How To Build Trust

In my case, as a practicing endodonist who also happens to develop endodontic products, one element in creating trust is to use whatever you developed to overcome the problems that were solved by the products developed. It also includes being open in communicating when and why there is a change in what we previously used. It is crucial to communicate with great clarity exactly why we use what we developed, what problems had existed that we overcame without introducing new problems. Trust is also enhanced by never degrading individuals. That any debates among conflicting parties be confined to data in terms of legitimacy, accuracy and relevance. Within that range, there is a broad expanse of critical thinking.

Of course, as a manufacturer, one who derives profit from the sales of the products, it is reasonable to doubt the objectivity of anything said about the products, but this is true for anyone representing any product. The best one can do is to offer workshops where the dentists can try the products for themselves in deciding whether or not the claims made for the products match the results attained. This form of trust-building is most effective on an individual basis, but is quite effective for those who go out of their way to take the workshops.

The reasoning why an alternative form of instrumentation is claimed to be superior must be so logical that it makes denial sound irrational. For example: the contention that rotary NiTi is vulnerable to breakage. First of all, it is not an isolated statement. Unpredictable separations have been the subject of many research article since their introduction. Indeed, they are not necessarily unpredictable because their occurrence is closely correlated to increasing complex pulpal anatomy, and that is so because the more curved and narrow the canal anatomy, the more bifurcations and mergers are present, the greater the chance of exceeding the torsional stresses and cyclic fatigue limits of the NiTi instruments, the two factors that produce separations when exceeded.

The manufacturers take steps to reduce separations so the practitioners can take advantage of the superior debridement and reduction in procedural time requirements that result from the use of rotary NiTi compared to the manual use of K-files that was the typical instrumentation technique prior to the introduction of rotary NiTi. Given the insecurity engendered in the use of rotary NiTi, one obvious direction in product development is to attempt to discover automated means to cleanse canals rapidly and thoroughly without exposing the instruments to stresses that could lead to their breakage in the canals. The traditional wristwatch motion of stainless steel K-files did not produce separations when confined to these short arcs of motion. On rare occasions these instruments would separate, but only when a greater arc of motion was employed in a canal that has a tight abrupt curve.

The 30o oscillating handpiece had been on the market for years, was generally used with K-files and too often led to the apical impaction of debris with loss of length limiting its popularity. But, for sure, confined to even shorter arcs of motion than the manual wristwatch motion and impossible to inadvertently exceed the 30o arcs of motion when using the handpiece, the instruments were guaranteed not to separate in the canal. So, we knew confined to short arcs of motion that the instruments and for that matter any twisted stainless steel instrument would stay intact.

I had learned years ago while still in dental school the advantages of an instrument designed as a reamer over that of one designed as a file. The reamers shave dentin away with the horizontal strokes generated by the handpiece. The same motion using a K-file engages and disengages from the canal walls without shaving dentin away from the canal walls until the pull stroke is applied, the difference resulting from the vertical flute orientation of the reamers versus the horizontal flute orientation of the files. The pull stroke of the reamer does not shave dentin from the canal walls and the push stroke tends to bypass any debris in the canal minimizing the chances of apically impacting debris. The results of the K-file in the 30o oscillating handpiece are just the opposite leading to loss of length and the transportation of curved canals to the outer wall.

The justification for favoring a reamer design over a file design is based on the simple mechanical fact that to shave away dentin from the canal walls the instruments must be more or less at right angles to the plane of motion. Given the horizontal plane of motion generated by the 30o oscillating handpiece, the more vertical orientation of the reamer fulfills that function. The more horizontal flute orientation of the file transitions the mechanics from one of shaving to one of embedding, similar to the highly horizontal flutes on a screw, the purpose of which is to create retention rather than removal. For the purposes of endodontic debridement, cleansing canals without inducing distortions, 30o oscillations of stainless steel reamers is the logical design to incorporate. After recognizing the advantages of a reamer over a file design, we realized that we could reduce the resistance the instruments encounter as they negotiate the length of the canal by placing a flat along its working length making the instruments even more flexible while providing two vertical blades that increased the efficiency of dentin removal from the canal walls as they oscillated 30o at high frequency. The short arcs of motion provided the security to prevent any separation even with the incorporation of the flat.

Basing one’s products on sound mechanical principles is the basis of trust. It is far easier to make an argument for their use when what is designed into the instrument is consistent with the results one wants to attain and that becomes most apparent when dentist take the workshops we offer. The main reason I am most comfortable in discussing the advantages of this alternative approach is because it is so well-grounded in logical mechanical principles. From the insight we had in seeking an alternative to rotary, the fact that instrument separation is eliminated as a possibility giving us the ability to apply these instruments vigorously against all the canal walls without inducing any other problems, we overcame the unintended consequences of rotary NiTi and made endodontic instrumentation safer and more thorough. And I am always happy to have that discussion with those who harbor another opinion.

Regards, Barry