Endo experience in USA
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From: Roberto Cristescu
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
- 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,
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
-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
- 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)