Frequently Asked Questions

Requesting a course

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If you don't find a course listed in our current schedule of upcoming seminars and are interested in a course in your area, please contact us and let us know. We require a minimum number of attendants for any given course. As a result, some research is required about the feasibilty of a course in your neighborhood. But we are looking for new places to share our techniques with the dental community at large and your area might just be the place for us to visit next! Please send us an email at info@RealWorldEndo.com and provide us with some information. 

EndoSequence System

I can’t find the canal.

This is most likely an access problem. Here is a tip concerning straight line access. Close one eye and look into the chamber. You should be able to visualize all the orifices. If you cannot see all the orifices, you do not have straight line access. Straight line access is the key to clinical endodontic success.

I find the mesial buccal canal , but cannot seem to find the MB-2.

The MB-2 canal is often obstructed by secondary dentin. A good way to remove the secondary dentin is with an ultrasonic. Also, transillumination will help you locate hidden canals.

I see the canal but can’t get into it.

Root canal therapy is getting more difficult each year. Try entering the calcified canal with a Stewart probe or a Real World Endo probe. If this does not work, an ultrasonic should help you. Piezo electric ultrasonics are the most under-utilized technology currently in Endodontics. We strongly recommend getting a piezo electric ultrasonic.

How do I go through porcelain crowns?

Carefully! Always use a small round diamond with a lot of water spray. Remember you are at the mercy of the lab tech who stacked the glass.

What burs do I need to go through a metal crown?

We like the H-34L bur by Brasseler for going through crowns or heavy metal onlays.

My rotary files will not go around some curves.

This is an access problem. For small, very tight canals, we recommend a .04 taper preparation. However, even the .04 is totally dependent upon the access.

You are recommending a larger access prep but my endodontist sends me back cases with this tiny hole in the tooth. What gives?

He has done 20 thousand cases and knows exactly where he wants to go. Still, the tendency (even among endodontists) to to go for a larger access preparation. This just makes sense and is particularly important with rotary files. Remember to remove all the caries and unsupported tooth structure.

What to do if I am breaking files

Files break because of either excessive torque or the build-up of cyclic fatigue. Remember to check the anatomy of the tooth. 2 canals that merge together is the # 1 cause of separation. Also, discard the files after use in extremely curved canals.

What to do if In the beginning I was doing fine, but recently I have broken some files.

The EndoSequence files should be in the canal for only 3-4 seconds. No more. After gaining confidence from well done cases, some clinicians have made the mistake of thinking they can stay longer in the canals and work the files. this is a mistake. Please, stay in the canal for only 3 seconds.

How do I handle a separated file?

Separating a file is not malpractice. Not informing a patient of such an occurrence is negligence. Tell that patient that you separated a piece of the file and that it will be incorporated into the final fill. Also, tell the patient that the tooth will be checked (like all endodontically treated teeth) at a one year and two year recall.

I cannot get my .06 taper rotary file all the way down when doing lower anterior teeth.

Due to the small nature of lower anteriors, these teeth can be handled easily with a .04 taper preparation. In fact, we at RealWOrldEndo believe that most all canal should be treated with an .04 taper. It saves coronal tooth structure and is more efficient. Studies also show that it's enough in terms of getting irrigation down. Therefore, no need to go bigger! Save those teeth and don't weaken them unnecessariliy. 

At the completion of my .06 technique, I am still 1 mm short.

Pick up a hand file and instrument the final mm, thereby creating a glide path to the final length. Then go back in with your .06 taper rotary file and this will get you to length.

At the completion of my .06 taper crown down, I am still 3 - 4 mm short.

In this situation, we recommend switching to a # 20 / .04 taper file. If the # 20 does not get you to length, most likely the # 15 / .04 taper will. Once you get to length with the # 15 /.04 taper, you can now go back in with the #15 / .06. Then, increase the apical preparation size to a # 20. Ideally, we would like you to never finish less than a size # 20. Rotary instrumentation is all about tips and tapers.

I find myself short by 2 mm on some mandibular pre-molars.

Mandibular premolars have a tendency to bifurcate in the apical 2-3 mm. Instrument with your rotary files only to the point of bifurcation. Do not force the rotary files past this point. An angled pre-op xray will help you diagnose these difficult cases.

Do I use a .06 taper or a .04 taper file for the MB-2 canal?

Unless you are extremely experienced, we recommend that you use .04 taper EndoSequence files to instrument MB-2 canals.

My .06 taper preparation is coming up short on MB roots. What’s wrong?

Lack of proper straight line access. You may be binding the .06 taper file even up in the chamber.

I broke a file. How come my torque control engine did not prevent this from occurring?

Torque control engines are an adjunct to endodontic treatment, not a substitute for proper technique. Also, a common cause of separation is cyclic fatigue. Torque control engines cannot help you with cyclic fatigue. The only way to handle cyclic fatigue is to use the files one time and then discard them.

How many times can I use these files?

Due to cyclic fatigue concerns, with all rotary files, we recommend single use.

What’s the best way to sterilize these files?

Although other sterilization units work, we prefer the cassette type units. Also, the files should be ultrasonically cleaned prior to placement in the sterilization unit. When ultrasonically cleaning NiTi files, keep them separate from stainless steel products.

When do I get my working length?

After the second rotary file. We do this for two reasons. One, getting to final working length after the use of two rotaries is much easier. Secondly, after two rotary files, you have opened up the coronal half of the canal. This means that you have now removed 50-70 % of the canal contents. Consequently, you are now less prone to push debris out past the end of the tooth.

My rubber stop seems to collapse. Am I doing something wrong?

We have addressed this concern and a new, stiffer, 1 mm silicone stop will forthcoming. This will eliminate any potential problem with stops.

Where are the length calibrations? I’m confused on my length

Currently, you need to set the rubber stop for your length determination. This will work absolutely fine. In fact, most endodontists use the stops for length control, not calibration rings.

The files seem too sharp.

The sharper the file, the more efficient it works in the canal. The more efficient a file works, the less torque is required. Net result of increased efficiency and decreased torque; less separation.

When do I use .04 tapers and when do I use .06 taper files?

In small, difficult canals we recommend the .04 tapers. Also, in extremely long canals, such as a maxillary canine, a .04 taper works well. However, whenever possible, try to do a .06 taper preparation.

What is the appropriate torque setting when using .06 taper files?

The best torque setting is in the range of 1.8 - 2.4 Ncms. If you are not familiar with Newton centimeters (like who is?) the best setting on your engine will be the two highest levels. The reason that you can use a higher torque setting is because we have greatly reduced the torque requirements of the file. This is accomplished through the use of alternating contact points.

What’s the definition of engagement? Is it before the handpiece reverses at one of the torque settings?

Absolutely. In fact, we do not want you to wait for engagement (it’s too late). Instead, we want you to think of instrumentation with EndoSequence as a rhythm technique. One back, two back, and three out. Do not stay in the canal longer than 3 seconds. These files are very efficient and when used with the correct rhythm, it’s incredible how everything smoothes out.

Do I need to use different torque settings for different files?

Theoretically, one can make a case for different torque settings with different files. However, one must add efficiency, as well as cyclic fatigue issues, into the final equation. Torque control in not a substitute for proper technique: it’s merely an adjunct. If you use the proper technique (rhythn based) and keep in mind the issue of cyclic fatigue, you will do absolutely fine. It has been our experience, through clinical experience and bench top testing, that one can use multiple files with the same torque setting.

How often do I need to change the batteries?

The batteries can be recharged 300 - 500 times. Consequently, even in a busy endodontic office the batteries will last 10 weeks to 3 months.

What type of batteries do I use?

AAA nickel metal hydride batteries, 600 - 700 mAh,1.2 V. One can get these at Radio Shack and other similar places. Although not advertised, Brasseler also carries the necessary batteries.

How do I sterilize the handpiece?

 We recommend that you autoclave the contra angle only. Wipe down the body of the unit with alcohol. Remember to lubricate the contra angle before you place in into the autoclave.

My handpiece was running fine but recently it seems to be weaker? Do I need to change the batteries?

It sounds like your batteries have become weak. First, we recommend that you recharge the batteries. If the handpiece is still running slowly after recharging, then you need to change the batteries.

I’m having trouble changing the torque control. What’s going on?

You need to turn off the “on/off switch” before you can change the torque settings. So this means that you cannot be spinning a file and expect to change the torque.

Why does my handpiece seem not to auto reverse itself?

Two answers for this question. 1) You may have your torque control setting on too high a number and 2) the batteries may need to be recharged. Of course, there really is a third answer. You may be performing the technique in the exactly correct manner!

It seems with this technique, that I don’t need to use any other cones or condensation? Is that correct?

Not really. The EndoSequence cones fit the preparations very well but we still want you to confirm the precision fit. Consequently, we recommend taking a D- 11T or D-11 spreader and then try to run it down alongside the master cone. It will not go down 16 mm as in lateral condensation. Rather, the spreader will penetrate to a depth of only 5 - 6 mm. When inserting an extra cone, which we refer to as a confirmation cone, it will also only go down 5 - 6 mm. However, the confirnation cone locks the master cone in place and also adds some extra gutta percha for the coronal seal.

My gutta percha cone does not fit my prep. I seem to be 2 -3 mm short.

This can happen in long canals, such as a maxillary canine, particularly when using a .06 taper preparation. There are two ways to correct this problem. 1) If you finish with a # 30 / .06 preparation, you can drop down one size and simply use a # 25 / .06 point as your master cone. This works well in the majority of cases. 2) Use a .04 taper preparation when instrumenting long teeth. This will always work. Remember, our cones are fully tapered all the way to the end.

What cement should I use?

Currently, we recommend either Kerr Pulp Canal Sealer (Extended Working Time) or AH Plus by Dentsply. We will have our own cement in 10 weeks.

When is your cement coming out and what type will it be?

Our cement should be out in 10 weeks. It will be a new modified glass ionomer.

How much sealer do I use?

Most dentists use too much sealer. Use only enough sealer to lightly coat the walls of the canal and the apical half of the master cone.

What’s the best way to place sealer?

There are two ways to predictably place sealer. You can use either a paper point or a hand file. Do not use a standard lentulo spiral as this can drive cement out past the apex.

Does your technique fill lateral canals?

Our technique currently uses the gutta percha cone as a master cone. Even with the addition of only one confirmation cone, you will fill lateral canals. However, in this case, you will fill the lateral canals with sealer (which we like) rather than heated gutta percha which will shrink upon cooling.

Why is there a size # 15 in the EndoSequence wheel, when you said to never finish less than a size 20?

Sometimes a size # 15 is all you can get (eg. a MB-2 canal).

Do you have an EndoSequence Wheel in sizes 45 - 80?

Yes, this should be available in the next 4 - 6 weeks.

Can I use other tapered gutta percha with this technique?

No. The only laser verified, hand rolled, ISO sized, tapered gutta percha cones are the EndoSequence cones. There are imitations out there but unfortunately, they do not fit as well and will consequently hang up in the canal.

How do I clean the spatula and glass slab (if employed), after use with Activ GP sealer?

Simply rinse the spatula and glass slab under water and the Activ GP will rinse off. The clean-up with this material is very easy.

What should I do if the initial mix of sealer is too thick?

Add an additional drop of liquid and spatulate as you would with regular sealers / cements. Having a powder / liquid mix (rather than pre-measured capsules) facilitates the creation of a proper mix.

Should I use the paper pad or a glass slab to mix the sealer?

The choice is an individual decision. However, to extend the working time in excess of 12 minutes (20 minutes is easily attainable), mixing the sealer on a chilled glass slab is the preferred method.

What is the purpose of the “Transporter” and how is it used?

The “Transporter” has been designed to facilitate placement of Activ GP Plus points in the posterior of the mouth. Simply grab the Activ GP Plus handle with the “Transporter” and take it to the involved tooth. A slight bend of the point that is grasped by the Transporter will further make insertion easy.

How does moisture in the canal effect the set of Activ GP sealer?

Glass ionomer cements (unlike resins and some other materials) do well in a slightly moist environment. However, we advocate desiccating the canal as well as possible. The use of precision matched paper points (sized to specific canal preparations) will make this possible.

Are “puffs’ a concern with Activ GP sealer?

Absolutely not! Glass ionomer cements (sealers) are extremely biocompatible. In fact, glass ionomers are used routinely in orthopedic surgery to hold fixtures in place. It is indeed difficult to find any dental material that is more biocompatible than glass iomomer. Even though Acitiv GP sealer is very biocompatible we recommend only a small puff rather than a large smear of sealer.

How do I remove a canal cap (excess cement placed at the top of the canal)?

A glass ionomer canal cap can be easily removed by either a bur or an ultrasonic tip. A canal cap should be no more than 2-3 mm. in depth. We do recommend creating a canal cap at the end of the obturation process of each canal. Activ GP sealer creates an excellent coronal seal.

Can Activ GP be used to fill a wide canal? Are accessory cones required?

Concerning wide canals such as those found in some premolars or molars:

Quite often, the dentist instruments these canals to too small a size. Instead of a #20/.06, they should instrument these canals to a #35, #40/.04 or even larger. A .04 taper works better in these larger apical size canals. This reduces a lot of the lateral space in the coronal third of the tooth.

While it is true that the thinner the sealer layer, the less dimensional change occurs, glass ionomer (Activ GP) is very stable and has minimal dimensional change. This is one of the significant benefits of a sealer based technique rather than thermoplastic obturation, which shrinks upon setting. Consequently, although the sealer layer may be thicker in the coronal third of some of these teeth, the dimensional change (lack of) does not merit an additional cone. Also, think what we are placing a the top of each canal...a canal cap with straight sealer and no gutta percha.

The key is a larger instrument size in these wide canal cases.

Can Activ GP be used with a variable taper preparation?

Yes, of course, but you're not taking full advantage of the concepts of precision and synchronicity. Also, a variable taper will increase the retreatment time due to the thickness of sealer in the coronal third. Single cones should be done with a constant taper preparation and the best possible cone fit.

Will Activ GP sealer flow easily into lateral canals?

Yes!!! Activ GP sealer has been formulated to flow easily into lateral canals. The hydraulics generated by a precision fit cone will move the sealer laterally and will fill the lateral canals (please see the video). The Activ GP cone should be inserted slowly into the canal and when inserted slowly, any excess sealer will generally flow back out through the orifice.

Is Activ GP retreatable?

Activ GP can definitely be retreated!! Part of the rationale of maintaining gutta percha in the equation was to facilitate retreatment. The cases with glass ionomer cements that are difficult to retreat, are those cases that are entirely filled with sealer (cement) rather than using a cone. Activ GP uses glass ionomer as a sealer not a “filler.” Never fill a canal with just sealer (any sealer).

Can we do a pulpotomy on non vital teeth?

No. Non vital teeth require a pulpectomy. Merely a pulpotomy will not do an adequate job with necrotic teeth.

What intra canal medication should we use on vital teeth?

Vital teeth require a pulpotomy and eugenol cotton pellet. Squeeze the eugenol pellet dry because it is the eugenol fumes, not the liquid itself that works.

What intra canal medication should we use on non vital teeth?

Calcium hydroxide

Why do we like calcium hydroxide?

Calcium hydroxide has a high pH, is antibacterial, and dissolves necrotic tissue. It is absolutely the intra canal medicament of choice for non vital teeth.

Can we use formocresol as an intra canal medicament?

No. In the past, we used “formo” strictly for pulpotomies. Formocresol as an intra canal medicament will create more post operative problems because of its vapors. We do not recommend its use even for pulpotomies. Do a eugenol pulpotomy instead.

Should I always use an antibiotic for emergency treatment?

No. Vital teeth (irreversible pulpitits) emergencies are the result of inflammation, not infection. Consequently they do not need antibiotic coverage. Use antibiotics only where indicated, which is in cases of infection.

What is the antibiotic of choice in endodontics?

Generally (assuming no allergy), it is Pen VK 500 mg., 1 tab QID, 7 – 10 days. In cases of slight – moderate cellulitis, clindamycin 150 mg., 1 tab TID or QID, for 5 days works well. Make certain that there are no colitis issues with the patient. Patients who present with a severe cellulitis need to be referred to a specialist or hospital.

How do I get drainage?

Often we can get drainage simply by opening the tooth. In these cases, let the purulence drain for a few minutes. If you cannot stop the drainage, take off the rubber dam and have them rinse their mouth with very warm/hot salt water rinses. Ten to fifteen minutes is usually enough to produce significant drainage. If there still remains residual drainage, the tooth may be left open for 24 hours. Put a large cotton pellet in the chamber, have them do hourly rinses with salt water, place them on antibiotics, and see them the next day. We try to close the tooth as soon as possible.

Should all necrotic teeth be left open for a few days?

Absolutely not. We generally leave teeth open (for 24 hours) only in those cases where we are continuing to have drainage come from the tooth.

Do I have to calibrate the unit before I use it?

No. The unit has already been calibrated

Will it work in wet canals?

Yes. In fact, the canals should be lubricated (wet) but the chamber must be dry. If there is fluid in the chamber there is potential for a contamination of the readings.

Is 0.0 the end of the root canal or the end of the tooth?

0.0 is the end of the root canal (cemento-dentinal junction).

Sometimes with an apex locator, I place the instrument into a canal, just a little bit, and the unit goes crazy. What causes this?

Generally, it’s a combination of two things. A large canal such as a distal canal in a lower molar or a palatal canal in a maxillary tooth. Additionally, there is very inflamed tissue (hyperemia) involved. There are two ways to improve this situation. The first is to do what endodontists do; we remove as much of the inflamed tissue as possible from the canal before we insert the file and use the apex locator. This often means removing as much as 2/3 rds of the canal contents. Another option is to simply use a larger file such as a # 25 Hedstrom in the palatal canal instead of a # 10.

Is it okay to use a nickel titanium rotary file with the apex locator?

It’s okay but we would prefer a # 10 Stainless steel hand file, 25 mm. in length. The hand file gives the clinician more tactile awareness and the extra length allows you to properly set the rubber stop.

Sometimes, when working on a maxillary canine or a palatal canal of a molar, I seem to come up short. What’s going on?

The latest generation of apex locators will register large lateral canals so the clinician must be aware of the occasional reading that “seems short.” For example, maxillary canines are generally 25 – 27 mm in length. If the apex locator signals 0.0 at 21 mm, we must be aware that it is, in most likelihood, reading a large lateral canal. Simply continue pas tthat mark and you should get a true reading of the end of the canal deeper in the root.

Is RC-Prep recommended to be used with the Kfile when using an apex locator?

Absolutely. We find that a lubricant improves the reading capability of all apex locators.

Can I use the PAL if I have made an access preparation through a crown?

Yes, but the chamber must be free of debris. Any remaining metal shavings in the chamber can disrupt the reading of any apex locator.

What components can be sterilized?

The following items can be sterilized up t o a maximum of 135O C. The file clip, lip hook, and the extension cord.

When I change batteries, do I have to change all of them at the same time?

Yes and be certain that they are all from the same manufacturer. AAA cell.

When should I change the batteries?

When the battery indicator shows a level of 50 % or less. Do not wait until they are totally exhausted. A poor battery situation can lead to inconsistent readings.

If I forget to turn off the unit, how long will it stay on?

The unit will automatically turn off when there has been no activity for ten minutes. This is referred to as the “Auto power-off function.”

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