As printed in the 2018 Newsletter for American Endodontic Society:
“Faster Than You Can Eat A Burger”
by Winnie S. Lee, DDS, FAES
As a second generation Chinese American & general dentist, I feel fortunate and honored to be in private practice for the last seventeen years. I’ve been trained by several notable famous clinicians in various fields of dentistry, among whom are Dr. Carl Misch, Dr. Norman Cranin & Dr. Brian Lesage. But my first mentor is my dad, Dr. Stanley Lee, fellow and of the AES. According to mom, Dad spent hours of frustration on endodontic procedures shortly after graduating dental school in the late 1970s. But his motivation led him to take local continued education seminars on endodontics, which ultimately led him to the AES . The combination of his endodontic diagnostic training and AES techniques gave him and his patients the confidence and assurance that pulpal pain relief was only an hour away. After he incorporated AES methods and techniques in the 1980’s, my mom overheard him reassure a patient’s spouse, “Walk next door to the Carl’s Jr. or Jack in the Box, I’ll be finished with the root canal on your wife by the time you finish your burger.”
Since I’ve been fortunate enough to have fabulous mentors and training along the way, I feel that they helped me a lot. I’d like to pass on some tips to other newer dentists just starting in their career. The most important elements that a newer dentist can incorporate in their treatment planning include the fundamental of restorative, endodontic and periodontal diagnoses.
Newer graduates tend to forget to empathize with the pulp in restorative treatment. Don’t over-etch when restoring a tooth and instead, remember to selectively etch a tooth. Don’t desiccate the tooth after etching the tooth. Read and follow instructions of the total etch system. Just because it doesn’t say “Desensitizer” on the bottle doesn’t mean the tooth will become sensitive after a restoration – there are many ways to prevent sensitivity when medicaments are used appropriately. Further, utilize diagnostic techniques like spraying a #2 cotton pellet with Endo – Ice or an electric pulp tester on several teeth in a quadrant and record your results in the record to help formulate an eventual treatment plan. Don’t use a base or liner unless you see pink while preparing a tooth. Use a desensitizer after preparing a tooth for a crown and don’t desiccate it during preparation or impression taking. Make sure your pulpal depth is sufficient for adequate bulk of restorative material – don’t expect 0.5mm of amalgam or composite restoration to be sufficient for occlusal load in the adult patient. It is always tender to bite with such a shallow restoration. Don’t be afraid to try out different layering techniques and different enamel, dentin and opaque shades to mimic tooth translucencies. Practice on typodont teeth or extracted teeth because practice makes perfect. Don’t be afraid of recommending a crown for the tooth when there is less than an equal amount of dentin supporting any remaining enamel of an unsupported cusp. When restoring teeth, don’t be afraid to re-contour adjacent restorations or enamel with enamelo-plasty due to adjacent or opposing teeth drift or mesial tilting. Always show the patient planned treatment by marking a cast in red ink. The cast should indicate intended areas of re-contouring and discuss the benefit of such treatment, obtain their consent before proceeding. After re-contouring a tooth or restoration, polish and place desensitizer as needed. Make sure all restorations have adjacent marginal ridges at the same height to prevent occlusal interferences and to obtain proper adjacent inter- proximal contacts.
Spending time in the endodontic department during dental school just felt natural to me. From pre-clinic and from my dad, I learned to always prepare the pulp chamber for straight line access for files, for proper access for irrigation medicaments and for visual access for all possible canal entrances. “Don’t open a tiny hole to work out of, whether it’s for endodontics or surgery – it compromises the entire case.” Many graduates groan when an upper molar root canal is needed but if you have adequate cases and visualization of the pulp chamber and canal entrances, you can find and instrument all canals present. Of course, you need adequate magnification, a cooperative patient and some patience. Don’t be afraid to take a few peri-apical radiographs from different angles to visualize the third dimension. Always file to a loose 15 or 20 sized file before using the rotary files, otherwise, you risk rotary file separation. Become proficient in restoring an endodontically treated molar with amalga-plugs and endodontically treated anterior teeth with the cast post and core technique from Schillingsburg’s Fundamentals of Fixed Prosthodontics.
Finally, an endodontically restored tooth doesn’t stand a chance if the fundamentals of the periodontium are not recognized. Respect the biologic width of 1.5-2mm by treatment planning a crown lengthening surgery with osseous re-contouring if needed. The tooth will be healthier with less inflammation and there will be more tooth structure for proper ferrule effect in many cases. Crown lengthening is contradicted if a furcation will be exposed in the process, if it includes the distal of a second or third lower molar due to facial mandibular anatomy, if it sacrifices and undermines supporting bone for adjacent teeth, or in the highly esthetic area. Remember, you want and need at least 3.5mm a axial height for adequate retention and resistance form for crown treatment so keep that in mind when you are performing the crown lengthening surgery.
So that’s it: we all want to come to a point in our dental career when we can look at our patients with confidence and say their pain will be gone and their tooth will be restored faster than their spouse can eat a burger. Then they can have their own!