Chris J. Lampert, DMD Printer Friendly Version

Finding Canals
by Chris J. Lampert, D.M.D.

Finding and treating all of the canals in a tooth is perhaps the most fundamental principle of endodontic treatment, yet it is rarely discussed. This is probably because of the obviousness of the topic, but missed canals usually lead to one outcome: failure.

Knowing that root canals fail for one reason only, the presence of bacteria, missed canals always leave uncleaned and unfilled space in the root canal system. The only question is when will the case fail? When I evaluate a failing case for retreatment, certain trends regarding missed canals are apparent. For example, in lower molars the most common missed canal is the distal-lingual canal. In upper molars, it is the second mesial-buccal canal. For lower incisors, it is the lingual canal. For upper and lower premolars, it is the palatal or lingual canal. Knowing these facts is important for producing a favorable retreatment outcome, and more importantly for preventing the need for retreatment in the first place. The following discussion should help you successfully locate and treat the most challenging canals.

Know the Anatomy

In addition to the above mentioned trends for missed canals, knowing the anatomical variations for root canal anatomy that exist in the different tooth types can’t be understated. Memorizing the percentages at the back of the endo textbook is not that important, but knowing the number and location of the canals is important. For example, if you know that an upper first molar usually has four canals and that the mesial-buccal root usually has two canals, then you should expect to find four canals. As another example, if you access an upper second pre-molar and only find one canal off center towards the buccal, then you should assume that there is a palatal canal. The key here is finding one canal not centered in the root. Knowing the anatomy gives you direction on where to look.

Part of knowing the anatomy involves having proper radiographs projected from multiple angles. It is recommended that three different pre-operative angles (mesial, straight, and distal) be taken on every tooth before endodontic access is initiated. Seeing the anatomical presentation in these three different views will assist in the location of hidden canals and confirm canal curvature. Knowing the anatomy is good, but seeing the anatomy is better.

Access Preparation
A proper access preparation, in both size and location, is another important step in finding the canals. As a general rule, if you are near the CEJ with the access depth, then you should have located the canals. If you have not located the canals by this point, then the access angulation is probably wrong. Creating the proper access outline for the given tooth also assists the clinician in canal location. For example, making a buccal to lingual slot preparation for an upper pre-molar makes it easier to locate the buccal and lingual canals. If a round access preparation is used for an upper pre-molar, the entry angles for the canals are less than desirable and the palatal canal is often missed.

Magnification and Illumination
Clinicians who use high-powered magnification and illumination for endodontic treatment know their benefits, and would not practice without them. The surgical operating microscope has unmatched clarity, illumination, and visual field depth when compared to standard loupes. High-powered loupes with a directed headlamp can also provide the necessary magnification and illumination, but lacks the ability to change magnification powers. Aside from locating canals, the surgical operating microscope opens a new world and also assists the clinician in finding fractures and incipient decay.

Ultrasonic Access Refinement
Piezoelectric ultrasonic units are an important tool for access refinement and canal location, especially in calcified teeth. Ultrasonic cutting tips allow for the controlled removal of dentin deep in the access cavity. Another benefit of ultrasonic access preparation is their thin design, which allows for excellent visualization of the tip during use. Because there is no bulky handpiece head obscuring the access opening, the clinician can see the end of the tip as it removes dentin from the pulpal floor. Piezo ultrasonic tips come in multiple sizes and shapes and many are available with abrasive coatings for increased cutting efficiency.

Cleaning, shaping, irrigation, and obturation are insignificant if you miss a canal.  Treating three out of four canals perfectly will ultimately fail in the long-term.  Combining the benefits of magnification, illumination and ultrasonics, with knowledge of endodontic anatomy, will increase your endodontic success. 

Chris J. Lampert, DMD maintains a fulltime Endodontic practice in Portland, Oregon, and is involved with research, testing, and development of new endodontic products. Dr. Lampert received his DMD from Oregon Health and Sciences University and his Endodontic post-graduate degree from Boston University. 

Dr. Lampert can be reached at drlampert@thedentistsnetwork.net

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Michael Unthank, DDS, Registered Architect, ADMC Printer Friendly Version

Dental Office Design - Plan for Success
Part 2 in a 6 Part Series
by Michael Unthank, DDS, Registered Architect, ADMC and Geri True, ASID, ADMC

Once your design program is established, (see Part 1 of this series), a compilation of all that you intend to include in your office will be created by your dental architect, interior designer, and consulting engineers. This “shopping list” is your thorough and complete set of construction documents; the drawings and specifications that will communicate to your contractor exactly what you wish to have for an office and on which your contractor will base the cost of your project.  Moreover, your agreement with your contractor will require him or her to provide and install all that is shown on the drawings. These drawings become legal contracts. If during construction or at the completion of your project you discover that an item has been omitted, your contractor is bound to furnish and install it, as shown on your drawings and as specified. 

If your drawings are incomplete or inaccurate, your contractor will have to make assumptions as to what it is that you desire. More often than not, these assumptions are incorrect or inappropriate. Any changes that you request after entering into an agreement with your contractor are called “change orders” and can significantly add to the cost of your project. Typically, your lender has appraised your project at its maximum value before the commencement of construction, and is not interested in providing additional funding for these change order items. The expense of these comes, quite simply, out of your pocket. Consequently, your goal should be to obtain a thorough set of construction documents so that change orders will not be necessary.

The days of obtaining a building permit with the proverbial sketch on a paper napkin are well behind us. The myriad of codes and overlapping federal legislation (such as the Americans with Disabilities Act) require a professionally prepared set of construction documents. Generally, state laws require that your construction drawings be prepared by a registered professional architect or engineer, licensed in your state. 

By training, architects are versed in assisting with the development of your design program. It is the role of the architect to glean from you (the client) all the pertinent program data. Your architect will rely on you to “bring him/her up to speed” as to what constitutes your practice life. If your architect is not experienced in dental office planning, you may be paying to be a part of his/her learning curve. It is absolutely in your best interest to request assistance from a design professional with specific and lengthy experience in planning dental and specialty offices. For the best result, enlist the services of someone who has a complete and intimate understanding of what dentists do all day.

Many architects base their fee on a percentage of the cost of construction. This could give rise to the perception that your architect stands to benefit from increasing the cost of the project. This perception (although it may have no basis in reality) runs counter to the team relationship that must exist to achieve a successful project. Contractual relationships which are open-ended with regard to costs are not in your best interest. Regardless of how the agreement is written, once the scope of the project has been established, an amount not to be exceeded should be determined.

This principle applies to your relationship with all the design professionals working on your project. If your interior designer suggests an hourly rate, request that his or her fee be stated as a “not to exceed” amount based on the scope of your project and the services desired. In all fairness, if the scope of your project or the agreed-upon service changes, so should the fee.

Laying the optimal groundwork for your construction or renovation project depends on three key factors:

1.  Effective program development
2.  Guidance through the planning process by the appropriate professionals
3.  Complete project design and documentation

Incorporating these critical elements will help to assure the smoothest possible construction process and maximize the return on your investment in your office.

Dr. Michael Unthank is a registered architect, dentist, and owner of the award winning Unthank Design Group, providing services exclusively to the dental professions since 1980. He has designed over two thousand dental and specialty offices and is an invited lecturer for major international dental meetings. Information regarding his dental office planning seminars is available at www.unthank.com

Dr. Unthank can be reached at mike@unthank.com

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Dr. Ryan Swain Printer Friendly Version

What Do Your Patients Value?
by Ryan Swain DMD

Anytime something is purchased, there is an exchange of value. Whether it’s the purchase of a cup of coffee, a new house or teeth whitening, the person who is paying money in exchange for a product or service is expecting more value coming to them compared to the value of the money that they are giving away. Similarly, the person providing the product or service in the exchange sees the money they are receiving as more valuable to them than the product or service that they are giving away. The transaction goes well, when after the exchange, both parties still feel they received more value than they gave away. Buyer’s remorse occurs when a consumer pays money for something, only to find out after the transaction has taken place that what they received was not as valuable as the money they paid. You know exactly what I’m referring to if you’ve ever bought a car that turned out to be a “lemon” or if you’ve paid for a high priced meal that didn’t taste very good. These things really leave a bad taste in our mouths - no pun intended!

In the effort to grow our practices, I’ve seen many of us lose sight of this concept of value exchange. We all tend to get overwhelmed by the many things we know we should be doing within our practices. As CEOs of our businesses, we have many things to consider, including but not limited to: how to market, what CE courses to take, who to hire, how to train team members, how to budget, what fees to charge, etc. I find that when I start to get overwhelmed by all of these things, it helps if I focus on one core principle - BRING VALUE TO THE PATIENTS! In order to bring value to people, we need to be keenly aware of what is most valuable to them in regards to dentistry. If we approach our decisions with this information, we can find our compass and many decisions become very easy.

Many dental gurus recommend that all dentists should set their fees in the 80-90th percentile for their particular region. I’ve seen many dentists raise their fees based on this advice. The problem occurs when these offices fail to concomitantly raise the value of the dental experience that is provided for their patients. Practices that are struggling are inevitably bringing low value to their patients relative to the fees that they are charging. This is a recipe for failure and frustration. Imagine what would happen if restaurants raised their fees to be in the 80-90th percentile but didn’t change the quality of their food or service. There would soon be a lot of buildings available for rent! So, how can dentists truly bring value to their patients? How can dental offices provide a service and an experience that is seen as highly valuable for thousands of patients?

I’ve learned that we can provide optimal value to the people in our communities by focusing on the main things that people want from their dental experience. It’s not complicated. Most people want to have their teeth evaluated, maintained and repaired in an environment in which there is a lot of trust and minimal discomfort. A valuable dental experience is one that involves minimal anxiety, and anxiety occurs when patients feel uneasy. Uneasiness can come in the form of physical discomfort (a painful injection) or mental discomfort (an unclear treatment recommendation). Whenever a patient experiences any type of uneasiness, the value of the overall dental experience drops. If you are finding that you’re not as successful as you’d like to be, I encourage you to focus diligently on this concept and make changes that are needed to eliminate uneasiness.

We can eliminate uneasiness and bring value to our patients by doing some or all of the following:

• Ensure that whomever is presenting treatment is logical, clearly spoken and elicits trust
• Go to great lengths to make sure that your injections are painless
• Make patients feel like family
• Ensure regular and convenient communication with patients regarding their upcoming appointments (Smile Reminder® is a fantastic service for communicating with patients)

My overarching point here is simple - NEVER LOSE SIGHT OF THE PATIENT EXPERIENCE IN YOUR OFFICE. Ultimately, patients are not just purchasing a crown, a root canal or a cleaning. Patients are actually looking to exchange money for trust, comfort and peace of mind as they seek to keep their mouths healthy and looking good. A painless, comfortable and trust building dental experience is extremely valuable. Dental practices that provide these things on an ongoing basis are the practices that are destined for success. Those that don’t bring necessary value to patients will struggle. The good news is that if we keep things simple and genuinely focus on the patient experience, a mutually beneficial value exchange tends to work itself out and everyone wins.

Dr. Ryan Swain is a graduate of the University of Florida College of Dentistry. He practices in Rochester, NY and focuses on Short Term Ortho and other conservative cosmetic dental procedures. He is president and chief clinical instructor for Six Month Smiles. Dr. Swain is a pioneer in the field of Short Term Ortho and constantly on the forefront of GP orthodontics. He has trained dentists internationally and prides himself on de-mystifying orthodontics for GPs. 

Dr. Swain can be reached at Drswain@thedentistsnetwork.net

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