Clinical

Non-surgical endodontics
in the new millennium
The author reflects on the changes that have
occurred in endodontics in recent times, concluding
that we are, no doubt, in the mist of a revolution

A
s we head towards the year 2001, step back that I used 10 years ago, today
is endodontics undergoing I’m using the crown down technique. I still
evolutionary or revolutionary do hand filing at the very beginning and
change? I dislike using the word end of my preparation, but most of the
revolution for just any old change. It gets cleaning and shaping is completed using
overused today for the marketing of a rotary instrumentation. I’m not going to
slightly changed product or technique. To miss the ‘old days’ with all stainless steel
me, evolution is the process of instrumentation and my hand cramping at
development and denoting a change in the end of a long 4 canal molar case. Don’t
position. Hence, it get me wrong; stainless steel still has a
should be used for place in endodontics because of nickel
modifications. titanium’s limitations. Let’s review some of
Revolution on the the more important changes I have found
other hand is a in endodontics that have led to the
drastic change. As I revolution.
reflect on the
alterations that have Starting off right
occurred in
endodontics, no Once a canal is found, I check to see if it’s
doubt, we are in the open to an ISO size #25. If it’s not, I use
mist of a #8 to #25 stainless steel K-type files to
revolution. A open the orifice. Don’t try to achieve
couple of years working length, just open the canal orifice
back, the AAE a little so the cervical enlarging
officially did away instruments can follow the canal. I’ve
with the term root always done it that way. Some will argue
Dr Joseph S Dovgan canal therapy. that a non-cutting tip is better for initial
graduated from Because of the canal exploration since you may be less
Creighton University number of changes likely to ledge it. I love K-type for this
with a Bachelor of in treatment and the since they cut through the pulp and not just
Science (physics) and terrible connotation compress it. Sometimes you can create a
DDS, Certificate in
it had, now we call difficult to get through plug of vital pulp
Endodontics and
it non-surgical by using non-cutting tipped instruments for
Master of Science
from the University of endodontic therapy. exploration and orifice enlarging. The non-
Iowa. He is a If you're into cutting tip seems to just push the pulp
Diplomate, American a bbreviations, down the canal sometimes making a clump
Board of Endodontics NSET for short. of pulp that’s hard to get through. After I
with a full time private Some concepts locate all the canals and the orifice is open
practice limited to remain the same, to size #25, I try to ‘seal’ the tooth off
endodontics in like the idea that from the oral cavity by using Cavit (ESPE)
Paradise Valley, cleaning and around the rubber dam clamp! Why wait
Arizona and can be shaping is the most on sealing? Especially with a microscope, I
reached on the
important thing we use the root and crown outline to look for
internet at
do with non- canals. If you conceal them with big globs
jsdovgan@phnx.uswes
t.net surgical endodontic of Cavit during the sealing process, you
therapy. Instead of can’t see them anymore making the

Endodontic Practice May 2000

 Clinical
Figure 1: Moyco Union process of searching much more likely to
Broach series of nickel result in perforation since you lose your
titanium coronal shapers
landmarks. The regular pink Cavit also
stabilises the clamp once it sets. I begin my
rotary instrumentation by using Gates-
Gliddens or nickel titanium coronal
shapers. The nickel titanium coronal
shapers are specifically designed to
enlarge the cervical portion of the canal
system. Moyco Union Broach
manufactures a series as shown in Figure 1
that are available through your dealer in
the following taper / ISO sizes at the tip:
06/25, 06/35, 08/45, and 08/60. They are
18 mm long, about the same length as
Gates-Gliddens. Gates work best at 5000
rpm while 300 rpm or less is ideal for
most coronal shapers. My favorite coronal
shaper size to start with is the 08/60 and
work down to the 06/35. I don’t use the
06/25 much. It takes 3 or 4 of the coronal
shapers to get the job done and seems to
take about the same amount of time as
Gates. I just seem to have less
transportation of the canal. If I’ve got a
great rubber dam seal, I usually use 5%
sodium hypochlorite during this phase that
helps dissolves organic debris. If you think
Endodontic Practice May 2000
your rubber dam seal is compromised, try
using Slide by Moyco. It’s must be
lubricated during preparation while
disinfecting and if it leaks, your patient
won’t be screaming about the taste or
complain about a sore throat the next
day! When do I use the coronal shapers?
Have you ever had a canal that Gates did
not seem to want to go down but files
just fly down to the middle third? If so,
I’ve found coronal shapers to be quite
useful in these canals. Also, if you are too
aggressive with Gates and seemed to
create stripping perforations on a regular
basis, I suggest you try some coronal
shapers. In my hands, the coronal shapers
prepare the cervical third, especially
those that are curved, much easier than
Gates, with fewer calamities. Another use
of the coronal shapers is prepping short
canals. These are canals that are less than
5 mm as measured from canal orifice to
end of canals. Occasionally these are
found as the mesial lingual canal in upper
molars. After using a #25 and perhaps
#35 coronal shaper to length, I’m done.
Keep in mind that nickel titanium coronal
shapers require you to regularly retire
 Clinical
them just like other nickel titanium rotary
instruments. In my surgery #25 / 35 are
used 4 times and #45 / 60 are used 6 to 10
times. Keeping track of the number of
usages can be a problem. Have your
dental assistant put a scratch mark on the
shank after each canal use.
Lubrication: it’s time to
slide!
By now, I’m at least a third of the way
down the canal system sometimes half
way. It’s time to irrigate and lubricate. Ten
years ago, I never thought of lubrication.
It’s probably the reason I had difficulty
doing step back in some highly curved
canals when I did them by hand. With
crown down instrumentation, lubrication
is a must. Rotary nickel titanium
instruments will separate in a few
rotations if they engage dentine and stop
rotating. This condition is more likely to
occur without a lubricant. Just as
important, small patency files are easier
to push through the end, maintaining
curvature and patency! All the rage in
lubrication seems to be EDTA containing
Figure 2: Moyco preparations. In my hands, EDTA only
Mark V Plus
electronic apex
softens the canal walls leading to ledging
locator with electric or transportation of the canal system.
pulp tip option
Endodontic Practice May 2000
Personally, I find flowable, optically
clear, water soluble lubricants the easiest
to work with clinically. Moyco has taken
glycerin and combined it with a form of
hydrogen peroxide making it available as
the product - Slide. Now you can see the
canal orifice. No more guessing or
pecking around trying to find the orifice
and possibly deforming the instrument.
With Slide you can place 1cc or 1.5cc in
a 3cc syringe with a short 23 gauge
needle and place it exactly where you
want it to be. Place it down each canal
and slightly overfill into the chamber. If
the canal is infected or bloody, Slide let’s
you know by bubbling and releasing
oxygen. You can irrigate and replace as
needed.
How long till we get there?
Since some of the curvature has been
reduced, it’s time to get preliminary
working lengths. Years ago, the only
‘reliable’ method was using radiographs
and tactile sensation. It used to take 3 or
4 radiographs at just the correct angle to
be confident about length. I tried the first
generation apex locators but never could
get them to work effectively. They
required calibration and seemed finicky.
Maybe it was because they used a DC
circuit with long wires acting as antennas
picking up lots of noise. Whatever the
cause, they seemed to require the canal
be dry to come close, and even then,
could not be counted on for accuracy. I
gave up and just stuck with what worked
until I tried the 3rd generation of apex
locators. They use multiple AC
frequencies to figure out the location of
the apex. These are highly accurate and
most cases need one or two radiographs
to confirm length. Angled radiographs
also require you to check for additional
canals if done properly. The J. Morita
Root ZX and the recently introduced
Moyco Mark V Plus are a couple of 3rd
generation apex locators. Each uses a
different set of frequencies and a different
mechanism to compare the two
frequencies, but both work well clinically.
While they claim sodium hypochlorite
does not impede their function, I have
found that it’s too unreliable with bleach
 Clinical

in the canal system. Instead, either paper so complex, our instruments and
point the canal system mostly dry or use solutions can’t get to every nook and
some Slide. One of the advantages of cranny. Hence, we can’t sterilise the canal
Slide is that it does not seem to interfere system with today’s technology.
with the newest 3rd generation apex Medicaments like formocresol just cause
locators. Small files such as #10 or #15 periradicular inflammation. Calcium
are the most
accurate for EALs.
Larger files seem
to be a little shorter
then expected so
sometimes you will
need to
compensate. Of
course, if you are
unsure or
something seems
out of wack,
confirm with a
radiograph. You’ll
need to take at
least one anyway
to meet the
standard of care in
my view. I usually
try to wait until I
have enlarged the
canal system so
larger files fit near
the end. Larger
files like size #25
are much easier to
read then a #10 on
a radiograph. The
newest generation
of electronic apex locators are not perfect. Figure 3: Three
Research studies indicate 75% – 96% hydroxide is the only inter-appointment control zone
configurations are
accuracy to within a millimetre or so. The medicament I use. It seems to decrease illustrated. The
Moyco Mark V Plus is available with an inter-appointment flair ups and the letters RL denote
optional electric pulp tester. Compared to literature indicates it has some other radiographic length
and the numbers
having 2 separate units for apex location advantages too. Not only does it disinfect, –1.5 indicate how
and pulp testing, the Mark V Plus can be but also possibly has an effect on the close a given file
purchased much more inexpensively and remaining uninstrumented pulp tissue size comes to the
full radiographic
is shown in Figure 2. If you’re thinking making it easier to remove chemo- canal length. The
about a new apex locator and need a pulp mechanically on the second visit. I prefer numbers 15, 25, 35,
tester, ask your dealer about the option. the powder. Use an amalgam carrier and 45denote the
largest file size
a nickel titanium condenser to pack it in extended to the
What if I can’t get it all (a set I designed works great). For four specified depth.
canals, it takes about one minute. Blow Courtesy Dr James
done in one visit? away the excess with a short burst of air.
Roane

The concept of sterilising the canal
system has been thrown out the window.
While it might have given you a warm
fuzzy feeling thinking that we could
achieve it, the reality is canal systems are
When the patient returns for completion,
irrigate and most of powder will come
out. The rest will mechanically be
removed during the instrumentation
phase. If you retreat, consider making it

Endodontic Practice May 2000

 Clinical
Figure 4: Moyco
endodontic two appointments with placement of
solutions calcium hydroxide into the canal system
once you have completed cleaning and
shaping. There is some evidence that the
retreatment is more likely to succeed.
Even in the new millennium, multi-visit
endodontics still has its place!
Crown Down
Time to continue the voyage to the canal
terminus. The middle third and most of
the apical third is cleaned and shaped
with rotary nickel titanium instruments.
The idea is to use larger size files first
and then progressively smaller
instruments until desired length is
reached. I use Moyco’s Pow-R 04 series
nickel titanium rotary instruments. They
incorporate the patented Roane non-
cutting tip, which is less likely to
transport, ledge, or gouge the canal
walls. Forget about using step back
during this phase, you’ll just separate the
instrument. Even with microscopes,
most separated instruments around
curves can’t be removed, because in my
experience, you’ve got to see it to
remove it! Prevention is the best policy.
That’s why you’ll want to set up a
routine to discard used files. Check
Endodontic Practice May 2000
every file between each canal use for
deformation and unwinding. It’s easy to
spot with the operatory light! During this
phase, your choice of lubricant is very
important. I believe a lubricant should
hold debris in suspension for removal via
irrigation. Moyco’s Slide excels at
holding debris in suspension. Thus, you
can avoid packing dentine mud and
making yourself work at getting to the
terminus again by using a lubricant like
Slide and checking for patency between
every rotary instrument. Don’t forget to
irrigate between every three instruments
and lubricate. The best way to get started
it is to ask your dealer when a course is
going to be offered in your area.
Are you a pulp lover or an
apical barbarian?
I’m not sure who coined the terms pulp
lover or apical barbarian, but they really
sum up some basic philosophical
differences. Pulp lovers like to be short.
They instrument short, they obturate
short, and believe the terminus is sacred,
never to be instrumented through. I used
to be a pulp lover. Unfortunately, I found
myself routinely short in moderately
curved canals after I ledged. While many
 Clinical
were successful, they were mentally
trying when they failed. Now, I’m an
apical barbarian and routinely keep
patency with an #8 or a #10. I found that
I could easily prepare the canal system to
the terminus in most cases by being a
barbarian and going through the end of
root. In retrospect, being short was
actually more difficult to prepare and
took more time, since I had to make sure
that I never went through the end. It’s a
lot easier being a pulp lover if you use a
step back technique. To better manage the
apical third, I believe you’ll find that
being an apical barbarian is the way to
go.
Step back flair
When I used lateral compaction, I used to
check if I had enough flair for the
spreader for obturation. Leakage studies
showed the spreader had to be within 2
mm of the terminus with the master cone
in place for decreased leakage. With
vertical condensation, I believe you must
have the heated plugger tip to within 4
mm of the apex. Hence, no matter which
way you obturate, you still must flair
enough to get the obturation instruments
down into the canal system.
The control zone
What is a control zone? It’s really a fancy
descriptor for a gutta percha cone
catcher! Some typical control zones are
shown Figure 3. In the old days, we spoke
about apical stop or seat. If you’re an
apical barbarian, all your preparations are
now apical seats. It’s easy to create a
control zone by using the Balance Force
Technique, advanced by Dr Roane, to
complete the apical 2 millimetres of the
preparation. I prefer a non-aggressive
instrument and use Moyco’s 02 tapered
Onyx-R. It’s made of nickel titanium and
has a non-cutting tip. It involves using
only rotary motion during placement,
cutting, and removal of debris. After the
instrument is placed to desired length, it
is rotated clockwise about 90 degrees,
engaging the instrument. Then using
counterclockwise rotation 120 degrees or
greater with pressure apically, the apical
Endodontic Practice May 2000
region is enlarged to the full instrument Figure 5: Inject-R Fill
diameter. The debris is loaded into the and Heat-R
flutes and carried away from the apical
foramen creating an apical control zone.
The Onyx-R has a ‘mushy’ feel and is
an acquired sense after a few
procedures. If you must have the tactile
feel of stainless steel, use the Flex-R
file. Be cautious. Overzealous
clockwise rotation can cause unwinding
resulting in separation. The Onyx-R and
Flex-R are specially designed and
manufactured for this technique by
Moyco. I only use one to three hand
instruments to complete my apical
preparation. That’s definitely a change
for the better!
Preparation for obturation
When I was in my endodontic residency
program, preparation for obturation
meant paper-pointing the canal dry!
What a long way we have come. Rotary
instrumentation produces a smear layer.
To remove it, I begin by rinsing with
2.5% sodium hypochlorite. Because I
know most of my preps are now open to
at least a size #15 at the terminus,
extrusion of 5% can result in severe
post op pain, or even worse, a sodium
hypochlorite accident. Two and a half
percent seems to be a happy
intermediate for me. Moyco
manufactures it as Endo-Klean. Now is
the appropriate time for EDTA to
remove the inorganic or calcified
component of the smear layer. Endo-
 Clinical

Dilator (Moyco Union Broach) contains squirting some

15% EDTA and a disinfectant too. Use a ‘cemento-percha’
small needle and syringe it into the canal. into a lateral
I use a fine or medium large gutta percha canal really
point and ‘pump’ for a few seconds in improves the
each canal. Place your largest file to success of the
working lengths in each canal and snap a case. It looks
radiograph to confirm working length. It great on the
will give the EDTA time to work its radiographs and
magic and you’ll meet the standard of I’m sure my
care. To finish removing the organic referring dentists
component of the smear layer, rinse again have been trained
with Endo-Klean and let it sit for a to look for it so
minute or two. Final rinse consists of I’m more than
hydrogen peroxide to inactivate the happy to oblige.
sodium hypochlorite and remove some Once you get the
salt. The canal is now prepared for hang of it
drying. Start with a small blast of air though, vertical
from a properly equipped Stropko to compaction can
remove gross amounts of remaining be quicker than
liquid. Paper point if needed. Syringe in lateral
95% ethanol alcohol available from compaction. If
Moyco as Endo-Dry and again blast a you like the
small amount of air from the Stropko. control of lateral
Paper point to verify that the canal is dry. condensation,
If it’s not dry yet, again syringe in some nickel titanium
Endo-Dry and blast a little air. Always finger spreaders
finish by checking with a paper point. In such as Onyx-
a nutshell its: Endo-Klean, Endo-Dilator, Flex are available
Radiograph, Endo-Klean, hydrogen from Moyco.
peroxide, air, Endo-Dry, air, and paper Literature
points. indicates less
stresses are
induced in the Figure 6a – c: Inject-R technique for
Obturation backfilling canal. Place Inject-R Fill into
root with nickel canal orifice then depress handle to express
Unlike other endodontists, I’m not a titanium spreader gutta percha. Condense edges into central
purest. I love vertical compaction, but penetration mass and now your done! Courtesy Dr James
Roane
one thing my endodontic training taught compared to
me was the literature is pretty one-sided. stainless steel.
Almost all the endodontic success studies This may lead to a decrease in vertical
were completed with lateral compaction. root fractures. In addition, nickel titanium
Antecedal cases aside, there are no spreader penetrates farther into the canal
prospective clinical studies comparing system compared to stainless steel. For
the two long term. Some may argue that those that laterally compact, you may
leakage studies show that vertical leaks want to consider adding a little heat to
less than lateral. The reality is no your method by downpacking with a
obturation mechanism is perfect and all System B and then backfilling once
endodontic therapies leak! Some just leak you’ve laterally condensed the apical
less then others. Clinically, I find that it third. Using this technique you will retain
really does NOT matter if you obturate the advantage of length control but you
with lateral or vertical compaction pick up more of the lateral canals. If
because cleaning and shaping is much vertical compaction is your way, consider
more important. Three-dimensional a set of nickel titanium pluggers for those
filling is easier to complete with vertical cases you can’t get the heat source to
compaction. You have to ask yourself if within 4 mm during the down pack. I

Endodontic Practice May 2000

 Clinical
have designed a set of 04 tapered nickel
titanium condensers. They are
manufactured by Thompson Dental, a
division of Moyco Union Broach. The
Dovgan condensers are specifically
designed to apply sustained pressure while
the warm gutta percha mass is cooling. The
04 taper adds physical strength to the
condenser so it does not deform as much
under pressure, yet retains most of the
flexibility of straight sided condensers. The
nickel titanium allows the condenser to be
worked around curves. This is another
application where nickel titanium has
replaced stainless steel. One condenser has
tip sizes of #35/45 and the other is 60/80.
Handles are color coded to match the tip
size for easy identification. Five millimetre
painted hash marks make depth control
easy. You can condense powdered calcium
hydroxide and MTA too.
Backfilling
Backfilling the canal system has never
been easier. The Inject-R fill system is
simple to use and maintain unlike some
backfilling devices. Inject-R fill system
basically consists of gutta percha in a tube
that’s expressed with a handle as depicted
in Figure 4. Place some sealer in the orifice
with a paper point or needle tube. Heat an
Inject-R fill in the Heat-R device and place
into the orifice of the canal. Depress on the
Inject-R handle to drive the gutta percha
into the canal and compact the edges into
the centre with a condenser and your done
(Figures 6a, 6b, 6c). No equipment to clean
or maintain and best of all it’s reliable.
The immediate future
Has concerns about instrument separation
kept you from moving to rotary endodontic
instrumentation? The electric motor folks
finally got together with some electrical
engineers to create an electrically driven,
torque controlled motor. Do you remember
when you got your first two-wheel bike
and it had training wheels? First you had to
learn your balance and the feel of the bike
before the training wheels were taken off.
Of course, this was to help protect you
from nasty spills during the learning
process. The Sprint TCM (torque control
Endodontic Practice May 2000
motor), from Moyco Union Broach, is a
new breed of motor that adds the comfort
of training wheels to nickel titanium rotary
instrumentation. I learned the old way by
using an uncontrolled air driven
handpiece. After I separated a few
instruments, I finally figured it out. You
don’t have to learn the hard way anymore.
Torque controlled motors have a circuit
that senses the amount of torque applied to
the instrument. When the amount of
torque exceeds the user-selected limit, the
motor stops going in the forward direction
and reverses. If you’ve had problems with
rotary instruments separating during
cleaning and shaping, proper use of
torque-controlled motors can help reduce
the chances of having an ‘event’. Hence,
this new generation of electric motors
even offers us old folks an opportunity of
having fewer separations. Moyco’s TCM
handpiece is autoclavable to boot so you
can sterilise it like your air driven
handpieces.
I think the next important gizmo for
endodontics will be an irrigator. Irrigation
has been mundane for years. Multiple
syringes containing many different
solutions have been the norm. I use
somewhere between 4 – 6 solutions
depending on the case. Soon a product
will emerge that will have 6 solutions at
the touch of a button and selector switch.
Many bartenders use a similar device to
dispense Coke, Sprite, Tonic Water and so
on. It has one nozzle but different buttons
on the nozzle for selecting different drinks.
This system allows for much more fluid to
be dispensed in a shorter time period. It
eliminates the wait for each syringe and
your dental assistant refilling the empty
syringes. In my office, a prototype device
cuts minutes off of each procedure. I’m
excited about the potential for this device.
It’s a revolution
When you look back a few years, there
really have been quite a few changes.
Going from step back to crown down tips
the scale from evolution to revolution! The
last 5 years has seen endodontics flip
upside down literally. I wonder what the
next 5 or 10 years have in store? Will there
be another revolution?