From: Terry Pannkuk
To: ROOTS
Sent: Friday, March 20, 2009 11:09 AM
Subject: [roots] : Sideways Molar

I was really hoping this one had simple anatomy due to it's miserable lingual tilting. Of course it didn't, it had
5 canals.  it occludes sideways on the buccal cusps . The access cavity prep design in this case was basically
focused on creating a direct line to each system, failure to do so increases the risk of missing canals, strip
perfing, and separating files. If the access cavity prep results in a nonrestorable tooth, you simply explain to
the patient that extaction is a better option and abort endo treatment.  If appropriate endodontic treatment can't
be peformed, then it shouldn't; as a matter of fact, I'd rather keep calcium hydroxide in the canals, place a
filling and let it go until it fails and has to be extracted than charge her for inappropriate endo, follow it up
with an investment in a crown, have the treatment fail and then extract.

There is no excuse for performing inadequate endo and having the patient invest in definitive follow-up restorative
procedures.

Ideal endo first, then ideal-restorative second.  The reverse is backasswards and inappropriate treatment - Terry




The MM is way overprepared, especially for this root form.

It seems you can show some uCT's of their own strip perfs and they still don't learn anything.

Here is a MM on a lower second molar from yesterday, as well as a MB2 in a MB/MB2/MB3 configuration Maxillary molar.
These "isthmus canals" or really Points of Negotiation (PONs) of the root canal system should pretty much never see
anything larger than a 20/V.06

I terminate most of these isthmus canals at a #20 hand file. I posted a protocol on this years ago.  Gawd!- John



No it's not..your wrong as usual. :):):) - Terry

John, how can you say this when Terry was the technician on this case.  No one knows better than the man with
instrument in his hand.  That’s why some of these arguments are so damned funny…sorry Ken but it was appropriate - Guy

Dear John, I am with you on this. I am also quite concerned about those "isthmus" canals as I think the root is very
thin in those places. Can you please re-post that protocol as it sounds very interesting - Thomas

From what I can see the prep in the MM looks more conservative.  The outline at the orifice level is similar to the
other M's, but looking down the canal it appears more conservative (since we have no other info about the prep of
the MM) - Kendel

Of all the MM's I've treated (and there have been many)....there was only one I treated about 5 years ago that drew
blood, and that was because a file snapped in the isthmus and I foolishly thought I could get it out....I did but
I shouldn't have.

The conservative access philosophy is derived from an agenda to sell newer instruments that protect cervical dentin
but inadequately flare the coronal third safely for introduction of rotaries. inadequately allow for complete
visualization of cracks, and inadequately create space for evacuation of intracanal debris and remnant tissue with
copious efficient irrigation.

This philosophy depends upon the acceptance that teeth will fracture if access is extended even if this extension is
only isolated to the areas required around the canal orifices.  In other words....this is complete commercially-dervied
baloney meant to sell new expensive burs and rotary files scaring dentists that they will crack teeth with absolutely
no scientific or experience-derived basis for that fear.

Today's popular endodontic myths are that it's better to-

1  use fewer files (which most likely leads to fewer intracanal file contact points and poor debridement)

2. not have direct line access (which in fact is more likely to shape the inside of a curve lead to a strip perf, or
block you out, especially on MB2's)

3. not use Gates Glidden burs because they are dangerous (basically the idea is to get you to buy more expensive burs
that fulfill myths #1 and 2, Gate's can be dangerous but are not if used passively and with knowledge of anatomy).

I'm going to get creamed for saying this because all the chirping commercial blue birds who have a financial stake or
who are influenced by those having a financial stake in perpetuating these myths are going to be offended by this
counterargument.

The bottom line which I constantly like to teach is to be responsibly conservative in your access, not taking away
dentin that doesn't need to be taken away to fulfill the objectives of idealized endodontic therapy, but in those
specific areas which do not represent significant circumference zones of the cervical root,, extend into the cervical
dentin as you need to via a "SEE" access or (strategically extended endodontic) access -  Terry

I have tried many fancy gadgets meant to be "orifice openers".   I always go back to the Gates.  I use the short
28 mm version in most cases----I don't need to go any further into the system than the length of the bud, if that.

They fulfill multiple purposes:  increase visibility, take stress off instruments that will travel deeper into the
system, and translocate, or "transport" the canal orifice away from danger areas to minimize the tendency of
subsequent instruments to want to cut on the danger side of the canal.

I've not found any new gadget, NiTi especially, but even some of the new stainless steel versions, that will do what
a cheap old Gates will do.

After a few years of using Gates in this way, it is easy to feel when a Gates hasn't yet done it's job.
I believe that the mid root file separations we see are due to failure to use a Gates to remove the early coronal
bends that place unbelievable stress on rotaries.

I agree with you that it seems the manufacturer's response to this has been to advocate smaller tapers,
smaller preps, and the obturation "solutions" for these preps - Kendel

You get it.  In a nutshell, if you succumb to all the commercially driven bad advice that's be promulgated for the
sake of leading lemmings to buy dumbed-down "easy endodontics" for the "gp", you will be getting a lesser result.

This is precisely why I've gone out of my way to avoid product endorsements other than matter-of-fact mentioning of
essential instruments and materials I use in a particular case.  There are many brands and products which are
interchangeable.  Usually the most expensive one is the least desireable, but not always.  Never say never. :)

My entire lecture focus is on critical thinking, planning, and generalized strategies for successful attainment of
endodontic treatment goals.

We are living in a very slick marketing world tainted in the same way our financial culture has led us down a poor
ethical path. It is extremely difficult to find a voice you can trust.  I don't expect to be paid a lot for
what I do, but I sure hope to be trusted and viewed to have honor and credibility.  It's a tough road to not have
commercial sponsors writing your lecture script.  I've gotten into deep caca calling these people out.
I'm cooling it a bit on the calling out and just trying to stick with my own written  script.  It's often times
difficult to separate the material/product and the person identified with selling it.
That's where clinical opinion  gets personal and all Hell breaks loose. - Terry

I have tried many fancy gadgets meant to be "orifice openers".   I always go back to the Gates.  I use the short 28 mm
version in most cases----I don't need to go any further into the system than the length of the bud, if that.

They fulfill multiple purposes:  increase visibility, take stress off instruments that will travel deeper into the
system, and translocate, or "transport" the canal orifice away from danger areas to minimize the tendency of subsequent
instruments to want to cut on the danger side of the canal.

I've not found any new gadget, NiTi especially, but even some of the new stainless steel versions, that will do what
a cheap old Gates will do.

After a few years of using Gates in this way, it is easy to feel when a Gates hasn't yet done it's job.  I believe
that the mid root file separations we see are due to failure to use a Gates to remove the early coronal bends that
place unbelievable stress on rotaries.

I agree with you that it seems the manufacturer's response to this has been to advocate smaller tapers, smaller preps,
and the obturation "solutions" for these preps - Kendel

	And when you snap em, you just grab the shank with eyebrow pluckers, put another one in, and go to town.
	4,3,2 and away we go - 	gary

You get it.  In a nutshell, if you succumb to all the commercially driven bad advice that's be promulgated for the sake
of leading lemmings to buy dumbed-down "easy endodontics" for the "gp", you will be getting a lesser result.

This is precisely why I've gone out of my way to avoid product endorsements other than matter-of-fact mentioning of
essential instruments and materials I use in a particular case.  There are many brands and products which are
interchangeable.  Usually the most expensive one is the least desireable, but not always.  Never say never. :)

My entire lecture focus is on critical thinking, planning, and generalized strategies for successful attainment of
endodontic treatment goals.

We are living in a very slick marketing world tainted in the same way our financial culture has led us down a poor
ethical path. It is extremely difficult to find a voice you can trust.  I don't expect to be paid a lot for what I do,
but I sure hope to be trusted and viewed to have honor and credibility.  It's a tough road to not have commercial
sponsors writing your lecture script.  I've gotten into deep caca calling these people out.  I'm cooling it a bit on
the calling out and just trying to stick with my own written  script.  It's often times difficult to separate the
material/product and the person identified with selling it.  That's where clinical opinion gets personal and all
Hell breaks loose - Terry

There is no such thing as endodontics for GPs.  Endodontics is endodontics and when you try to dumb it down quality
suffers.  This never GI system from Brassler makes me nervous because the statement in a throw away says it allows
quality endodontics for all levels of practitioners manure.  Endodontics is endodontics and doing it right is the
same for specialists and non-specialists.

I was at an Ultradent lecture and it was teaching the use of Ultradent’s files and Gyromatic handpiece.  The process
was taught to completions and the lecturer then said, if you want to go to rotary at this point then you can do it
safely without concern of separation.  Where have I heard this before.  Supposedly we were preparing the canals
without altering canal shape but then you can go to rotaries at this point??? Come on.  This is endo for the GPs.
It seems simple but irrigation in this technique is much more important than with convention rotary because you
are only stirring up the pulp tissue removing none.

Teaching Endodontics for the General Practitioner needs to stop.  I took a three long weekend course at the UF taught
by Dr. Vertucci.  He never mentioned endo for GPs.  He was teaching rotary endo with NiTi files.  There can be no
difference between GP endo and specialist endo.  Sure, we use differing systems but the process should be the same.
JMO RD opinion, i.e. Terry is correct - Guy

Kendel, I’ve tried GGs and simply cannot get the feel.  I think it is the technician’s choice.  I still keep falling
back to the SX, which many vehemently hate.  I use it very passively and short but I can carry it into that MM that
Terry has and not worry about ledging or breaking it off.  I’ve sure you can do the same with the GGs as can Terry.
I just don’t like the feel.  But then again, I’m not near you guys skill level so I’d dang well better stay with
what I’m comfortable with - Guy

John, The entire modern endodontic community has either stolen, borrowed, or repackaged those Schilderian principles...
unfortunately scientific/intutive validation of that thievry is grossly lacking.  The simple intuitive logic of
clean/shape/pack is pretty much as 3-D obvious as a thinly sliced cone beam voxel. :)

You're access cavity preps may exhibit exquisite skill, but a demonstration of exquisite skill means nothing if
the wad of half digested septic debris is simply tumbling like laundry in a washing machine beneath your poorly
flared, blind peripheral orifice entries. :)

Take that little bite of cervical dentin out, I promise it won't hurt you -  Terry