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  Endo experience in USA


The opinions within this web page are not ours. Authors have been credited
for the individual posts where they are. - www.rxroots.com
From: Roberto Cristescu
To: ROOTS
Sent: Sunday, October 23, 2005 7:51 PM
Subject: [roots] ROBERTO's USA-ENDO IMPRESSIONS - introduction

Hi, So being back home I have to write you my impressions about the past 
3 months that I spent in Terry's Office, in Santa Barbara California. 
First of all I want you to read those "statements" ,  because I want to 
be honest and as much as I can objective :

- I have been for the past 10 years a great fan of USA. Despite the fact 
that in the last years  there have been sometimes some political/economical 
issues between Europe and USA, I constantly  remained a great fun of USA. 
I say this because I want you to know that what you will read is 
written by a person which from the very beggining starts with a high 
appreciation and many good  feelings for the USA and for the endodontic 
speciality of this country.

- What I will write is not a "general statement" that apllies to all 
USA endodontic offices. It is only what I saw in Santa Barbara 
(Terry Pannkuk), Las Vegas (Nishan Odabashian, Doug Rakich 
and Ben Schein) and San Diego (Gary Carr)

- My observations are ones of a recently graduated dentist (last year) 
from a developing country  (Romania), a country where there is no endo 
speciality and where unfortunately there are not so many chances for the 
future starting this type of speciality. So please forgive my lack of 
knowledge or poor English

I'll write my impressions in many parts:

Part 1 " About endo organising:

- I never thought that an endo office can have more operatories, each of 
them beeing fully equipped for high standard endodontics. This was a huge 
surprise for me. After that I realised that in order to be well organised 
and to escape the "dead times of the room setting up" it really means 
a lot.

- When I started last autumn my career as a dentist I thought I'd love to  
have a day only for consults. Because I wanted on that day to be fully 
focused on taking pre-op pics, impressions for study models, checking of 
the occlusion, medical history etc. I realised soon that this was really 
weird for my city/country because no one I knew was doing  this so I said 
maybe it was a bad idea and I abandonated it after 3 months. In Terry's 
office I was happy to see that indeed he has a day fully dedicated to 
consults. A consult takes about 45 mins, maybe less if the patient has 
already completed the medical history/pain history online.

- I never thought that there is a real science of how to schedule the 
patients. Shelly, Terry's best assistant, showed in the staff room no less 
than 2 A4 papers full with instructions on HOW TO PROPERLY SCHEDULE. There 
are many types of appointments, each type of those appointments have a 
predeterminated time, unless there are some special recommendations 
(let's say that at the consult you can see a very weird and tough anatomy, 
or a post/Silver point that you have to remove, then you can adjust with , 
let's say ,more 30 mins the initial visit .

- I never thought that patients could come at 8.30 a.m. for a dental 
treatment. What is happenning in my country is that almost only the active 
population affords dental care, so they have time to come to treatment only 
after 4/5/6 p.m. or in weekends, when they are not working. Those are the 
"HOT" hours for dentistry in Romania. I never thought that I could see so 
much punctuality, because I knew that I am not in Switzerland...Yes, with 
only 2 exceptions in 3 months (were about 5 - 10 mins late), all the patients 
were on time or earlier in the office. And yes, there were no missed 
appointments without a phone call (which from time to time happends in my 
country- you schedule a 2 hour appointment for a patient and you end up 
staying there like a fool waiting him to appear and he never shows or calls).

- I thought that the general dentists are not referring a lot of patients to 
endo offices and I thought that I would see 1 or 2 patients a day. It was not 
the case, nevertheless Terry does not like more than 4-5 working patients a day. 
But I heard that there are endodontists that are seeing up to 15 paqtients a day
...which after seeing Terry performing endo and spending a lot of time with 
the patients, makes me a little curious how are the others performing high 
quality endo treatments ( as endodontists who graduated an endo program)...
I mean how can they still be so fast and very good.

- I never thought that a software ( I speak about TDO) can help you so 
tremendously in organizing your office, diagnosis making, treatment planning, 
treatment's info keeping, recalls. It is really fabulous and so helpful !

- I was a big fan of 4 hands dentistry and of the TEAM WORK concept, but after 
I got into Terry's office I realised how important is to have a very well trained 
team , that works very hard and with great passion. I said that before, many of 
Terry's assistants know more about endo than some of the dentists I know. And 
that's only because Terry and Cami (his partner) tought them everything. I am 
looking now for my future practice limited only to endodontics for a person to 
assist me and to teachher what I've learned in USA.

- The high rate of success and the very well organised pratice can be achieved
only with a lot of serious work, After my 3 months in USA I am back with the 
feeling that this country is the best because their people are working so damn 
hard and serious compared to other people around the globe. Every detail is very 
hard studied and arranged. There is no little thing that it's called "unimportant". 
EVerything is IMPORTANT and MUST BE TOP CLASS DONE.

- the operatories are ergonomically build so that you don't have a lot of unused 
space. In my country we are used in private clinics with a huge room and in the 
center of it the dental unit, BUT that means you cannot reach anyting (the drawers 
with materials that are near the walls of the room). So it 's a waste of space to 
have a HUGE operatory with the dental unit in the center. And it's a totally foolish 
thing to invest the most part of the money in the dental unit...this should only be 
confortable for patient that's all. It's so much important to have all the accesories 
near the unit ( scope, X-ray, endo equipment like Obtura/Sys B/ , electrosurge, 
ultrasonics, etc.).

Part II About diagnosing :

- In my country there is an old saying that "a german thinks 10 times before and 
afterwards cuts only ONCE, instead a romanian cuts ONCE and afterwards thinks 10 
TIMES how to repair the bad cutting :-))) ". That's the same with properly 
diagnosing in endo.

- As I've previously said in part 1, my feeling is that it is advisable to have 
a first visit for diagnosis. In this procedure the staff must be really involved, 
beginning with the Blood pressure/pulse measurements, actively asking about what 
medication is the patient on, introducing in the software the medical and pain 
history (in case there is no laptop in the waiting room so that they  can introduce 
themselves the informations in the software). Of great importance and help is to 
have a software that can give you all the info about the medications of the patient. 
I remembered a rich lady , Terry's patient, which was taking about 20 medications ,
and with TDO we figure it out that there were 8 GREAT INTERACTIONS between those !!!

- As I was in TDO users offices, I really felt how easy was for the asistants and 
endodontists to archive all the information. The assistants are doing lot of testing 
cold, perio probing, percussion, mobility) and afterwards the doctor double checks 
everything. This way you can have a very well trained stuff and also you duplicate 
some ofthe most improtant tests. In TDO Multi Tooth Page you can see very 
beautiful the results of those tests and also the recommended treatments and prognosis 
also perio prognosis !).

- It is obviously important to test not only the tooth for which the patient was 
referred, but also  the one in front and the one distal to it. So usually for a patient 
sent for one tooth , you test 3 teeth , and from time to time you can detect that in 
reality the adjacent tooth has an endo pathosis and need RCT.

- I saw a lot of patients that didn't needed RCT, but still were sent for an endo 
consult. Allthough sending  them back means losing money, it's ethically and 
profesionally to recognise if there is not an endo problem. I saw in Terry's office 
patients that were having some symptoms but didn't need an RCT and he sent them back 
for e.g. new temporaries (the temporaries were leaking). If he would have done the RCT 
the patients would have become symptomless and he could have cashed money, but he was 
enough ethically correct to say it clearely that they were needing only new temporaries. 
This is one of the many things I learned from USA : it's not about having a lot of  
money or live in a rich country to do high class endo....it is about knowledge, 
skills and ethics

- FIber optic is really a GREAT TOOL for diagnosis. I saw beautiful images with cracked
cusps....The picture you can take is really impressive and it is a huge help in explaining
the patient what is happening. You can get a clue about a cracked tooth from bite stick 
test, percussion or chewing tests, but fiber optic is just simply wonderful ! I was very 
excited every time Terry was doing this test !

- Occlusal checking and also checkin the quality of the restorations 
(open margins -> marginal leakage) is part of the diagnosis.

- I was really impressed with really wonderful posterior gold crowns or inlays seen there. 
I was having the feeling that in the country of "cosmetic" and "esthetic" dentistry I will 
see only "american white" ceramic all over. I saw on most of the patients of  one's of 
Terry's best referrals, really piece of art  prosthetic work with gold...beautiful margins 
and contours, ideal occlusal contacts, less invasive tooth preps (the patients were in the 
endo office for other teeth but I was also admiring those jewels ).

- I understand also the need for more pre-op angles of radiographs, and what I really 
learned was the assesment of fine details of the coronal restoration on the X-Ray. And the 
digital radiography makes everything so easy because it's so many times less dangerous for 
patient and also allows you to quickly re-take a radiograph. You can see the radiograph on 
the entire monitor of the computer and analyse it . You can also use the software to make 
adjustments. And what I really liked was the setting up of the Schick sensor of the digital
radiology so that you can measure the aproximative size of the lesions. TDO also has 
in the Diagnosis page a place where you can insert the lesion size, and you can make 
statistics regarding success rate depending the lesion's size or other criterias 
(it is the so called, right click query).

- The microscope is also a great tool for diagnosis. You really can reach with its 
powerful light source  and magnification areas where with the eye (or eye + loupes) and 
an explorer could not see&feel  what is happening. You can easliy inspect the 
obturations/crowns/inlays margins, possible lines of fractures/cracks. Even starting 
from this moment, the diagnosis, you can easily understand the need of a scope in 
endodontics....unfortunately here I have to say that this is a part where with all 
the knowledge and good will and ethics in the world you are just powerless if you 
don't have the money to buy a microscope...I am sad to say but I think that  the 
microscope for endo will still be a luxury for most of the dentists dedicated to endo, 
in "non-rich" countries. ALlthough I was so deeply impressed to find out that in Poland 
there are already many microscope users and we have all seen the beautiful pictures 
Maciej has sent us. Well done polish guys, I admire you so much !!!!

-of great improtance : how's the patient mouth opening ! If it's limited you might 
consider prescribing a premed with a miorelaxant .

- After establishing the right diagnosis ofcourse you need to do a treatment plan 
and discuss it with the  patient. I was so happy to see how the patients were really 
interested in what is going on with their teeth and what an endo procedure means. 
I didn't saw patients asking for 100 % SUCCESS RATE, FAST TREATMENT and CHEAP FEES 
as most of our patients here in my country are demanding...It's really weird for me 
to see dentists claiming they have almost 100 % success rate and also patients asking 
really angry to deliver them 100 % success and guarantee of a BIOLOGICAL , MEDICAL WORK 
I remembered a phrase in Schillingburg's Fixed Prosthodontic book, where he writes that 
when you buy a TV, you place it in the room and just use the remote to open it, and you 
still can get only 1-3 years guarantee....you place a crown in a mouth, where the 
patients eats every day , lot of different  foods (some really hard), there is a huge 
amount of bacteria in the oral cavity, the saliva and the oral fluids are always in 
conatct with your crown,  some of the patients have high muscle forces that stress the 
crown, and yet, the patients are demanding LIFE TIME GUARANTEE of your corwn :-))))) .
Anyway, I understood how important is to sincerely talk with the patient about the 
treatment plan, to explain them the alternatives, to advise them that an endo treatment 
is not something "sweet&easy&quick".

- And yes, finally what I really liked big time was that the doctor is not involved in 
talking money "numbers" with patients. The assistant is coming with a printed page of 
the fees for the proposed endo treatment....The doctor only has to give the patient all 
the info about the MEDICAL issues....I am really ashamed and in a bad position when 
I have to tell myself the fee for a RCT to my patients, allthough we don't have the 
American fees....I know now that for SURE my assistant will have to do this part....

The conclusion is that, despite the lack of microscope, THERE IS NO ECONOMIC EXCUSE 
NOT TO MAKE A THOROUGH AND CORRECT DIAGNOSIS

 Part III Cleaning & Shaping

-I found interesting the anesthesia techniques. I knew and used sometimes anesthetic 
on necrotic teeth, but  I saw there all the teeth beeing anesthetised, regardless if 
they were vital or not. This is a great tool to gain patient's confidence, because you 
avoid any disconfort during the treatment. And you can easily clamp the difficult teeth 
(for those who use the rubber dam, which are the most of us), without any pain for the 
patient if you touch their gums a little more. And ofcourse more injections for vital 
teeth, not only one. It is interesting to see the differences in patients's behaviours, 
because I met a lot of patients in my country with previous bad dental experience because 
of poor ansthesia but they are still asking us not to anesthetise them (many of them 
believe they are "allergic" or  "Cardiacs" ). In California the patientswere receiving 
anesthesia without asking why do you inject the third carpule now ??? And I thought
the californians are wimpy, but it appears that not in this case.

-I should say again the need for proper premed if the patient has a limited opening of 
the mouth (we should assess how wide are they opening when we make the diagnosis). 
So we should consider the use of miorelaxants.

- I learned how easy is to place the rubber dam "all in one": clamp-rubber dam sheet-frame. 
Again I saw some very well organised things : the assistant is inspecting the patient chart 
when she sets the room and she knows what clamp to place depending on the tooth and if the 
tooth has a temporary crown or not. And I learned how  easy is to clamp bicuspids also with 
butterfly clamps, and even molars that needed the temp crown to be removed. For sealing the 
rubber dam Terry uses Dycal, which sets quite fast and it's a good hard barrier !

-a great tool is the mouth prop. I don't know how many worldwide are using those but they 
are just simply great…it helps the patient to relax and it offers you the safety feeling that 
the patient won't bite downwhen you're with a rotary file in a canal. If someone doesn't know 
what a mouth  prop is I can post him a picture. Wonderful ! There are different kinds, metallic 
ones , or some made of rubber, which are little.

-I remember I read in an endo book that in endodontics a proper access cavity means  
destiny :- ) from time to time I see very little access cavities and beautifully looking 
X-rays, but seeing  through the scope I understood the need for a proper access cavity, so 
that you can easily have straight line access, and to be able to localize and negociate all 
the root canal entrances. The use of composite finishing burs allows you to smoothen the pulp 
chamber walls and floor and to clearely see all the marks of possible canal entrances. I guess 
in this stage, when you use a scope, you do need a chair with rests for your arms, because 
when you use the highspeed to make the access cavity and you do not have a resting point for 
your arm it is difficult to smooth so nice the walls ( I cannot see all the detalis of my 
access cavities here  without a scope, but working on some extracted teeth under scope 
I realised the importance of that rest for your arm you are working with). And as you all 
have seen here on ROOTS, go mesially on upper molars to find the MB2 or MB3 and on the lower 
ones through the isthmus between MB and ML and maybe you're lucky to find the ML ! I really 
think it's hard to find those "extra" canals with a little access cavity. And regarding 
finding the MB2, I think in 3 months there were only  2 or 3 upper molars without MB2. 
I have been taught that the high percentage of MB2 is common for the american population, 
not for the one  from Europe (and in particular the romanian one)..but I think the lack of 
proper access cavities, the lack of scope and the lack of the knowledge to really "feel" 
where to find those lead to that misconception about low incidence of MB2s in my population. 
There was a really interesting difference between the californian patients and the romanians, 
and I am talking about the presence of mandibular tori ! Terry and I used to laugh often about 
this, because it was funny for me to see the vast majority of patients presenting mandibular 
tori, some very proeminent. We do have here palatal tori , butthe mandibular ones are really 
the exception !

-Huge surprise : seeing Terry developing sooo nice apical shapes with the kerr handfiles !!! 
Never  thought about this. And something extremely important I learned with Terry was the 
continuous pre-bending of the files during the treatment. They are prebent before the 
treatment, but everytime he uses a file, after he takes it out of the canal his assistant is 
checking it (throw it away if necessary) and pre bents it again. It was hard for me at 
beginning to keep up with Terry's rapid movements, because I didn't had the skills to quickly 
check the file and prebent it, and I appreciate so much he didn't get mad at me and was 
calm :- ) Also the use of Gates Glidden, helping for initial radicular access very important, 
taking them passively until meeting resistance. I was using GG at much lower speeds compared 
to what I saw in USA, and I understood why I was more inefficient at using them (I was afraid 
of breaking them, or making strip perfs). It was nice to find out that actually the assistant 
can pass the GG right in the handpiece, the same with the rotary..you just point the handpiece 
to the assistant and she with the GG/rotary file in the cotton pliers is inserting it into 
the handpiece.

-After one and a half month I asked Terry : You really aren't filling at least one canal 
atleast 0.5 mm short ??? : - ))) . I was seeing case after case how he negociates the 
curvatures and the blockages and managing to obtain apical patency….I waited to see a case 
filled short but it didn't appeared….The same the rest of the time. Wonderful ! And I 
understood the big help of a radiology in the operatory, and if it is a digital radiology 
that's makes your life easier !!! It is also something really nice that most of the referrals 
doesn't start the endo by themslves blocking and ledging the case. I really have to say that 
this is still a BIG mistery to me : what determines the GPs in USA to reffer the molars to the
endodontist before accessing them ? If I could find out that secret maybe I could manage to 
convince some of my future referrals not to do this thing on their patients.

-I think that all of us know the importance of irrigation , and the use of different irrigants. 
ROOTS has  offered us in the last years many useful presentations and articles to convince us 
incorporating NaOCl,  EDTA, CHX and recently sterilox in our irrigation protocol. I had the 
eeling that using sterilox on irrigation, helped a lot in what concerns the tissue dissolving, 
so this irrigant might be a good future choice !

-on retreats chlorophorm is a great guttapercha dissolvant. For dentists from countries like
mine we  still have to fight a lot of the formaldehyde paste fills, which are not so easy 
dissolved. Anyway for the  removal of the coronal part of the guttapercha the use of  
GG is a great tool !

-surprinsingly for me , the posts came out pretty easy. Indeed most of them were prefabricated 
not cast  ones. I also saw the first time in my life silver points. Terry removed some during 
my stay there, and it  was funny that allthough they were corroded in the apical part the teeth 
didn't had apical pathosis.

- Really nice to see under scope the "irrigation game" to find out if two canals communicate – 
I am  talking about placing NaOCl in MB 1 and seeing it coming out from MB2 , or placing an
 microsuction tip in  the MB2 and seeing how the NaOcl from MB is dissapearing :- ) This is 
 really awesome !! And yes it was of  great help to use those microsuction tips, I guess they 
 were from ULTARDENT, some  very narrow and long  purple tips that allows you to aspirate 
 from the root canal..and for cases with really big acute apical abscesses like we have to 
 deal in our countries those should help us big time !

- Quite frequent I've seen resorbtion cases. I don't intend to write too much about those but 
I remember a young nice lady who had resorbtion on both maxilarry molars, and the pictures of 
the pulp chamber were showing very nice the pattern of the resorbtion and the invading tissue. 
Anyway it is advisable to carefully inspect the pre-op Xray and also the aspect of the pulp 
chamber walls when you do access the tooth and properly diagnose if there is evidence of 
resorption.

- the use of rotaries was not the "MAIN" aspect of the cleaning&shaping part. Nevertheless 
during 3 months I really haven't seen any rotary breakage, please believe me. So it is really 
also about how you use them, when to use them (on some difficult cases Terry didn't use at 
all rotaries)…I liked at Terry that he was very organised and he tried to follow his protocol 
no matter the tooth was a difficult one and he had towork harder. The protocol was very well 
established and was followed by him and his assistant…

-Again I have to stress the joy I felt seeing 4 hands endodontics, with the assistant doing 
a lot of things. Knowing how to prebent files, when to pass the irrigants, how to accurately 
place the endo suction near theaccess cavity, how to place the stoppers depending on the WL 
of the canal (the tip of the pear shaped stopper should point where the bend of the file is) 
and also actively registering some important info in the TDO. I know there have been some 
discussion about USING or NOT USING an assistant scope. What I can say after seeing Terry's 
& his assistants' work, after assisting with him, after seeing other great endodontists 
working (Doug Rakich, Nishan Odabashian and ofcourse Gary Carr) : because Terry delegates 
and asks so many  tasks to his assistants they really cannot work with an assistant scope ! 
For others maybe this is a way of  doing things and it really works great without doubt. 
But we as individuals are different and we cannot have universal laws applied to all of us. 
It's almost impossible to quickly check the files, prebent them, place the stopper as it 
should be, enter the data in TDO, grabbing irrigation syringe & the endo suction and still
be with your eyes in the  assistant scope. I felt the need of an assistant scope when I 
needed to place the endo suction on a lower molar on the right side (dentist's side) 
because it was so difficult to see where to properly place it, but Terry helped me and
placed it on the right position (or the assistant can look in those moments on the monitor 
from the operatory, because she can see there what she is doing). Nevertheless , because 
I don't think I could ever find and train an assistant like Terry's , and because of 
education purposes (other dentist can assist and look through the assistant scope) I really 
think that a scope with an assistant scope is more "my type".

I hope I wrote the main parts….the sad thing is no words can replace what you cannot 
see those  endodontists working is just fabulous, it's hard for me to describe, and also 
english is not my native langauge…..

The main thing about cleaning and shaping is that we can achieve good results with not 
so expansive tools (for e.g. beautiful apical shapes)…it still remains the problem of 
accurately identify all the root canals (which is greatly influenced by the use of the 
scope)…and to make a great and organised team with our assistants (if we have them)
K 3 lightspeed

Crown replacement

Root reinforcement

Vertical root fracture

Periodontal pocket

Cox crapification

Cold sensitivity

Buccal sinus

Nikon 995

Distal canals

Second mesial canal

Narrow escape

Membrane

Severe curvatures

Unusual resorption

Huge pulpstone

Molar access

Perforation repair

Maxillary molars

Protaper shaping

Pulsing pain

Apical periodontitis

Mesial middle

Isthmus protocol

Fragment beyond apex

Apical trifurcation

Jammed K file

Mesial canals

Irreversible pulpitis

Bicuspid abscess

Sideways molar

Red Dye allergy

Small mirrors

Calcified molar

Extraction and implants

Calcificated central

Internal resorption

Bone lucency

Porcelain inlay

Bone allograft