I’m not new to teaching endodontics at this point. Something I’ve come to realize, after teaching at my local dental residency and training E-School dentists, is that endo access is something a lot of dentists struggle with. And it’s probably one of the most important steps during the root canal process. And worst of all… a lot of dentists don’t even realize they’re struggling with access! So if you’re a dentist, period, this post is for you!
You may think that instrumenting is your hardest step. And no question it can be tricky. But if your access is off, it will make your instrumentation even harder. That’s why it’s important to know the shape that your access should be, and where that access should be, within the occlusal table.
Take it from me, when your endo access is off, it can make finding your canals a struggle. Why? Because you lose all of your landmarks, and it also makes straight-line access more difficult, which leads to mishaps like file separation during your instrumentation.
Can you see how one step will impact the next? It’s like a terrible game of dental dominoes.
I will talk more about access shape and anatomy in another blog, but for today, I want to talk about something that I see dentists do often that needs a little attention. This is a “trick” that you need to approach with caution. I love to teach endodontic tips and tricks, but today I want to warn you about this one.
Stop Doing this Endo Access “Trick.”
Are you one of those people who accesses a tooth and waits for the handpiece to “drop” to give you your cue that you’re in the chamber?
I’ve definitely heard this trick being used and being taught.
But when I teach access to my students, I really don’t like to rely on this method… unless you’re paying super-close attention to your radiographs. You can get yourself (and your patient) in some deep doo doo if that feeling of the “drop” is the only gauge you use to know whether you’ve accessed the tooth chamber.
You know me, I love tooth stories! So let me share with you a few radiographs that help explain what I mean.
This information may also help guide you in your risk assessment! What you learn in this post may help you cherry pick the teeth you may want to treat in your practice, and which ones you’d rather refer out, because they look like they could cause you grief and anxiety. It’s always good to know your limits.
Case #1: A Safe Tooth Story to Start.
Let’s look at this first example. If you look at the chambers of this patient’s teeth, you can see that they are huge. These are some wide open spaces!
I just happen to be doing a root canal on tooth #19 on this patient, but I would think this rule could apply to any one of his molars, since he has very long and open chambers.
In a case like this, you will most definitely feel the “drop,” and I think it’s pretty safe to do so. Just make sure when you are making this assessment, that you are making that judgment from the bitewing radiograph and not the periapical radiograph. The bitewing will be more accurate!
Case #2: A More Calcified Tooth.
Let’s move on to another case.
This patient still has a chamber inside their tooth, but that chamber is a little more calcified than the previous case.
This case still has a good chamber and is by no means calcified, but it’s not as open as Case #1.
You probably could get away with feeling for the “drop” into the chamber, but you are starting to get into a danger zone. It’s just not as simple, straightforward, and safe as Case #1.
This is where I would start depending more on my Endo Explorer than the feel of my bur.
Here’s my strategy. When cases start to get like this, I like to drill a little bit, have a peak to see where I am in the chamber, drill a little bit more, have another peak, etc. I think you get the idea.
For this patient, I was focusing on tooth #14. Do you notice just how much that crown gets in the way of this assessment from the periapical view? The bitewing is such a better image to make this assessment with.
Case #3: Coronal Calcification Everywhere.
Now, let’s crank that calcification way up!
No matter which way you look at tooth #30, it has a lot of coronal calcification. The straight angle shows it, the off-angle shows it, and the bitewing shows it. It’s there with a vengeance, baby!
If you depended on that feeling of “dropping” into the chamber in a tooth like this, you can guarantee that you would be “dropping” into the furcation because a chamber like this, just will not give you that “dropping” sensation.
You’re not going to like that, and your patient isn’t going to like that. Not one little bit.
Every Tooth Is Different, So Approach Access with Care.
Every single tooth is completely unique, and they can have varying degrees of calcification in the chamber. So a one-size-fits-all approach to endo access, such as waiting for that “dropping” sensation, just isn’t always going to work. Sometimes you’re going to do some damage that way, and it can lead to all kinds of problems.
My number one tip for you today is to take a good look at your tooth and how much calcification there is present before you start on the tooth, so you can know what to expect to feel as you begin accessing the canal.
This is why I like strong magnification (seriously, don’t skimp out here! I use 5.0 or higher) for good visualization. It’s my crutch when it comes to access preparation. This is the only way to be consistent with getting good at your access, and making the process efficient.
I also advise that you use your endo explorer to guide you. This will help you find your path into the chamber and then into the canals from there.
Knowledge without action doesn’t mean much, so let’s talk about what you’re going to do from here, now that you know this little access “trick” isn’t all it’s cracked up to be.
How Will You Approach Endo Access from Now On?
If you want to know if you’re on target for the chamber when it comes to access, you’ve got to be able to see clearly and make wise judgements using magnification and radiographs.
And don’t forget, you don’t have to take every single case that wanders into your practice. If you evaluate your radiographs and see that you’re going to be anxious and nervous about a case, then refer it out. I want you to experience joy in your job, not stress!
Case #3, for example, would take some extra time, because I’d want to talk with my patient and set their expectations so they understand this could be a two-visit root canal.
If you’re paying attention to details like this, you can evaluate what’s the best case for you to take on and which you want to refer to a specialist.
Build up that strong referral network, and you can look at the time economics it would require to complete a tricky case yourself versus banging out a couple of crowns a lot faster, instead. Just some food for thought!
So I want you to go from this blog post and think about two things:
- How will you approach access differently now that you know that waiting for your handpiece to “drop” into the chamber can actually cause you to perforate and come outside the tooth?
- What boundaries will you set regarding which types of endodontic cases you’ll take on and which types you won’t, when it comes to access? What will you do instead with that time, when you refer tricky cases out to a specialist?
Let me know your thoughts in the comments.
And most of all… empower yourself! You are your patients’ doctor, so they’re really looking to you for guidance with their oral health.