Kase of the Month - Irrigation is King
In endodontics as with many other things in life there are no shortcuts. Everything that leads to a successful outcome when doing root canal is dependent upon the preceding steps when initiating treatment. Obviously proper diagnosis Is first. To avoid the dentolegal stuff; communication, alternatives, documentation and consent are paramount as well! Cutting to the nitty gritty, when doing root canal if you don't have proper irrigation, the treatment will probably not fall into the success rate of standard endodontics. Debridement is dependent on irrigation, thus If there is not enough irrigation solution in your canal contacting tissue and canal walls the you aren't debriding properly. Whether it's 5.25% sodium hypochlorite, 18% EDTA, or your final irrigation solution of 2% chlorhexidine, all must ultimately get close enough to the apex to do their job. Using 30 gauge needles bent to follow the canal with no wedging and light pressure is key. Delivering solution to the apex is also done with negative pressure irrigation systems where the irrigant is drawn from the pulp chamber to the apex under suction. Most importantly establishing a proper glide path and shape to a patent apex is the key to getting solution to the apical 1/3. Once you start creating your shape and approach a your expected taper the irrigation needle can be placed in a more apical direction. You can't get a 30 gauge needle down a canal that's been instrumented to a 25 with no taper in the proper dimension. That's just math!
Here is a case of an RCT on tooth number 3 that was failing apically and laterally. Knee jerk diagnosis would be a missed MB2. Thus a CBCT scan was taken to verify the cause of failure and sure enough there it was. There were radiolucencies that involved all the root apices thus the decision was made to re-treat the entire case. The old gutta percha fills were removed with gates reamers and solvent. The unfilled MB2 was identified and cleaned. Remember a radiographic confirm to the apex locator isn't a bad idea because the insulating effect of the old gutta percha fill can throw off the electronic reading from the apex locator resulting in over instrumentation. Copious amounts of irrigation solution is important to help disinfect the contaminated canals and open any lateral anatomy that may be present. The case was obturated and lo and behold if you look along the mesial aspect of the palatal root you will see a sealer puff of cement through a lateral canal approximating the mesial bone loss in that area. This emphasizes the fact that proper irrigation is paramount to a successful result.
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Douglas S. Kase