigants can enhance the treatment success to a great extent. This helps in facilitating the flow of irrigants to all those places where our files cannot reach
a) Drying the canals with paper points:
This is yet another step which is very underestimated and skipped by many practitioners. Drying the canals is mandatory to achieve good bonding of obturating material and canals.
b) Common obturation techniques:
There are various obturation techniques and using any one of them would be fine. Honestly speaking, if the canals are cleaned well and dried properly, the technique of obturation does not have much impact on the success and failure of tooth.
I. Single cone technique:
This technique works fine for molars and upper premolars. Make sure the single cone fits tightly in the canal, especially at the apical third and is well coated with sealer.
Palatal canal in maxillary molars and distal canal in mandibular molars have to be cross checked and if needed lateral gutta percha cones should be compacted.
II. Lateral compaction technique:
Ideal technique for anterior teeth and lower premolars with single canals. Try to achieve three dimensional obturation with fluid tight seal (no lateral spaces).
III. Down pack and back fill technique:
Another great and easy technique which can be used in all teeth. However, it requires specific obturating armamentarium which is not available in all dental set ups.
c) Sealing the gutta percha:
It is very important to seal the gutta percha exactly at the orifice of canals. Make sure there is no remanant gutta percha in the coronal cavity as it may affect the placement of permanent restoration.
It is best to seal one canal at a time and not altogether.
d) Cleaning the cavity after irrigation:
Clean the cavity with either saline or isopropyl alcohol and dry it properly with cotton pellet. Any contamination in the cavity with affect the permanent restoration.
e) Sealer puff:
Not desirable. Neither harmful.
It may cause temporary post-operative pain which can be controlled by medications. It is important to understand the difference between sealer puff, sealer extrusion and over filling.
f) Under and over obturation:
As long as the bio mechanical preparation is done properly and the canals are clean and sterile, a little short or a little over obturation is fine and wont effect the outcome of the treatment.
Anything in excess is not acceptable and if it happens then the obturation should be repeated.
The following instructions should be given to the patient after the treatment: