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 teremendously 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 teach her 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 reffered, 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 inetersted 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 patients were 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 down when 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 , but
the 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 continous 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 prebents it again. It was hard for me at begginning 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 at least 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 refferals 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
endodontists before accessing them ? If I could find out that secret maybe I could manage to convince some of my future
refferals 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 feeling 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. Ayway 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 resorbtion.

- 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 to work 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 the access 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…Seeing 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