From: Terry Pannkuk
To: ROOTS
Sent: Tuesday, September 08, 2009 7:27 AM
Subject: [roots] Shaping versus Cleaning and Shaping

Access ---->  Cleaning/Shaping  -----> Obturation.

One weak link in the sequence leads to a weak result.

I rarely get young patients with caries exposures but this 20 year old male patient was one of the simplest
molars I've treated in a while. You can see how the MB canal orifice courses mesially at an angle before it
traverses the relatively straight middle and apical third of the root.  It was very simple to deal with,
BECAUSE I extended the mesial access out toward the mesial marginal ridge and wasn't afraid to extend out
and over the MB cusp tip.  There was a very subtle mesiolingual groove that was not troughed with jackhammering
ultrasonics. It was simply smoothed out and extended mesiolingually with a very narrow flame tip composite
bur using light touch without removing dentin from the distal wall (only the mesial wall away from the furcation).
This is much safer than ultrasonics which create a very rough pitted prep with much less efficiency and control,
especially if the access is kept dangerously underextended. Failing to extend out the mesial wall and thinking
you can use ultrasonics to remove bulk dentin will greatly increase the odds of strip perforation.

I also made sure irrigant was churned with numerous recapitulations using a series of precurved hand files
(kept constantly precurved by my chairside assistant), minimally using rotaries which provide shaping without
much cleaning.

I suspect that a novice shaping this canal in 5 minutes is wholly ignoring the very important fundamental of
"cleaning" the root canal system.  You rarely see this type of  "RADIOGRAPHIC LOOK" on an "all rotary" case.
Rotary files do not "CLEAN and shape" and soaking without churning irrigant is no substitute for "CLEAN" - Terry



Beautiful.  Joey D, "And  you are right, Rotary files don't clean.  We should probably rename the channels
irrigating canals"

Nice post Terry...as usual. I figure that something like Cleaning after Shaping sounds okay for you? - Gustavo

Well, not exactly, "Cleaning after Shaping' misses the point that shaping facilitates cleaning if performed
properly and should be performed concurrently - Terry

Just call it debridement and disinfection  ;-) - Fred

There is no debridement or disinfection without a developed shape providing convenience form.  You cannot have
one without the other, hence "cleaning and shaping" - Terry

There is no debridement or disinfection without a developed shape providing convenience form
Terry, that's only true due to the limitations of the irrigants for cleaning.
Change the irrigants properties, and you MIGHT not have to have convenience form for cleaning.  Of course,
this is just a theoretical arguement.  Nothing exists yet that doesn't have to have conveniece form - Joey D

Correct, "yet" is the important part of the argument.  Judging from the epidemic lack of scientific integrity,
the future is being promoted and marketed duplicitously and too early. :):):) - Terry

LOL.... Take care Terry...there are a lot of people in love with lasers... Gustavo

So is the plasma probe kind of like Superman's x-ray vision? It can see through dentin to find nasty bacteria?

Terry, It is clear for me that Shaping allows Cleaning. Sure...

In fact, in the ‘Cleaning & Shaping’ concept developed by Schilder, the cleaning of the root canal space is
produced simultaneously with its enlargement and shaping. So, Schilder claims ‘Cleaning & Shaping’ as a joined,
synchronized and simultaneous trans-operative procedure in which when the root canal space is shaped it will
be also cleaned. In other words, the 2 procedures are intimately connected, both conceptually as well as
mechanically-temporally. This is an undoubtedly a very interesting concept for a long time, and it represented
a sharpen rupture with the concept involved in the old step-back preparation philosophie.

However, we need to be aware that when Schilder have developed ‘Cleaning & shaping’ concept, it was impossible to
shape a full molar in just few minutes. And this is a crucial problem because, even now, cleaning need to be faced
as function of time....NaOCL needs time to do its job well. If we take into consideration the reliable and fast
enlargement results obtained by currently NiTi systems (TFs, ProTapers and etc..), it can be more significant
speak in terms of ‘Cleaning after shaping’.  Actually, a proper tapered-preparation can be achieved so fast that
it breaks down with the traditional concept proposed by Schilder.

I figure that the very first time in which that kind of concern was addressed was in the superb Castellucci
textbook and after by Zehnder (2006) in his excellent review about irrigation.

In the current background, ‘Cleaning after Shaping’ can bring some advantages and benefits on RCT; we are able to
take the full potential of the some trans-operative disinfection procedures using irrigation in a full scale after
the canal be shaped. Just my 0.2 cents - Gustavo

@Gustavo: I'm in line with you, Gustavo. And on top of that, what about adding some PUI?
Let's call it "shaping for cleaning", we haven't had that one yet ;-)

@Terry: A quite fast preparation doesn't necessarily mean a lack of ethical integrity or a lack of respect for the
nature of disinfection, dissolution and cleanliness. Bringing down your preptime even gives you more time to invest
in disinfection. It's like Marga learned us: it's all about the 3 P's! - Bart

I can live with "Shaping for Cleaning" since it doesn't imply cleaning as a delayed temporal event.  It is quite naive
to think that the popular focus on a fast prep instills any sort of meticulous attention to thorough cleaning.
That's almost as ridiculously disingenuous as the concept of lazy perfectionism. :):):) - Terry

So no you are telling me that all dentists and endodontists are acting unethically nowadays?
That's very sad, Terry. Btw, with a quite fast prep i didn't mean a single instrument or 20s prep.
Actually i meant rotaries (=fast) compared to hand prep (=slow). Although there are fast hand preps and slow
rotary preps :-) Sorry for this misunderstanding.
And indeed, Terry, shaping for cleaning also involves disinfection and debridement during your prep.
So can we conclude that by now, we are on the same line? ;-) - Bart

I think that most dental schools are desultory institutions molding an attitude of acceptance of mediocrity instead
of achievement.  Those who teach that laziness can be construed as perfectionism are in my opinion unethical and
this delusion has led the pop culture of immediate gratification, instant results, commerical promotion, and the
overall degradation of health care which has become a world wide concern.

Let's look at a book that both Ken Serota and I both enjoyed reading, "Outliers: The Story of Success" by
Malcom Gladwell.  In one chapter he writes, "..success follows a predictable course.  It is not the brightest
who succeed....Nor is success simply the sum of the decisions and efforts we make on our own behalf.
It is, rather, a gift.  Outliers are those who have been given opportunities-and have had the strength and
presence of mind to sieze them."   Malcom Gladwell's compelling observations of successful/extraordinary people
show that they work their asses off like the 12 year old KIPP student who gets up at 5:45 am to go to school then
studies until 10pm each night. It's about the 10,000 hours to achieve expertise. It's about the passion to address
details that no one else bothers to see.

Endo education has become a sorry state of affairs focusing on "short-cutting" complicated clinical procedures,
laziness, lack of accountability, covering up problems with excuses, inadequate outcome assessment, and crap science.
In many respects its demise spawned from the lucrative economics and draw that brought entrepreneurs into the
profession instead of healers and objective scientists. Too many profit from distorting reality and selling junk
instead of truly having the born passion to innovate and advance the profession.

I'm not saying "all" about anything.  Not "all" dentists and endodontists are acting unethically.  One should
never say never and never say always, but there is a disturbing trend of disgusting professional ethics and a
culture that rewards mediocrity instead of recognizing and celebrating excellence in health care.  Health care
reform should focus on quality and positive incentives, not increased access to incompetent practitioners who
falsely call themselves professionals - Terry

One should never say never and never say always, but there is a disturbing trend of disgusting professional ethics
and a culture that rewards mediocrity instead of recognizing and celebrating excellence in health care.

Terry, it's more then just healthcare.  Our culture rewards mediocrity in most areas.  Gone is the drive to do the
best you can do.  Now it's about doing the least you can do and get by with it.  Excellence is more and more disliked
by society.  It's all about what "cheats" or corner cutting that can be done and get by with it. Often those traits
are admired.  As you have so well stated.  With health care, reform should focus on quality, ethics and positive
incentives vs access to incompentent care.  I'll argue, as access to care increases, quality goes down because of
the numbers.  The entire healthcare slide down the slippery slope into medicoracy or even less quality started in
the 80's with "pay X per procedure" mentality by Medicare.  Then it became about how many procedures could be done
in a day, driving production without any balance on quality. It became that's "as good as I could do in X time and
that's all I get paid for"  Factor in the federally government requires by law ALL individuals who are "sick" to be
seen in an ER/Hosp, means many, especially illegal immigrants, get medical care free that inturn passes the buck to
those who have insurance and or the ability to pay.  Problem is health care providers must now work 2X as hard to
get paid, since X percent will never be paid for a given procedure.

Obama said "Illigal aliens" won't have the availability of a plan under his option.  I about died laughing, since
they already have access to a plan...the "I don't have to pay" plan....they have to be seen anyway in the hospital
under federal law - Joey D

Lazy perfectionism.  An Oxymoron. You can't be lazy and get perfectionism. Especially in Endo - Joey D

Dear Bart, PUI is performed when shaping is finished. So, no doubt....must be included in "Cleaning after Shaping".
But, your idea  "Shaping for Cleaning" sounds amazing since it fits better! - Gustavo

Dear Gustavo, Actually, to be honest, it is not invented by me :-)
I heared Pierre Machtou using this "formula" already a couple of years ago - Bart

Bart, I hear what you are saying but I worry that the one file/20 second prep prepares and removes so much dentin at
once that it takes just as long to unblock the anatomy occluded. There is a lot of dentine mud mixed in with pulpal
contents/bacteria created by a single pass with say a 25/08 twisted file. They are amazingly efficient and I think
the danger as with any technology is in its misuse.

I think of them as similar to cerec.

In the right hands cerec can produce some exceptionally accurate and aesthetic restorations when the operator takes
the time to design the occlusion, prep correctly under magnification and cement carefully. Along with the benefit of
no impression or second appointment for the patient.

Or a drillem billem fillem can charge the same for a botched 45minute crown on a carious core with a dodgy thermafil
endo. I see some terrible cerec cases in my area, they have been bought by people wanting to cut out the lab bill
and do them as quickly as they can. :-(

The problem will always be a patient may well perceive quick is better for them. No one wants to spend that long in
the dental chair, or would they if they knew how long what they were getting will last?

I see files like Twisted File as refining my shape, not creating it. If someone could say that that 20 second file,
combined with the Dovgan Superduperkillsanddigestseverything Irrigant (soon to be invented i'm sure :-) ) does the
same job then it's great for the patient.

Just my two cents/pence as I have had my head turned to trying to do things too quickly. Thankfully the clinicians
here help to guide us, if we didn't care we wouldn't even be reading these posts - Gareth

Gareth, That was exactly what I was saying: endo is about the three P's and about respecting the nature of disinfection.
And for the record: I don't use twisted files, and i do not perform one file or 20s preps. I cannot imagine a root canal
system that can be efficiently shaped, debrided and disinfected in such a way. But there is a difference between a one
file/20s prep and not using rotaries at all... Bart

The problem is one of ethics and integrity.  The shape is created so fast that those developing it don't bother
to clean afterwards because it isn't demonstrable on a radiograph.  Furthermore, there is no doubt in my mind
that the shaping is done without adequate intermittant irrigation and all the lateral exploration that would
naturally evolve during the traditional cleaning and shaping process with hand files doesn't happen.  Any attempt
at cleaning afterwards is compromised by the clogging and burnishing of crap into the anatomy that was not explored.
Simultaneous cleaning and shaping is necessary so that the operator is intimately made aware of the anatomy so
that it can be properly explored and flushed clean.  There is also a frightening number of separated file incidents
these days that are just being accepted as "part of doing business".

That in my mind is utter BS being promulgated to make novices feel better about a crap result - Terry

Gustavo, Cleaning is a function of time. NaOCl takes X time to disolve tissue.  I'm using a Schielder-esque equation
here.  Now that presumes a couple of other things....that biofilm removal is also about the same time as it is to
dissolve tissue.  Pretty soon more questions, like what about changing the equation, like what happens when you add
energy to NaOCl?  What happens when you change the formula of NaOCl to make it 2-3 X faster on necrotic tissue.
What happens when you change other chemistries?  What becomes the "magic" irrigation formula?  For years, it's
been NaOCl, then an instrument, then more NaOCl, then an instrument, then more NaOCl..... What if we need to add in
other chemistries between NaOCl in order to attack biofilm more predictably?

Schilder's concepts were based on the function of standard NaOCl.  We need a new paradigm that incorporates the
shaping as really irrigation channels that allow us to irrigate as a function of X time.  Thus the reason you
indicate traditional concept like Schilders breaks down.  We already know the 30 minute soak doesnt work, so we
must keep irrigating repeatedly, with volume.

Terry's comment is true for any paradigm, shaping facilitates cleaning if performed properly and should be
performed concurrently.  IT only makes sense - JOey D

Joey, I take this opportuniy to tell that is nice can chat with you again here. Although nonreligious, my thoughts
were with you.

I am in line....We need to invest our time in irrigants...actually in the improvements in the NaOCl solution will
be welcome....This is one of future goals...Lets work on this? - Gustavo

The problem is one of ethics and integrity.  The shape is created so fast that those developing it don't bother to
clean afterwards because it isn't demonstrable on a radiograph. Exactly....Just What Terry said - Joey D

Perfect.....Ethics and integrity is an obivous issue. - Gustavo

Sounds good to me :::)) Joey D, "I appreciate the good thoughts"

any comments on an article that I happened to come across....
http://www.photonics.com/Content/ReadArticle.aspx?ArticleID=39622

How does the plasma get where it needs to go without shaping?
That would be my first question, my second would be,
PLASMA COOL!! It's like a dental light sabre (Touch of humour there btw) - Gareth

Subject: RE: [roots] Shaping versus Cleaning and Shaping

How much time?  How many appointments? How many solutions? How long a soak? How many devices/scopes? How many types
of imaging BW/PA/cbCT is necessary? ($$) How technique/operator sensitive? How far do we push the endo-restorative
agenda? Air abrasion, orifice bonding, buildup? How much stuff do you need?  Do I ( as an Endodontist ) demand
that my referrals submit  to MY demands doing the posts/ cores/buildups/endo restorative castings- just because
I say so? Do I decide when tooth is too cracked?  and do I extract/place the implant right then and there?

And the big question..how much ($) and time  are patients willing to spend to have YOU satisfy YOUR OWN demands
for endodontic excellence ?  ( as opposed to an implant  which (a) claims to have equal success to endo  and
(b)does not decay.)

Where is the tipping point?

You know, its comical that on other forums there is discussion on how the specialty is killing itself slowly by
adopting a Michigan Model mentality.  The fact is that what we do is also a business. If  you get paid the same
for a single 90 minute appointment as the guy who does 3x 2 hour appointments, guess who people are going to see
regardless of how well you clean and shape.if the perceived results ( by the patient) are similar?  The difficult
part is always finding a compromise - not a 15 minute molar but not a 3 appointment/ 6 hour one, either.

Does anyone think that patient’s give a rat’s ass whether that PDL is completely regenerated as long as their tooth
is functional and asymptomatic? Shimon Friedman will again present his findings at the Oct. Boston U. alumni meeting.
He will say science and evidence based treatment shows that NONE of this junk has made a damned bit of difference
in the literature and outcome studies.  Most studies are of limited value, are poorly done,  have outcomes are all
over the place and as soon as we develop one protocol, another device, solution, technique, material.whatever.comes
along and all the previous research is obsolete. We have to do it all over again.

What does it all mean? It means that WHO is treating you .is a lot more important than ANY OTHER FACTOR.
And that is something that science simply cannot measure.

Terry P. is right as usual - Rob Kaufmann

Rob, There may be many reasons why Friedman doesn't show a difference, but one includes length of time of follow up.
They probably do make a difference but our mechansim of measuring isn't sensitive enough.

One other problem is the "science" of endo really hasn't advanced.  With all the known "stuff" we have, we still
deal with the same limitations - Joey D

I had a long conversation on the phone with George Huang on Saturday.  I wished him luck, assured him that I had a
very sincere and deep respect for his contributions as an endodontologist which in my view is an important to the
progression of the specialty as being a teaching clinician, BUT warned him that his very sincere efforts to propel
Schilder's legacy at BU were undoubtedly going to be thwarted by greed, politics, commercialism, lying, laziness,
lack of committment, bureacracy, competing agendas, jealousy, egocentricity, zero sum game playing, intellectual
dishonesty, ignorance, exploitation, dishonor, cowardice, arrogance, manipulation, nepotism, brown-nosing,
indifference, lack of funding, misplaced priorities, micromanaging, powermongering, ivory towerism, lack of
common sense, relativism, lack of passion, lack of common sense, poor perception, blurred vision, false assumptions,
distorted truths, poor communication, lack of support, and evil.

I offered to say anything that could be of additional support and played golf 5 days in a row. correcting a ball
positioning error that had previously misaligned my swing plane creating a duck hook. I  won two local tournaments
winning a grand total of $510, which microscopically helped to mitigate the useless lost productive time I spent
outside of my office thinking I had a chance to make a difference for an institution I really had believed in.

Such is Life. One makes a difference only in the arenas that they have influence and control, but remember,
"nothing ventured, nothing gained".

You cannot quantitate the necessary time to achieve excellence for a model that is different in each instance - Terry

Terry, Are you sure you couldn't have added a few more jingoisms in that one sentance?
It was awefully nice of you to call.  But it's BU loss - Joey D

Terry one makes a difference on his own life and family and that is more than enough.  You don't need to fight to make
a difference, just do your job and let it go.

Keep serving your patients and doing the wonderful job that you do and that is a heck of a difference - Carlos Murgel