Making Endodontic Instrumentation Safer, More Effective And More Efficient

Common sense mechanics: By using the instruments with short arcs of motion in a 30o oscillating handpiece they are virtually immune to breakage. From the perspective of the instruments that makes instrumentation safer. From the perspective of the debridement process that makes instrumentation more effective because the dentists can apply the instruments against all the canal walls with vigor knowing they won’t separate. They are also more effective because the frequency of oscillations at 3000-4000 cycles per minute activate the irrigants that are driven into intimate contact with the canal walls. Used in an engine-driven 30o oscillating handpiece at 3000-4000 cycles per minute the entire instrumentation process is more efficient eliminating practically all hand fatigue and dramatically reducing procedural time requirements. By using stainless steel relieved reamers in the 30o oscillating handpiece, the instruments are more flexible, better able to adapt to all pulpal configurations than the traditionally used K-files further reducing the potential for canal distortions. The predominantly vertical flute orientation of the reamers also reduces the potential to extrude debris apically.

Compare this approach to rotary NiTi. Compared to the manual use of K-files engine-driven rotary NiTi definitely made the instrumentation process more efficient. It eliminated a substantial portion of hand fatigue and significantly reduced procedural time requirements. However, it did not make instrumentation safer as evidenced by an increasing incidence of instrument separation that in turn led to the precautions of centered shaping even in the presence of highly oval canals and eventually more conservative preparations that reduce without eliminating separations, but at the expense of less effective debridement. The added precaution of treating the instruments as disposable, a one and done approach, also greatly added to the cost of employing this technique. Employing rotary NiTi increased productivity compared to the manual use of K-files and frankly K-files used manually can often be so hand fatiguing that their utilization was compromised, employed short of their full potential.

The price the dentists pay for the greater productivity of rotary NiTi compared to the manual use of K-files does not reflect the options that dentists have today to maximize safety, effectiveness and efficiency. The dentists today can employ stainless steel relieved twisted reamers in the 30o oscillating handpiece at a frequency of 3000-4000 cycles per minute that eliminates instrument breakage, provides for three-dimensional debridement, eliminates canal distortions, reduces procedural time requirements, allows for multiple usage of the instruments with great cost savings and reduces the apical extrusion of debris. All these advantages stem from the fact that confined to short arcs of motion separation is no longer a concern and, consequently, the precautions rotary NiTi employ to reduce separations that at the same time compromise debridement are no longer necessary.

To date, the manufacturers of rotary NiTi have not been able to eliminate instrument separation as a cause of concern. Indeed, every rotary NiTi user is familiar with the precautions needed to reduce the incidence of separations including:

.Minimal deviation from centered shaping as much as possible regardless of the complexity of the pulpal configurations.

.Using a light pecking motion to reduce the possibility of encountering excessive torsional stresses.

. More extensive manual use of k-fiels to widen the glide path to reduce the resistance the rotary instruments encounter.

. More conservative centered rotary NiTi canal preparations.

. Single usage or the necessity of using new instruments of the same dimension when negotiating particularly complex pulpal anatomy.

. Their use in expensive handpieces connected to motors that control torque and autoreverse in the presence of apical resistance.

None of this is necessary when employing stainless steel relieved reamers in a 30o oscillating handpiece at 3000-4000 cycles per minute. There is no tradeoff between safety and results. Both are maximized using this alternative approach.

Most dentists are not aware of these common sense insights because the major manufacturing corporations of rotary NiTi in cooperation with the dental schools have established a closed system of endodontic education that prohibits the student bodies from being exposed to any information that doesn’t support the use of the sponsored instrumentation systems. The students are treated as consumers and the endodontic programs are constructed to be one of indoctrination not education. If this were not the case, the study in the 2021 November issue of JADA would not have documented that 80% of academic endodontists are the recipients of industrial payments with the largest payments going to those that the sponsoring corporations consider the most influential opinion leaders.

There is no getting around the blatant fact that such industrial/academic relations constitute an obvious conflict of interest. Even after the publication of this article, I am not aware of any effective actions to curtail this form of bribery. One can only assume that the lack of reaction results from the fact that it is no longer genuinely considered a conflict of interest. It is merely one of the ways business is "legitimately" allowed to conduct itself. Any transactional agreements between industry and academia are acceptable if they are financially rewarding to both. We have already gone pretty far down the road of “crony capitalism” for this type of behavior to be accepted as the norm. The fish rots from the head down. That is not an inaccurate metaphor when applied to the industrial/academic relations that are the norm today. What a wonderful example the schools are setting for the student body that is being “educated” under these circumstances.

What disturbs me more in the long run, is that imposing an educational system that is so constructed to encourage students to eventually buy the sponsored products is essentially authoritarian, imposed from above, leaving little if any room for the distribution of information that does not support the sponsored products. This nation pays a price when the development of critical thinking skills are sacrificed on the alter of commercial interests. The irony is that the present situation came about by schools deciding to throw in their lot with corporations that look at critical thinking as an impediment to their singular goal of expanding their influence and profits. So much better to have a student body that accepts whatever they are taught as gospel, a task made far easier when any contrary data is excluded from the school premises.

In this day and age, too many have forgotten that there is value in democratic ideals, that a democratic society is one that represents alll its citizens, that it takes effective government to control and prevent those in society who wish to overcome this basic tenet, those elements that support greater concentration of power into the hands of the few that support legislation for unlimited political donations from the morbidly wealthy while encouraging voter suppression for those deemed to disagree. When government takes the side of those who wish to eliminate those democratic ideals, everything that we thought representative of decency is turned on its head. Exacerbation of racism, defining the United States as white Christian nation, intolerance of immigrants, women’s reproductive rights, various sexism issues are standard fare to divide us culturally and we should be aware that those who promulgate such divisions are the same people who find democratic principles repugnant.

And finally, just for the record, those who are in real power, the owners of major corporations and financial institutions are using these divisive individuals to sow chaos for the purpose of restoring an order that will protect and expand their hunger for ever increasing amounts of power that will guarantee their expanding profits far into the future. Those individuals are not for the common man. Yet, they will use those they can manipulate to be the destructive tool in their unending quest for ever more profits and power.

How does one go from being critical of endodontic teaching programs to being critical of the political trend that are present today? I make the leap because what is occurring in the microcosm of endodontic “educational” programs in the schools results from the same corporate influence that is occurring on a much larger scale nationally. Authoritarianism may be hard to perceive in the construction of an endodontic program, but its goals are the same as those achieved in the Supreme Court decision on Citizens United that declared that unlimited donations (obviously by the extremely wealthy and those who own them) are simply a form of free speech. Take a look around. Does voter suppression, gerrymandering and increasing amounts of incarceration support democratic institutions? We all know the answer. The problem is that today, too many people are willing to sacrifice democratic principles and that is simply unfathomable to me.

Regards, Barry