Faster, Easier, Better: Endo Tips for GPs, From a GP

You're listening to The Dr. Phil Klein Dental Podcast from Viva Learning.com. Welcome to the show. I'm Dr. Phil Klein. Root canal therapy for many GPs is one of the least favorite procedures to do in the office. It is seen as a tedious, stressful, and very meticulous procedure fraught with technical perils that are difficult to recover from. Today, we'll be exploring how the combination of making good endodontic technology choices along with good diagnostic and technical knowledge, will streamline your endodontic procedures for a successful outcome and increased productivity. Our guest is Dr. Douglas Ness, a general practitioner with over 30 years of clinical experience. He currently heads a multi-specialty group practice in the San Diego, California area, where a substantial portion of the clinic demand is endodontic services. Dr. Ness, it's a pleasure to have you on Dental Talk. Thank you, Phil. It's great to be here. Yeah, so I miss San Diego because I was there for many years. Actually, I practiced in Pennsylvania, but I moved to San Diego for a while, and I really, really loved it until we moved to Austin, which we love also. So hats off to you for being in San Diego. Best weather, certainly, in the United States. Before we get started, I would like to thank Jay Morita for sponsoring this podcast. Jay Morita is a leading supplier in the dental industry with a product portfolio that covers a wide spectrum. of dentistry including 2d 3d imaging laser equipment hand pieces apex locators and consumable dental supplies so thank you jay marita for your support and also uh as a fyi to our audience dr ness our guest today will be presenting a viva learning webinar on september 22nd at 7 p.m eastern time titled easier better faster endo tips for gps from a gp so i encourage everyone who is doing endo in their practice to register for that webinar on vivalearning.com. So getting to our podcast today, with decades of experience doing root canals in your practice, Dr. Ness, I'm sure you've learned what works best and what doesn't. Can you share with us some key factors in the success of your endo treatment, including endodontic equipment that you continue to rely on? Endo has been really a... of my practice since the beginning since i finished my general practice residency i've always enjoyed it always just had a good hand of it and never really you know wanted to refer it out and always enjoyed you know kind of growing and getting better and uh you know i've gone the course from the hand file step back technique all the way through as soon as you know rotary you know maybe 20 years ago or so started to get in north america i was i got involved i mean i I'm always looking for ways, sensible ways that if I can do the same procedure, you know, more efficiently in less time and maintain the same level of safety and outcome, I mean, I'm definitely going to investigate that. And, you know, rotary technique helped. And then especially when we move toward torque sensing hand pieces and. Also prior to that, you know, I was, as soon as I could, you know, I got into Apex location, a digital Apex location really early, probably in the 90s as soon as I heard about them and adopted those. And the research was pretty clear that it was equal to a radiograph. And I've been using that as my go-to instrument throughout the procedure. And now that, you know, a device like Merida that combined the two in the Tri-Auto ZX, to me that was just... the most amazing device when they came to North America in 2018. I mean, that to me is a must-have. Do you do molar root canals as well as the anteriors and bicuspids? Absolutely. For me, and just like any surgeon, any dentist, you build on your foundation and your practice and you keep building on cases. And that's what my talk will be next month, is how to select your cases. But to answer your question, yes, there's not a lot that I... refer out and in fact in our area in our type of practice where we work on you know predominantly medicaid uh care myself and another general dentist dr bastion is a phenomenal general dentist clinician that does a ton of endo uh we we handle san diego county's needs endo needs a large part of it for the uh the medicaid population where the the For the most part, the endodontic specialists don't take on those cases. That's a great thing you're doing, Dr. Ness. I actually practice in Philadelphia as an endodontist. We also saw quite a bit of Medicaid patients, public assistance patients. And without our service, they would not have had root canal. They would have had the teeth extracted. It was actually very satisfying. It was a very satisfying experience to know that because of our office doing root canals on these patients, these teeth were saved. And this was on all age groups. You know, it doesn't matter how old they were, they were going to take the teeth out. And it was just too hard to really accept that. So our practice started doing a lot of that. So thank you very much for your service. We appreciate it, Dr. Ness. Our lower price points, we have to be hyper efficient and our systems have to be, you know, very efficient and very, very safe and predictable. And so the torque sensing, length determining handpiece like the Triado ZX. As one facet, I use a nighttime rotary filing system that I can use as single use. Let's start off with the torque reducing handpiece. So what does that actually do? I know the acronym is OTR technology, and that basically means optimum torque reverse function. You actually set the torque, and when it reaches that threshold, it stops and reverses direction in the file, correct? Correct. If you can elaborate on that, please. Exactly. You know, definitely I'm not the engineer, but the user of the device in a practical sense. Your manufacturers of your files have torque limitations on the packaging. And so you can go into the, you know, it's a little computer on your handpiece. You can go and set and adjust the newtons of torque for your file system, the torque range to where that handpiece, when it... gets to that set point is going to auto reverse 180 degrees and then rotate back and then start its rotation again. And the key is it can sense that binding of the instrument in milliseconds much more than your brain, your tactile sense, and then you can back off on the handpiece much faster than you ever can, which is going to help you drastically limit your chance of file separation. That's a key point. So between you using disposable or one-use NITIs and the OTR technology from Jay Merida, it's almost impossible to fracture an instrument. Well, nothing's impossible, but we've limited it. We've gotten it as close to zero as I think we can. So basically our system, my file systems, I've got, you know, basically it's a generic version of a ProTaper system. and the price points are so low that I treat it like a scalpel blade or I treat it like a burr. So tell us about the actual handpiece. We talked about the OTR technology, but it also connects to an apex locator. That's what the beauty, you know, and Merida was, you know, they're really the, they're kind of the gold standard and came out with the, you know, I think the first apex locator, one of the first, you know, they took the cordless handpiece and integrated an apex loader cater into a lightweight cordless handpiece you know it's just a perfect marriage of instruments that you need and to have those things operating simultaneously i mean you can watch the die as you're approaching the apex while you're filing you're being super accurate you can set not only by your torque limitations you can also set it by where you like to finish your apical stop are you a half millimeter person are you a one millimeter person from the apical frame and you know you can you can set your instrument where you like it and it is going to auto reverse at that point and also gives you an audible beep so you know you're there and you can your cleaning and shaping becomes uh totally integrated with your your length determination do you ascertain the length prior to instrumentation or you just go straight into it um what what i do For most of my cases, I still use a hand file. There's like five, excuse me, there's eight programs on there that are preset. And the first program is apex location only. And so it has the standard, you know, it has the cord coming out the back end of the hand piece with the clip and the ground for the cheek. And so just like any other apex locator, it operates exactly the same. And so you can use the clip on the file and then, you know, find your working length. So I do that in a traditional manner with the instrument. And then once I know my length, now I can go to my rotary file. That system starts with an O2 taper, about a number 10 super NITI file. And so that first file is very similar to the 10 hand file in its diameter. So, you know, I'll start my initial shaping with that. It also has a setting or it runs in reverse. If you like to use a Lentulo spiral or I just use a rotary file in reverse and use it to coat the walls. of the canal when i'm done with the sealer it helps really transport the sealer and give you a nice dense fill because i use a single cone system since i machine it to a fitted cone i generally use a single and most of my canal is a single cone fit with sealer so if people a lot of people that like using a reciprocating file system it does have a program that has a reciprocating feature so you can use those type of cutting systems if you prefer that so it's a very versatile Honestly, to me, it's like a must-have now. How would you rate the reliability overall? I believe it came out in summer of 2018, and we bought one. And a month later, we bought a second one. It's not Root ZX2, right? It's the TriAuto ZX. TriAuto ZX. And so we've had two devices basically for three years. And our practice, to give you some perspective, we do, between Dr. Bastian and myself, we do about a... root canal procedures per month. That's a lot of root canals, yeah. Yeah, and at least 50, 60% of them are molars. So you're asking that before. Yeah, we do tons of molars. And we have had zero, neither one of those hand pieces, knock on wood, has needed any service. They just keep on, I mean, they just keep on chugging. You just need the contra angle. You can detach it. You can autoclave it. You just lube it like your other hand pieces. Surface disinfection, it's very easy to care for. It's battery-powered, so you just keep it in a charging stand. A real nice thing about it, on the handle, on the grip, it has a computer screen, the control screen, where it will have your apex, your digital readout and your millimeters, how close to apex you are. That's separate from the contra-angle head, and there's a 270-degree swivel on it. So you can position the head as you approach your access, you know, with the file oriented properly, and you can rotate the body of the handpiece so your eye can see the screen. Within a molar, you might have two or three different angle approach angles, you know, for each canal, and you may have to pivot that. You can pivot it a few degrees so you can always be reading that. It also has a... The musical audible tone gets a little different as you approach the apex to a solid tone when you hit it. And so you always kind of know where you are, whether you memorize the musicality of it or you want to see the visual on the screen. And I use loops, so I'm always kind of glancing to my hampis back and forth. Huge confidence factor there, having that screen in front of you. Do you still use a rubber stop on the file? I do. I keep it on more. I use it because that's where, you know, my assistant will set the rotary files before we lock them into the handpiece. So I tend to keep, you know, they come pre, you know, they're pre-mounted in the packs or file packs. And so, you know, and I'll call it a working length. My assistant will always, you know, once we get a working length established, then she'll, you know, while I say using the purple, the initial rotary file, she'll go ahead and set the length and all the next in the series so that it's all ready to go. So it's. I think we keep the rubber stoppers at a convenience. But, you know, my files do have, you know, millimeter markings on them. But instead of trying to memorize which, you know, almost like implant drills, trying to memorize which line is which, the rubber stopper for me is just an easier visual. You know, it's just faster for me to keep that stop. And for me, my own nature and out of necessity, you know, I like to be as efficient and timely with my procedures as I can be. What is the Route ZX2 OTR? Have you seen that? Because I've noticed that on Jay Morita's website. The Route ZX2 is their endomotor without the integrated apex locator. So the programs within it are the same. You have the OTR, you have the OGP, which is another thing we hadn't talked about, the optimal glide path program. That's a very cool feature. we all learned in school and of course you've been an analyst you know the the with the k file the watch winding technique you know where you're supposed to go back and forth you're kind of twisting back and forth and progressing down the canal they've been able to duplicate that in a in a program on the hampis so it gives you that kind of watch winding approach and you can use um a company uh mani from japan makes latch and k files And so you can use, and number 10, so you can use your initial exploring, you can do it fully. You can do your endodontics fully automated without hand files with that OGP program. And it'll walk down tight canals, calcifications, and they actually have a demo video. I'll probably put it on my presentation with a handheld, you know, extracted tooth, one of the. Endodontists in Japan demos it, but you watch that thing just walk right down the canal and come out the apex within just seconds. So that's a nice feature that, you know, I am dabbling with it. I'm mostly doing my initial length termination still by hand with K-files. But, you know, I have cases where I see that on the x-ray, you know, where the canal is really patent. I've done a few cases with that, and it does work as advertised. Because I see on their website a Tri Auto ZX2. That's the one that I use. I have two of them, and I could probably use a third one some days. The website is very clear as far as how this thing works and how it's laid out. You can see the screen right on the handle of the handpiece. It's a home run. It was well thought out, and I knew about it. I think it was late to the U.S. It was about a year, almost two years delayed for whatever, maybe FDA approval. I don't know what. But the rest of the world had it. I heard my friends overseas in China and stuff, you know, I'd seen it. Because before I came to San Diego, from 2011 until 2015, I worked in mainland China for a few years. And at the trade show there, I saw it come out. I was like, this thing is pretty neat. So the rotatable LCD display, that's for real. That's not a gimmick. No, that's 270 degrees. So that's what I was talking about. You can rotate it so that that screen is above my thumb, let's say, in my hand. So I can very quickly glance at the screen and just see what's happening. So you have audible noises. It lets you know as you're approaching the apex. your determination. Then, of course, you know, when it reaches the apex, it auto-reverses. So if you're doing your rotary file program where you're doing your cleaning and shaping, and if you just held it there, it's just going to sit and run in reverse. You can program it to stop or you can program it to auto-reverse, and I tend to have it auto-reverse. It's very versatile that you can have a lot of your preferences. You can custom. It has, like I said, eight places. that are already preset, but you can override. You can, if you like a custom setting, you have a couple that you can custom set, you know, and some doctors do. I tend to, all that I tend to set is the torque and the apical distance where I want it. So as far as efficiency and time savings doing root canal, and you sure do a lot of root canals in that. practice of yours in San Diego between you and your... About 25% of our practice volume or revenue. I just did the report the other day and the easiest thing is you just look at percent of revenue. It's about 25% endo right now. You are the person to ask as far as efficiency. So, and again, we're kind of talking, really, we're focusing on the Tri-Auto ZX2, right? What would you say that does as far as efficiency and time for, you know, doing a standard tooth number 30? Okay, so, well, this is not a magic bullet for someone that is not skilled at endo. This is not going to make you, you know, a great clinician. This will make a great condition even better. This is going to make a good one maybe great. You've got to have those basic, you know, foundational principles. You know, if you're already taking an hour and a half, you know, it depends on what you're doing. If you're taking an hour and a half to do endo and you're using rotary files, I might want to look at a lot of things you're doing. But, you know, if you normally schedule an hour to do a molar endo, which is we still do that, but we, my actual time, you know, from the time I pick my handpiece to cut my access to the time I put my temporary filling in, if it's, if it's, if it's not complicated, say it's a younger, you know, a teenager or something that, you know, every canal's patent, a lower 30 probably take me, you know, once the patient's numb. So the rubber dam's on time. I pick up my handpiece till I put that last bit of cabin in there. 25 minutes, probably. So when I practiced endo in Philadelphia, we were doing about 900 root canals a year. In a busy year, maybe we'd get to 1,000. So you and your partner are doing more than that. The actual working time for a molar root canal, a vital case, was around from start to finish, 45 minutes. 15 minutes, we let the patient get numb. 45 minutes, they were out the door after that. And that's really good. So you're a specialist, so you've got more proficiency than most of us. Yeah, most of the time, I mean, the cases that were the most difficult were finding the canals. Once the canals were found and we got in there with a number 10, that was it. Case over. Then it's just, you know, unless there's some ridiculous curves down there, if it was a standard mower, even if the roots were long. And some of those molars can go 28 millimeters. That's a long route. Yes. But they, the case was over. The stress was, there's no stress anymore. Once those canals were found and we got our length, that was just, the rest of it was just going through the motions. It was actually enjoyable. Well, true. That's because you do that. And again, from an end and out perspective, that'll be true because you do, you know, that's how you get efficient. Just in anything, you know, and I learned that from, you know, orthodontists and. manufacturing you know you get more efficient when you do the same thing over time oh sure you don't have an end on a certificate from a postdoc program but you're doing as many root canals as you need to be you know technically as proficient as any endodontist yeah what we don't do and pretty much we take what we don't uh do in our practices i don't do retreats that are And I don't, you know, with posts and cores and all that, you know, probably one out of a hundred cases. I got to, I get stumped with the calcified case and I just, and it's just not worth my time. And I just, you know, it's either going to be extraction or you got to go to the specialist and pay out of pocket. Right. But, you know, I've gotten proficient enough, not just by necessity, my practice, that's what it needs. And so I stepped up, you know, my, when I bought the practice, I had, there was a guy doing mostly endo and he, he left and I, I was already doing some endo. I've always done endo, but I really put it in the hyper gear when I stepped into this practice. Before, I would maybe do 10 molars a month, and now I'm doing, you know, that in two days, you know. This instrumentation that you use using these very advanced devices or hand pieces that Jay Merida offers is really something. It's like become part of your hand. A Tri-Auto ZX2, you pick that up, and that's like, you know, a professional tennis player picking up a tennis racket. It's also your – it is. It's your brain. Well, if that tennis racket was actually computerized, too, because it can react faster than I can. You know, we used to have file separation problems, too, with other motorized systems, especially when they weren't – the earlier ones didn't have the, you know, the torque sensing and reversing and stuff. And so, you know, over the years, and this is – but now this thing, you know, reacts faster than you can. Of course, you know, when you're – removing your instrument you still need to be inspecting these nitai instruments to you know and looking with through loops to see in any especially the 10 especially that first one when it you start to sense any unwinding man get rid of that thing throw it away especially if you get a you know an mb canal that's a curved root and it's it was tight you know you really had to really file that 10 file a lot it's still a lot of binding in that initial hand file And you can stress those nighttime rotary files out to where you might need two of those things. How did you get involved with Jay Merida as a company? Eventually, you started using the Tri-Auto ZX2. How did you start that journey? Over the years, I had a Root ZX as an Apex locator. I knew it was super accurate. It's really the gold standard of Apex locators, in my opinion. And I've had that most of my career. I used other ones over the years, other brands too. But I found out about the device through the literature. And again, when I was overseas in China, I heard this thing was coming. I was thinking, you know, it's one of those, you know, you hit yourself in the head and go, why didn't I think of that? You know, put that, because I technically had been doing it. I'd always hook the Apex locator, you know, for a few years, I had been hooking the Apex locator onto my rotary file handpiece. It wouldn't auto reverse, but it would tell me when I get close to the... the apex and i would i would be able to you know use that rotary handpiece even without my rubber stopper and just know exactly where to stop and to re you know come back in my stroking cleaning and shaping so i've been kind of doing that in a primitive way with two instruments well and then all of a sudden oh marita's put these things together in one device and then a small instead of a a unit like their other devices you know has a has a little console and then it has a corded handpiece now they've come up with to compete with some of these other ones in a cordless handpiece but not only did they give you all the features in their tabletop device in a miniaturized you know cordless device that's handheld but they also put their you know kind of award-winning you know root zx apex locator inside this and i'm like well this is it's the perfect marriage of what you need because at the time i was looking at a new rotary handpiece serona had come out with one that was kind of cool that runs off an ipad runs off and has all the preset programs every file system under the sun already they've already programmed everything you just hit a button and it knows what torque to you know put it at and everything and i go that's cool and it's a nice hand piece and it was very you know it was very smooth and sexy looking and all but I still need a separate device for my apex location because I'm I was by then used to you know hooking my apex locator on the clip onto the file the base of the file and doing it that way and now Merida put it all together I said well that's a no-brainer and then I got the device and I'm like within a month I bought a second one because my associate every time I was looking for my this handpiece my associate had it. And I'm like, we were fighting over it. So very quickly I had to buy two. Yeah. So for our audience, if you want more information about this, you can always go to Jay Merida, their website. And also you can just Google try auto ZX2 TRI and then space auto and then space ZX2. And you can read about it. And yeah, it's fascinating how they've miniaturized. the technology into a handpiece how does it autoclave you did go over briefly before how do we protect all the lcd components well you don't autoclave that so the base the console you're going to just surface wipe with alcohol uh what's in your hand the the um the contra angle head snaps off and that can be surface it can be autoclaved it can be lubed and treated like your other slow speed handpieces it's all plastic but it's heat resistant so Your initial package just comes with one contraangle and the base handle, and then you can buy additional contraangles if you want to change. Well, listen, I think you covered it quite a bit. It's, again, a fantastic service to your community, Dr. Ness, that you're doing root canals on patients that would otherwise probably have a lot of these teeth extracted due to the cost for going to an endodontist that's going to charge them, I don't know, what is it, $1,500 and up? In San Diego, it could be even $2,000. Promolar? No, it's not great. You know, it's probably 1,200 and up. But the fantastic thing is that you have the advancements in handpiece technology, and this OTR is just incredible. I mean, for this. Oh, we can do this level of care for our patients. We're doing a high level of endodine care. I mean, I don't approach a tooth, no matter what insurance or how much I'm making on the case, you know, any differently. With the instrumentation, I do exactly the same. But we get it done in a very timely manner that makes those, You know, Medicaid cases, profitable too, because we can get in and out of the case and do a high level. We know we've got a great end result. On the obturation side, real quick, before we conclude this podcast, you said you use a single cone technique. What's your obturation process? So I use a mated cone, a matched cone. So I use Dentsply Sirona's ProTaper Cones. Got to purchase cones. that are matched to the file shapes of the ProTaver system. And then I've been using the last couple of years, I've been using Septodont's new BioRoot RCS, bioceramic sealer. Yeah, I hear really good things about that. Phenomenal research. Per unit dose, I think it's a little bit, and it's come out to be a little more cost effective than some of the other MTA sealers. And I've used several different ones out there. We've got great tissue response, great healing. It's easy to, mix for my assistant it's a powder liquid so some people don't like that anymore but you know once a while you get a big palatal root or a big distal root on a molar and then you know i have to do a little lateral condensation add some accessory cones but um generally speaking it's a it's a single cone technique uh beautiful um it cleans out of the you know once you've obturated the excess you know you can a little bit of a rinse water rinse you can clean it out of your pulp chamber and you know before you put your pellet in It cleans up really nice. The teeth settle down real quick, you know, and it's got a lot of good research on biocompatibility. So I'm really pleased with it. Yeah, that's from Septodont. Well, listen, Dr. Ness, pleasure. Yeah, it's been a pleasure to talk to you. And we're looking forward to your webinar on September 22nd, 7 p.m. Eastern time. Easier, better, faster. Endo tips for GPs from a GP. So that's going to be an interesting perspective from your standpoint. We look forward to that, and we'll talk to you in the future, hopefully, on more podcasts about how the general practitioner could really master endodontics in an efficient way. We thank you very much for your insight. That'd be great. Thank you, Phil. I'd love to do that. Appreciate it.