Root Canal Treatment Efficiency with Aide Shawn Stampfli
Hi. I’m David Landwehr and I’m extremely happy to introduce my assistant Shawn Stampfli, as a specialist in her own right – an expert at assisting with endodontic procedures. You’ll find a lot of great tips in this piece as you’re seeking to increase your proficiency with Root Canal Treatment. I think I speak for all endodontists when I say I applaud you and your staff for committing to save more teeth for your patients. We all have the goal of giving our patients the very best treatment plans and outcomes they can possibly get.
And if a tooth is saved in your chair or mine, believe me I celebrate right along with you. As you grow your endo proficiency, I always think it’s important to remember that specialists are here for you. Whether it’s for education or treating your patients clinically. So my coaching to you, if you’ll allow, is to take all the great tips you can get from this piece and from other endodontic colleagues to guide your decision-making on case selection. Base it not only on your proficiency, but also with your patient and your practice in mind.
There may be cases where you are truly best served by referring to your local specialist. While treating certain endodontic cases may be beneficial to your practice, many referring dentists tell me the referral option can be a practice builder as well. I hope you will appreciate the insights Shawn is about to share with you and thanks for watching. Hi, I’m Shawn Stampfli and I’ve been an assistant at Capital Endodontics for 18 years. Like others, I began as a general assistant and migrated to the specialty of endo with the desire to really perfect a procedure that allowed me to help patients get out of pain.
There are a lot of commonalities amongst all of us assistants in our roles for our clinicians as well as our patients. I want to reinforce some of those and then show you some particulars about assisting in endodontic procedures that hopefully will benefit you in your root canal therapy proficiency. I’ll go through some patient interactions, and certainly a review of our instruments and typical setups, some key standards of care, and some tips in a procedure that help the clinician be as efficient as possible.
Our demeanor and communication with patients when they first arrive and when they come back to the operatory can really make a difference. Like you, our first impression with a patient is to be reassuring, demonstrate our experience as much as the clinicians’.
Make sure they feel that they are with a finely tuned team – shifting their worry or actual pain to confidence with what we can do for them. In our case, a referred patient shows up typically hearing that they’re being referred because ‘this is a tough one’ and we need to counter that with reality but also reassurance that we’re going to choose the best plan with them. In our office and with my experience, I actually have some of the first case history and current state discussions with a patient.
In your practices, perhaps you do some of that as well. Or, I know many clinicians prefer to personally handle that much detail, which coming from the clinician, is sometimes really well-received by the patient.
With my endodontists, I do a fair amount of the pre-diagnostic testing with patients – just the key measurables to provide to the doctor who will interpret all the information toward the eventual treatment plan. Thermal and percussion testing and certainly any more x-rays that are needed as we almost always like to do our own, even when we are sent the referral images.
Just because we have certain preferences about what we really need to see when dealing with roots. Things like making sure the whole tooth and the root system is visible and getting three different angles straight on, mesial, and distal. Seeing the bone clearly helps us see any periapical radiolucencies so we can better evaluate success at recalls.
I’ll go into more detail about these tests a little later. We find the more that I can prep, the more efficient it makes the patient’s time in the chair, which isn’t a bad thing for our office efficiency either. As I finish my part of the diagnostics, they are automatically sent to my clinician who can now call together all the referral data, history, and test information so he can arrive to this patient with key thoughts in mind and also with the next level of questions and tests to go through to confirm diagnosis and treatment plan.
Like any of your procedures, communication with the patient about what’s going on in terms that they can understand can be really key for treatment plan acceptance, as well as putting them at greater ease for whatever treatment is suggested. Hopefully you see that the greetings by both myself and the clinician are purposeful and reassuring, while we do tests and gather information to lead us toward treatment plan options to present to the patient.
Now here’s a few of the specific tests that we do and the manner in which I do them to illustrate this. Here’s the tools I use for testing. The mirror, the locking pliers, and the explorer allow me to do thermal and percussion testing, which gives great information to the doctor while saving our team some time as I gather it.
A really nice tip during any tests is to coach the patient to hold up their hand when sensitivity happens. This makes it easy to withdraw and discuss sensitivity while it’s fresh on their mind.
Percussion: usually I do one tooth on each side of the tooth in question. Sometimes we’ll go to the upper quadrant if it’s a non-localized area. Percussion can take a lot of forms, depending on the patient in the case. If they’re in a lot of pain, I’m not going to tap. I may just apply some finger pressure.
If I’m not getting any response from this, I’ll move up to some tapping. If there’s a positive response to percussion, it most likely indicates inflammation in the bone around the tooth.
It also could indicate a crack within the tooth. Now, moving to thermal testing. I’m going to put cold on a few teeth surrounding this tooth.
If anything is sharp or uncomfortable, I want the patient to let me know. We do this with Endo-Ice® and a cotton pellet in a plier and just touch it to the suspected tooth and nearby teeth. Like the percussion test, depending on responses, I will tell the patient what’s normal and I’ll also be sure to ask how long the sensitivity lasted. This is a key indicator. A very healthy response is that they feel the cold, it goes right away.
That’s a healthy tooth with healthy pulp. Anything more sharp or lingering from the cold lets us know that there’s inflammation inside the tooth. If they don’t feel it at all, it lets us know the bacteria had already made its way in and it’s a necrotic pulp, so you won’t feel the cold at all at that point. And that’s typically when you have the percussion sensitivity or the dull achiness with your tooth.
The cold test is probably the best to let us know when a Root Canal Treatment may be needed.
If it’s a very sharp response with a cold that lets us know that the pulp tissue is inflamed and it’s not going to be able to recover on its own. Tapping is pretty important too, because it lets us know if there is any inflammation in the bone around the tooth. Let’s get into some endo procedural details as an assistant. Once treatment is decided and agreed for root canal therapy, the first step is getting the patient numb. I have my part in that, and probably like you, the clinician handles the actual injections.
I have a q-tip for the topical anesthetic. While applying this, I’m also making sure there’s no medical history of things like high blood pressure, heart disease. Because the doctor may want to adjust the anesthetic accordingly. One of the biggest standards of care and the next step to prep for the procedure is to prepare the rubber dam or dental dam. The importance of the rubber dam is to keep all bacteria out of the tooth that we’re working in and not allow anything to get in the mouth.
You wouldn’t want patients aspirating anything. That could be dangerous, obviously. It also isolates the tooth for visibility during the procedure and it just keeps everything clean and dry. We’ll go more into this and how to properly prepare the rubber dam a little later, but now I’m going to step back and run through our entire cart and instrument tray and some smart things to have at the ready, including the rubber dam items, well before a procedure starts.
In fact, as we specialize in only endo treatments, we keep our operatories continually prepped in this manner, even before patients arrive, just to be that much more prepared and not to keep patients waiting too long.
The mouth mirror – for the doctor to be able to see the tooth and down into the pulp chamber and canals. The spoon – which is used with the rubber dam to get the rubber around the wings to make a complete seal. The explorer – which is used to help locate the canal spaces. A locking plier – which is used to hold the paper points to dry canals. These are the rinsing solutions: sodium hypochlorite, which rinses out any debris and also disinfects.
And then also some QMix®, which will be done at the end. It takes out the smear layer before we get ready to dry and fill the canals. We have the syringe, which will get either a short or long needle, depending on if you’re working on the upper or lower tooth.
And then the anesthetic, according to doctor preference, matching different strengths of anesthetic with patient and case needs. This is the rubber dam napkin that will go on before the rubber dam is placed on the patient’s face.
We have our pluggers, which are used when we fill the tooth with the gutta-percha to pack down the gutta-percha into the canal spaces. There are several that we use with our warm vertical obturation method. Then we use the plastic instrument or other people call it the ‘beaver tail’ or the ‘glick’.
This is basically to place the temporary filling into the access that we made in the tooth to do the root canal. And the q-tip, to just smooth out the temporary filling.
And then we have our EndoActivator®, which is wrapped in the plastic to ensure extra cleanliness. This is used to mix the irrigant around, to get it into the micro anatomy in the canal spaces. So he uses this when he does the hypochlorite and the QMix at the final rinse. Here’s the under ring that holds all of our hand files and some of our ProTapers®, Gates Gliddens and anything that the dentist may use during the root canal. We pre-load it with the smallest hand files.
Basically, he’s always going to use a 21 millimeter 10 file to access into the canal spaces and then work his way up 10, 15, 20, 25. Usually starting with 21 millimeter and then as he gains length, we work up to twenty five-millimeter. In our procedures, I wear the endo ring because the doctor has already got the mirror and the handpiece.
It’s just easier for him to pluck from the sponge if I’m taking care of the sponge holding the files. This alone demonstrates the importance of the assistant and how root canal therapy is definitely a four-handed procedure.
Looking at our sponge for this particular case, this is the size 10, 21 millimeter hand file and the 15, 21 millimeter hand file, which are typically what we start with. I usually have some backup files ready because the canal spaces to start with are so small. He’ll usually go through a couple of these ten files just to gain access to those canal spaces. Then we have the 25 millimeter 10 and 15 files. And eventually once we get length, he’ll actually use a 31 millimeter to find the length of each canal space.
They are all color coordinated with the size at the top of the hand file.
You’re always going to have the purple tens, white is 15, yellows are 20, 25 red, 30 blue, 35 green, 40 black and so on. Depending on the size of the canal space, you’re usually going to stay within the 10 to 35 sizes, unless you get an anterior that’s pretty large. Know your color code, it’s going to help out a lot just because the dentist will shout out numbers like ‘I need a 10 file’, ‘I need a 15 file’, so just knowing the colors right away helps out tremendously. It makes it a little easier for everybody.
Here’s a quick overview of the ISO color chart and the way files are universally designated, just for your information. ISO is the International Organization for Standardization and they just make sure that different products across the world are similar in certain natures. And in the world of endodontics, the color of the file and the tip size of the file are standardized. So when you see files that are white, yellow, red, blue, green, or black, those are ISO tip sized in order of 15, 20, 25, 30, 35, and 40. The tip size the 15 is 0.
15 of a millimeter, the yellow is 0.2 of a millimeter, the red is 0.25 and so on and so forth. The ISO color chart repeats itself. It goes white, yellow, red, blue, green, black and then repeats itself: white, yellow, red, blue, green, black, and white, yellow, red, blue, green, black again, up until size 140.
There are also three other sizes available.
There are 6, 8, and 10 and these are pink, grey, and purple. And that is how they do ISO standardization for hand files. The #557 bur is typically used to access the tooth, if it’s a tooth that just has a filling in it. If there happens to be a crown on the tooth, like a porcelain surface crown, go in with a diamond burr.
But the #557 burr is going to be the main staple for access into the tooth.
This is an obtura gun for the obturation or filling phase, used to backfill once we’ve got the initial gutta-percha pieces in there. The mixing pad is just what we use to place our sealer which we use with the gutta-percha when filling the canal space at the end of the procedure. The cotton pellets are used to put into the chamber right before the temporary filling is placed. The apex locator is used to find the canal length of each root in the tooth.
So it’s especially helpful in deciding and confirming the size and lengths of files for each treatment. This is Cavit™, our temporary filling material that we use to fill the access of the tooth when we’re finished with the root canal.
These are our paper points in several different sizes and they’re used to dry out the canal spaces. We typically use the medium paper points. We go through quite a few packages of these, typically four to five packages per patient, depending on the tooth.
We’ll use more for a molar tooth certainly. This is the ProTaper® that we use and Vortex Blue™ rotary files. They are also color coordinated 15, 20, 25, 30, 35, according to the size the dentist needs to access the canal spaces. They start small and then they’ll work their way up with the larger sizes as the canal length is acquired.
System B™ is what we use to sear off the gutta-percha in the canal space and then we use the pluggers to pack down the gutta-percha.
It heats up by pushing the coils to the middle. While we have our own system and spaces for accessing all these things, I know when a general dentist’s office implements endodontics into their office Dentsply Sirona Endodontics reps help them organize what they need. They provide a cleaning and shaping organization box. It’s a tackle box really, with labelled stickers on, so they know the names of the products when they have to go reorder. In that cleaning and shaping box, they’ll put hand files, rotary files, orifice openers, irrigation tips, lubricants, anything that would be used during the cleaning and shaping process.
Clearly, you and your clinician will have your own preferences on instrumentation choices, but our office uses Dentsply Sirona systems almost exclusively, as you saw in previous mentions of the ProTaper family as well as Vortex Blue.
Another very popular system in the general dentist offices is the WaveOne Gold® reciprocating files for its simplicity and number of files. Here’s a little more on that system: Some of the reasons people love WaveOne Gold are the fact that it’s very efficient, you only have four files in this system and you’re using the red one, the primary as a single file technique about 80 percent of the time. It’s very easy to keep track of which file you’re using, which files need to be ordered, what files are on the shelves in inventory and the entire system also has matching obturation systems available for it. It’s simple, easy to use and very efficient.
It’s going to save a lot of chair time. Your patients are gonna like that as well. They’re going to be able to get out of the chair quicker but it’s also going to provide excellent results, provide a great shape which leads to great irrigation and a successful long-term result. For the latter stages of the treatment, Dentsply Sirona also provides an obturator box.
There’s Guttacore®, gutta-percha points, sealer, size verifiers, anything that they would need to complete the root canal.
So it gives you a little bit of comfort in knowing where to start when you implement endo into your practice. A majority of endodontists use a warm obturation technique. The challenge with a warm vertical technique for general dentists is that the learning curve is really significant, especially if you’re not doing root canals all day every day. So a solution to providing a warm obturation technique to a general dentist’s office would be a carrier-based obturator. It’s the only way you can get a 3-dimensional fill from the orifice to the apex.
A very popular obturation system in general dentist offices is Guttacore, which is a simple carrier-based obturation method that works well with WaveOne Gold instrumentation as well. Here’s a little more about that system for you to consider: Guttacore is a great option when filling a root canal because the warm flowable gutta-percha on the carrier will move throughout the anatomy and fill all that space inside of there that could potentially harbor bacteria and things like that or keep it from coming back in.
It’s a matching system that goes with our files, you simply use a size verifier to ensure that you’re choosing the right sized obturator. You heat the obturator in the oven and then in a single insertion technique you have about 10 seconds from the oven to the apex. You simply slide the obturator down into the root canal space, wait a second, break off the handle and that’s it.
You can easily make post space in it. They are much simpler to retreat than a plastic carrier should you ever have to retreat it, and it’s a very efficient, effective system that’s had a lot of research done on it and it’s proved to be one of the best filling techniques out there. Now that we’ve reviewed a lot of the instrumentation, I want to go through the details of the important rubber dam preparation and placement.
As I said before, this really is the standard of care for root canal therapy for a lot of good reasons. One importance of the rubber dam is to keep that tooth isolated.
It’s the only tooth in the mouth that you’ll see. You also don’t want any saliva coming into the tooth and you don’t want any irrigants going out of the tooth into the mouth. Finally, it’s very important if you drop a file you don’t want that to get aspirated into the patient’s lungs, so security and safety on both ends. Now for the actual preparation and use of the rubber dam. I’m going to show you how to prep a rubber dam for the teeth in different places in the mouth.
In order to punch for tooth 19 or any lower posterior molar or pre molar tooth, you’re going to go a little bit right of center.
And that’s just so when you place the rubber dam on the patient’s face, you’re not covering up their nose with a rubber dam and frame. So a little bit right of center, it’s possible for the clinician to also cut away some excess once it’s in place. But if we can punch it right, we save some time and possibly add some comfort for the patient while they wait. If you take the clamp wing and put it in the hole on the one side, making sure it’s secure.
While you’re holding up the frame, you’re just going to pull the rubber with your other finger and get that rubber over the end of the other wing.
I always grab from the top to secure it. Go to one corner make sure it’s nice and tight and then you actually pull on the other top end so it’s nice and tight. Then I go to the bottom two corners, same thing. Just pull nice and tight and secure, then secure the middle piece.
The sides you’re going to leave loose, just to give the dentist some room when they actually place a clamp in the mouth – a little wiggle room. And then once it’s on the face, we’ll adjust it if it’s necessary. Now I’m going to do tooth number three, the second one from the back on the upper right side. I’ll use the actual number three molar clamp. This would also be good for tooth number two or tooth number fourteen or fifteen.
And for this you put the clamp upside down so that the wing is facing down.
That way when you place it in the mouth that it’s actually away from the tooth, so access is better. You can see it’s not in your way. I’m going to take the rubberdam punch and go about half way in from the punch and a little bit right of the center also. You don’t want to punch it too high so when you place the rubber dam it’ll go over the patient’s nose.
Sometimes you have to straighten out the clamp if it gets a little crooked as you get it in there.
Now a lower anterior 24, 25 – the front two teeth. So this would be good for all lower anteriors. We would punch just pretty much in the middle left to right, but a little lower than center top to bottom. Using the number 9 clamp for the anterior 24, 25 area, what you’re going to do is put it in sideways and get the hole on the one side in.
Then you’re going to stretch and pull it over until you get the other wing in the hole and it will look like that. Sometimes you’ll have to readjust to make sure it’s straight across. You don’t want it too slanted since you are doing a front lower tooth. And now a top front anterior tooth – so teeth 7 through 10. On these, you’re not going to go too far into the rubber dam, but still center.
So about halfway into your punch or halfway into your rubber dam, And these are going to be the teeth that are closest to the nose so you don’t need to go too far into the rubber dam to get the hole.
You’re going to take your clamp number nine sideways, then put the one wing in the hole. Hold that and then pull. Stretch over the other wing and then just make sure it’s pretty straight across. See the rubber dam napkin for comfort for the patient.
Recall that at this point the patient is numb. The doctor fits the rubber down not only to the tooth, but also checks that it’s not blocking the patient’s nose or anything also. You can see how the rubber dam clearly provides safety for the patient and also how it isolates the tooth and protects the gums and surrounding tissues from the bleach irrigants or anything used during the procedure that is meant only for the tooth being worked on.
In our endodontic office, the doctors use microscopes for visibility – a really great tool for the kind of very small detailed work we are doing. While sometimes assistants may join in viewing through microscopes, typically I stay focused on the larger field of the procedure so I can pay attention to smooth handoffs of instruments and even keep an eye on the patient.
Suction, of course, is a primary function during access as we are removing dentin to access to the pulp. Here you see my prepared sponge for the hand file portion and how I’m the one managing it and providing it as needed.
You’ll also note how I keep the irrigation syringe just as handy. In root canal therapy, since we are filing and removing dentin continuously, irrigation between steps is almost constant. So it’s pretty regular switching of explorer and syringe that I’m responsible for.
One little trick here on the syringe needles which helps with harder to reach teeth. Before the procedure begins, I’ve done some pre-bending of the irrigation needles as well as the paper points which we also use frequently for drying the canal. For the bending of the needles, I just use the cap of the needle. For the paper points using the locking pliers and my own ruler I put a slight bend to them at the measured length we are working. It’s just easier access for the dentist to get into the canal space to dry it.
The doctor can call out for things as needed – to not have to come out of the microscope or focus on the patient. But in our case, I can usually anticipate from experience what’s needed next.
And we have specific placement in the sponge for each necessary file, so the doctor pretty much can grab by feel and I’m just making sure. Because we are working on such small incremental shaping and cleaning, in order to preserve as much tooth structure as possible, you can imagine how important accurate measurements are in planning and preparing what size files will be needed. And also knowing that during shaping, it’s possible that working length may slightly alter as you work in curved canals and potentially affect the original anatomy.
So doctors are frequently remeasuring or checking lengths to match the procedure.
Here’s a really handy tool our doctor uses to accomplish this. On the mirror is actually a ruler so this rechecking can be done quickly and with a single instrument already in his hand at all times. Let’s talk about instrument hand-offs during the rotary phase, again with the emphasis on efficiency in helping the clinician stay focused on the patient as much as possible. I’m responsible for opening sterilized packages and loading the hand pieces.
In order to be a little quicker as we change files, we keep two hand pieces going so that while the clinician is working with one I’m preparing the next size file.
We keep the system going to the end of the procedure. We found switching out files in one handpiece just isn’t as smooth or fast as with two, where both of us can be constantly working and not waiting on the other. It’s good for us and any chair time saving is usually appreciated by patients also. Remember that necessary rubber dam is keeping their mouth open constantly.
During hand-offs, while I normally can anticipate every next step, occasionally the doctor may have a different need. And for us it’s as simple as him silently refusing to take what I offer, alerting me to switch to something else. These kind of little cues are just a simple way of being smoother. For our obturation, we generally do warm vertical. So this involves a similar continual exchange of different-sized pluggers, compacting the gutta-percha as we fill the completed canals.
And, of course, once the canal obturation is done, we place the cotton pellets and Cavit into the chamber as a temporary filling, until the final restoration can be done later. After every procedure, there’s the autoclaving or sterilization of equipment and resetting the operatory for the next patient. For us, this does not include the files as we are a single-use per patient practice. You know we didn’t go through every single step of the root canal procedure in detail. Most of that knowledge and responsibility clearly resides with the clinician.
It’s our role to serve both patient and clinician in having a smooth experience, striving for immediate pain relief and great long lasting outcomes. I’m glad you’re interested in root canal therapy as another service for patients. And I hope you learned something about how we, as assistants, play a vital role.
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