The Art of Endodontic Assisting

The Art of Endodontic Dental Assisting A Step-By-Step Guide By Katie Dettamanti, RDA, CDA and Mary Jane Ingalls Buchanan IllustratIon and GraphIc desIGn By Lindsey Frazier SSimimplpeleApApprporaocahch AdvAadnvcaendcInesdtrIunmsterunmts ents ExperEt xTpraeinrtinTgraining

Katie Dettamanti is a registereddental assistant with the state ofCalifornia, and has been workingas an endodontic assistant for overeleven years. Her expertise in frontoffice administration includesmedical insurance cross coding,medical record software, employeemanagement and training. Katiealso works as lead administrator forthe Dental Education Laboratoriestraining facility in Santa Barbara,California as CE course coordinator.

Copyright 2017 by Dental Engineering Laboratories, LLC Dental Engineering Laboratories, LLC 1515 State Street, Suite 16 Santa Barbara, CA 93101 www.DELendo.comAll rights reserved. No part of this manual may be photocopied or reproduced in any formwithout written permission from the publisher. Moreover, no part of this publication can bestored in a retrieval system, transmitted by any means, or recorded or otherwise, without writtenpermission from the publisher.Limits of Liability and Disclaimer of WarrantyWhile every precaution has been taken in preparing this manual, including research,development, and testing, the Publisher and Authors assume no responsibility for errors oromissions. No liability is assumed by either publisher or author for damages resulting in the useof this information.



TABLE OF CONTENTSWelcome ....................................................................................................................1 Pre-Requisite Skills.........................................................................................1Introduction ...............................................................................................................3Chapter One: Patient In-Take1.1 Endodontic Assisting is Like Getting a Root Canal ..........................................61.2 The Psychology of Endodontics........................................................................61.3 Patient Welcome ................................................................................................71.4 Professional Manners and Patient Comfort.......................................................71.5 Patient In-Take Forms .......................................................................................7 1.5.1 Personal Demographics .....................................................................8 1.5.2 Insurance Demographics.....................................................................8 1.5.3 Comprehensive Medical History ........................................................8 1.5.4 Medical History Questionnaire ...........................................................8 1.5.5 Schedule of Medications.....................................................................8 1.5.6 Allergies ..............................................................................................8 1.5.7 Declaration of Practice Policies ..........................................................9 1.5.8 Cancellation Policy .............................................................................9 1.5.9 Insurance Claim Forms .......................................................................9 1.5.10 HIPAA Forms......................................................................................9Chapter Two: Diagnostic Data2.1 3D Imaging......................................................................................................12 2.1.1 What Is CBCT 3D Imaging?...............................................................12 2.1.2 What Are the Benefits of CBCT 3D Imaging? ...................................12 2.1.3 Operational Strategies.........................................................................122.2 2D Radiographs...............................................................................................132.3 Problem-Focused History................................................................................142.4 Subjective Dental History ...............................................................................142.5 Objective Dental History.................................................................................142.6 Symptom Reproduction Techniques................................................................15 2.6.1 Pulp Testing.........................................................................................15 2.6.2 Percussion ...........................................................................................15 2.6.3 Biting Pressure ....................................................................................16 2.6.4 Thermal Testing ..................................................................................16 2.6.5 Creating Ice Sticks for Thermal Testing .............................................17 2.6.6 Cold Testing Procedure.......................................................................17 2.6.7 Heat Testing Procedure .......................................................................182.7 Trans-Illumination ...........................................................................................18 2.7.1 Trans-Illumination to Detect Cracks in Teeth .....................................182.8 Diagnostic Charting.........................................................................................192.9 Operatory Preparation and Set-Up ..................................................................192.10 Transfer of Information ...................................................................................19 i

Chapter Three: Treatment and Financial Planning 3.1 Treatment and Financial Coordination ............................................................22 3.2 Treatment Phases.............................................................................................22 3.3 Understand the Patient.....................................................................................22 3.4 Consent Forms.................................................................................................23 Chapter Four: Consultation and Procedure Set-Up 4.1 Consultation and Procedure Set-Up ................................................................26 4.2 Conventional Root Canal Treatment Set-Up...................................................26 4.2.1 Doctor Organizational System ............................................................26 4.2.2 Doctor Instrument Checklist ...............................................................26 4.2.3 Assistant Instrument Checklist............................................................28 4.2.4 Obturation Tray...................................................................................28 4.2.5 Restoration Tray..................................................................................30 4.3 Procedural Preparation Activity ......................................................................30 4.3.1 Estimation of Lengths .........................................................................30 4.3.2 Fresh Sodium Hypochlorite and EDTA ..............................................31 4.3.3 Lubricant .............................................................................................31 4.3.4 Water Check for Doctor and Assistant ................................................31 4.3.5 Bur, Rotary File, Ultrasonic Tip and Handpiece.................................31 4.3.6 Rubber Dam Punch .............................................................................31 4.3.7 Rubber Dam Clamp Selection ............................................................32 4.3.8 Anesthesia ...........................................................................................32 Chapter Five: Assisting During Treatment 5.1 Anesthesia........................................................................................................36 5.1.1 Topical Anesthesia ..............................................................................36 5.1.2 Nerve Block ........................................................................................36 5.2 Isolation ...........................................................................................................36 5.3 Access..............................................................................................................36 5.4 Negotiation ......................................................................................................37 5.5 Cleaning the Smear Layer ...............................................................................38 5.6 Gauging ...........................................................................................................39 5.7 Irrigation..........................................................................................................39 5.7.1 Two-Visit Approach ............................................................................39 5.7.2 Single-Visit Approach.........................................................................39 5.7.3 Ultrasonic Approach ...........................................................................40 5.8 Obturation.......................................................................................................41 5.9 Cement Mixture..............................................................................................41 5.10 Paper Points....................................................................................................42 5.11 Cone Fit Technique.........................................................................................42 5.12 Carrier Technique ...........................................................................................43 5.13 Final Restoration ............................................................................................43 5.14 Post-Operative Care .......................................................................................44ii

5.15 Sterilization ....................................................................................................44Terminology and Definitions...................................................................................48Forms AppendixNotice of Privacy Practices .....................................................................................52Authorization Form .................................................................................................59Patient Consent Form ..............................................................................................60Treatment and Financial Policy Form .....................................................................61Consent for Root Canal Treatment..........................................................................63Consent for Composite (Tooth Colored) Fillings....................................................64Consent for Crown and Bridge Prosthetics .............................................................66Refusal of Recommended Treatment ......................................................................68In-Take Sheet...........................................................................................................69Internal Financial Agreement Sheet ........................................................................70Fee Form..................................................................................................................71 iii



Welcome These guidelines have been written for training context in which a training manual will be adelivery source for the hands-on educational experience. The manual will either compliment a stand-uptrainer or will be downloaded from an internet training session. This training manual also is intended tobe used as a self-study tool.Pre-Requisite Skills This manual is written for an audience that already is trained in dental assisting. 1



Introduction More than likely you are encountering this course as a practicing dental assistant, a seasonedveteran, a beginner or somewhere in between. You may currently work for an endodontist or generaldentist that does endodontic procedures, and have some chair side experience in endodontics. So why gothrough additional training? What is the gain? As a dental assistant either assisting a general practitioner or exclusively in the endodontic field,you are a trained professional with a responsibility to your doctor and your patient to demonstrate astandard of skills specific to endodontics. Endodontic techniques, tools and technology are alwayschanging and ultimately, require advanced training. It is specialized training that distinguishes youamong your peers, enhances your professional practices, and commands higher rates of pay. Specialtytraining is access to the upper echelon of the dental assisting community. It is the objectives of thiscourse to: (a) introduce and practice endodontic assisting through patient intake, treatment, and postoperative care; (b) learn the latest technology and techniques in endodontic assisting, and (c) provide easy to use charts, forms and materials for predicatable, smooth patient care and office organization. The goal of this course is not to create more work; but to refine and enhance your skills with acohesive and practical method of application for predictable outcomes. Organization and practice willbe an easily repeatable formula that will instill confidence in you and your doctor, making your mutualpractice experience less stressful and more rewarding. Thank you for participating in Dental Education Laboratories’ Endodontic Specialty AssistantTraining. I hope your experience here enhances your personal performance as well as the standing of ourcolleagues in the dental profession. Sincerely, Katie Dettamanti, RDA, CDA 3



Chapter One: Patient In-Take

Chapter One: Patient In-Take1.1 Endodontic Assisting is doctor, an important component to any successfulLike Getting a Root Canal relationship where referrals are a source of patient traffic. To begin, you may not like assisting inendodontic procedures. When I first began Endodontics is a dynamic procedure that haswork in a dental office, the assistants would the ability to save natural teeth: The foundation ofmetaphorically draw straws to see who would oral health and facial structure integrity. As a trueassist the doctor in an endodontic procedure. It professional trained specifically in endodonticwas so boring! treatment, the dental assistant demonstrates a higher level of professional skill as well as Looking back, lack of fundamental concepts bringing the best of modern dentistry to patients.and understanding of endodontic treatmentinhibited the ability to respond effectively in 3 It is a common cliché that a root canal is theprimary activities of the endodontic treatment epitome of a painful experience.process. This doesn’t exactly make the job any easier • engage ~ an active understanding of what especially when, as the assistant, we are more is needed for efficient in-take and data likely to experience the less controlled, often collection for correct diagnosis; agitated emotional behavior of the patient. • anticipate ~ advanced set up and As a professional, it is not the job of the preparation for immediate care in the assistant or office staff to ascertain the mood or operatory; and “character” of the patient. The role of doctor and staff is to provide a medical service to another • participate ~ coordinated procedural human being. You can expect some of the interactions between doctor, patient and following behaviors at in-take: assistant • Pain Specialty training identifies the individual • Fearassistant as having these additional, more • Apprehension about treatment methodscomplex set of skills. Facilitating the interactive Concerns about:relationship between doctor and patient is the • Costs of treatmentprimary function of the dental assistant, an • Insurance complexityactivity that is both interesting and purposeful. • Scheduling • Inconvenience1.2 The Psychology of Endodontics Put yourself into the place of the patient. Endodontic treatment is an emergency-based procedure. Whether in a general practiceor a practice specific to endodontics, the patientseeks treatment in response to pain. Frequently,fear is appurtenant to pain, making initialreception an important element of the patientexperience. Depending on your practice, thepatient will arrive either (a) as a referral fromanother practitioner or (b) self-directed basedupon symptoms. The patient may present as a“walk-in”, making it important that the doctor’soperatory is organized and equipped to respondin an immediate care capacity. Knowledgeableand compassionate in-take creates trust with thepatient and reflects positively on the referring6

The Art of Endontic Dental AssistingWhat if you had to go to the doctor and they is anxiety provoking.thought something was wrong that you didn’treally understand, but you saw and heard terrible (a) Be cheerfulthings about all of the time?! (b) Address patients in formal manner, i.e., It doesn’t really inspire confidence in the Mr. Jones, Miss Jones, etc.process or outcome of treatment. In-take is theopportunity to set the foundation of the patient- (c) Indicate a place where the patient candoctor relationship. leave personal belongings.1.3 Patient Welcome (d) If the operatory is chilly, have a clean blanket available. The patient is always the most importantperson in the waiting room, and conversation (e) Describe simply what you are doing.between staff should be of a professional nature. (f) Ask specific questions about the patient’s Confirm: physical comfort. Does the patient need to use the lavatory, is the patient cold, etc. (a) When the patient is expected (g) Keep conversation professional. (b) That records have been delivered by the referring doctor Keep in mind that you should never reach beyond your scope of practice. You are not (c) Ask how the patient is feeling licensed or certified to diagnose the patient’s condition or express an opinion on treatment. The Consent Forms must be signed patient has more than likely consulted friends,BEFORE the patient sees the doctor. The family, and Google about their symptoms priordoctor should see the patient AFTER to their upcoming appointment. The patient maysigned consent has been obtained. make a comment such as, “I bet you’ve never seen teeth this bad before!” or, “am I going to • Offer Reassurance ~ Indicate a time when need my tooth pulled out?” Never agree that the patient can expect to meet the doctor. you’ve seen anyone with dental care that “bad” or “yes, actually I believe we may need to extract.” • Hospitality ~ Offer the patient water. • Plain Language ~ The patient may not be Upon completion of this course and some practice, you will become very competent in familiar with endodontic terminology. Use reading patient CBCT scans, 2D radiographs plain language when explaining forms or and associating symptoms with data. Even with answering questions. the best intent to reassure a patient, it is never • Do Not Offer Advice or Give an appropriate to share an opinion, discuss or Opinion explain diagnostic data with the patient.1.4 Professional Manners 1.5 Patient In-take Formsand Patient Comfort Correct patient in-take and patient in-take Keeping your patient calm, comfortable, forms go hand-in-hand with the legalities of theand assured is dependent upon (a) how you dental world. These forms cover crucial and basicspeak and (b) active listening. People often feel information for legal and insurance purposes asuncomfortable when it is not possible to see well as to benefit you in contacting or caring forwhat is happening or if activity is unfamiliar. the patient.The loud banging of doors, abrupt movement ordisappearing from sight for long periods of time A basic in-take or ‘Welcome’ form should include the following sections: 7

Chapter One: Patient In-Take1.5.1 Personal Demographics 1.5.3 Comprehensive Medical History The personal demographics section of the in- The comprehensive medical history sectiontake forms should include the following: of the in-take form should include the following: a. Full legal name (for insurance and a. Medical History Questionnaire records purposes) and preferred name b. Schedule of Medication b. Mailing address c. Allergies c. Phone numbers: home, cell, work. Multiple numbers are always 1.5.4 Medical History Questionnare preferable. A comprehensive medical history is d. Email necessary for a full understanding of your patient’s health and potential medical e. Emergency contact person with phone complications. Many people may think this number and a signed form that gives is overkill and do not understand why so permission for the office to contact much information is important, especially this person regarding the patient, their because “we’re just looking at teeth!” Did visits or treatment. you know that people with celiac disease have a higher instance of internal and1.5.2 Insurance Demographics external root re-sorption? These medical nuances are important for proper diagnosis The insurance demographics section of the and treatment planning by your doctor.in-take forms should include the following: 1.5.5 Schedule of Medications a. Insurance company name (scan a copy of the card’s front and back to ensure A full account of any medications that correct information is recorded) the patient is currently taking is extremely important. If a patient has taken any non- b. Insurance company address steroidal, anti-inflammatory medications prior to their consultation, it will not be c. Insurance company phone number possible to reproduce their symptoms during diagnostic testing. If the patient is on blood- d. Insurance company identification thinning medication, it is imperative to number document that information for the doctor, especially in the event of surgical treatment. e. Insurance company group number 1.5.6 Allergies f. Insurance subscriber (this may not be the patient, especially if the patient is It is also of the utmost importance to a minor the subscriber will most likely find out what allergies the patient may have, be a parent or guardian) particularly allergies to medications. For example, if your patient notes that they have g. Insurance subscriber’s date of birth experienced an allergic reaction to Penicillin, it is imperative to alert the doctor so that Amoxicillin, or other similar derivative, is not prescribed. It is recommended that new prescriptions be compared to in-take forms to check for error.8

The Art of Endontic Dental Assisting1.5.7 Declaration of Practice Policies 1.5.9 Insurance Claim Forms 1. Financial Policy Does the office provide insurance claim This form states and confirms with your forms assistance as a courtesy, but requires the patient to submit the bill to their insurer patients what is expected of them financially carrier themselves? and addresses the following: 1.5.10 HIPAA Forms a. Does your practice collect co- payments up front and allow the The Federal Health Insurance Portability and insurer to reimburse the patient? Accountability Act of 1996 (HIPAA) Forms. b. Do you allow extended payment plans a. Notice of Privacy Practices or offer in-office insurance programs for your patients? b. Authorization Form c. Is payment in full expected at the time c. Patient Consent Form of service? Organized information such as when The intent of this law is to protect the payment is expected for services confidentiality and security of healthcare rendered and how insurance company information, and provide notice of the reimbursement works will reduce the standards for the electronic exchange of potential for misunderstanding and private and secure health information. unsatisfied expectations. Providing the HIPAA Privacy 2. Miscellaneous Policies Authorization Form to the patient is a. Cancellation Policy mandatory. It is a disclosure, not an b. Insurance Claims agreement. It explains the procedures to which the office will adhere to protect the1.5.8 Cancellation Policy transfer of medical information. This form also allows the patient to consent to the Does the office require that the transfer of their Personal Health Information patient provide 24-48 hours notice prior (PHI). It also serves to protect the doctor to any appointment for rescheduling or against patient complaints that may arise cancellation? due to the exchange of information between offices and insurance providers. (See Forms Appendix for Forms Referenced in Sections 1.5.1- 1.5.10) *You are in control of all of the information necessary for the doctor to properly diagnose anddevelop a treatment plan; and to obtain signed and dated consent and acknowledgement of receiptof mandatory disclosure documents for legal compliance.WARNING: On occasion, a patient may express reluctance or not wish to sign and date Consent Forms and otherdisclosure documents. DO NOT PROCEED! Tell your doctor immediately. The potential liabilityexposure to your doctor is extreme. It is not your responsbility to defend the Consent Forms anddisclosures. Ask your doctor to intercede in this eventuality. 9



Chapter Two:Diagnostic Data

Chapter Two: Diagnostic Data2.1 3D Imaging The in-take documents provide a general idea of the patient’s primary complaint. After the in-take forms are competed, a 3D Determine whether a limited view or large viewCBCT scan is the next step in data collection. is needed:This step is relevant if the office is so equipped. Itis a natural transition from reception to the CBCT Limited View ~ Isolated, single-tooth ormachine before entering the operatory for 2D quadrant complaints require 40x40 limited view.radiographs and diagnostic testing. This is about a 2”x2” window of the patient’s mouth. This small focus increases the quality. It is best to educate your patient aboutthe CBCT machine. The imposing size and Since the 40x40 limited view is so small, itunfamiliar appearance of the CBCT machine is limited to the specific area. Why not capture acan be intimidating. It is best to provide a plain larger area, just to be safe?language, concise description of the purpose ofthe machine. Large View ~ A 100x80 larger view is suggested in situations where the patient2.1.1 What Is CBCT 3D Imaging? describes “radiating” (referred) pain, overall mouth pain or multiple areas of pain. • CBCT is the acronym for Cone Beam Computer Tomography The CBCT 3D imaging technique is very similar to taking a panoramic x-ray. The patient • CBCT x-ray imaging allows the clinician will need to remove any jewelry, glasses, hearing to see in 3D perspective (volumetric) aids or removable dentures. This is to avoid the everything about individual tooth anatomy capture of metal objects. and the fullest extent of any existing disease state before invasive procedures Continue taking the CBCT scan by are performed. following the specific directions provided by the manufacturer.2.1.2 What Are The Benefits? 2.2 2D Radiographs • CBCT imaging has a very low amount of absorbed radiation potential When a patient comes to the office, • Resolution approaches 50 microns making particularly from a referring doctor, there may be it possible for lateral canals to be seen some apprehension about the need for additional preoperatively. x-rays. The resistance is frequently based on • CBCT prognosis determination for teeth misconception: with failing endodontic treatment cuts short the exploratory time for both the (a) Misinformation regarding the amount of patient and the doctor radiation absorption. • CBCT imaging used in diagnosis increases the percentage of predictable The ADA, in collaboration with the outcomes of a treatment plan FDA, developed recommendations for dental radiographic examinations to serve2.1.3 Operational Strategies as an adjunct to the dentist’s professional judgment of how to best use diagnostic It is helpful to explain to the patient that the imaging.use of CBCT 3D imaging is an advanced, state-of-the-art technology that speaks to a higher Radiation exposure associated withstandard of care delivered by your doctor. dentistry represents a minor contribution to the total exposure from all sources, 12 including natural and man-made. State laws and regulations set specific requirements for the use of ionizing

The Art of Endontic Dental Assisting radiation (which includes X-rays). Figure 2.2A– Nomad™ Hand-Held X-Ray Unit Important facts regarding radiation Figure 2.2B– The assistant folds back the hinged rubber specific to dental treatment may be found dam frame in order to take an operative x-ray with the hand- on the ADA website: http://www.ada.org/ held x-ray unit and digital sensor. en/member-center/oral-health-topics/x- rays In a nutshell, the procedures and equipment governed by the ADA and FDA is highly regulated, and modern technology has been designed to obtain the greatest effect with the least amount of exposure.(b) The imposition of additional costs. Even though x-rays are provided by a referring dentist, it is important that multiple angles are taken before invasive procedures are performed. The doctor requires films for a definitive diagnosis. • Anterior teeth ~ 1 film • Two-Root Pre-Molar ~ 2 films • Molars ~ 3 films The portable Nomad™ X-Ray unit is a hand-held device that can be used instead of a large wall-mounted x-ray head. The Nomad™, with any digital x-ray sensor, can be taken to any location in the office. The size of the hand-held device is less intimidating than large wall mounted machines, and the fact that you stay present during its operation (instead of ducking into a cement bunker), offers reassurance that the radiation exposure is negligible. Using digital x-rays, it is possible to take as many x-rays as needed to get the perfect image for the doctor, which is far superior to cone-cut or mediocre films. If the patient continues to be resistant, NEVER ARGUE. Seek the assistance of your doctor. (See Figure 2.2A-C) Figure 2.2C– The doctor operates the hand-held x-ray unit and takes an operative digital x-ray with the Nomad™. 13

Chapter Two: Diagnostic Data2.3 Problem Focused History Buchanan, L. Stephen, Roots Journal, 2/2011. If the pain is outside the Endodontic Zone, Systematic, symptom-based questionscoupled with active listening are the best pre- it is most likely temporomandibular joint paindiagnostic strategy for the collection of data and caused by grinding and/or clenching of the teeth.patient cooperation: Note this observation in the data record. Follow with the following questions: • Systematic, symptom based questions ~ Use a well-organized and logical format • Is there soreness or discomfort upon for asking questions regarding patient awakening? symptoms. • Is the patient experiencing an • Active listening ~ Acknowledge and increased amount of stress? confirm information by repeating what you believe the patient is describing. • Does the patient suffer from frequent Affirmative body language such a nodding headaches or migraines? of the head and eye contact emphasize you are paying attention and understand • Has a night guard ever been the patient’s experience. recommended?2.4 Subjective Dental History Check to see if the cusps are flattened and if the teeth appear ground down. Subjective history is the collection of Lastly, the patient may be certain that they areinformation as to (a) type of pain, (b) the location, experiencing pain on a lower molar, yet the areaand (c) the duration. appears normal in the 2D/3D radiographs. In this situation, inspect and test the upper quadrant of (a) Type of Pain: teeth to deduce if the pain may be referred from an upper molar rather than from a lower tooth. • Shooting Figure 2.4– The Endodontic Zone. • Sharp 2.5 Objective Dental History • Throb Objective dental history is the history of • Ache a particular tooth or quadrant in the mouth. It should be noted if (a) the patient had previous • Dull • Nagging • Radiating Providing the patient with a descriptivevocabulary may help them to verbalize theirexperience. (b) Location ~ Ask the patient to physically point to the site of their pain. Note if the area they point to is in the Endodontic Zone. The Endodontic Zone is the area in front of the ear from the top of the cheekbone down to the lower border of the mandible. If the patient indicates that their painprimarily radiates in front of their ear and downtheir neck, it is outside of the Endodontic Zone,as described in “A Case of Diagnosis By Access”,14

The Art of Endontic Dental Assistingroot canal treatment (RCT) on the identified If the tooth is in a thin, acrylic temporarytooth, (b) there is significant restorative work or crown, the patient may be experiencing normal(c) new crown. sensitivity due to imperfect margins. If the tooth has a new permanent crown, it is imperative to (a) If the patient had previous RCT, they will ask the referring/general dentist if glass ionomer likely present without major discomfort cement was used. Glass ionomer cement is a and without stimulation. This is because common irritant to newly crowned teeth. the root canal system was previously treated and, therefore, no (or very little) Ask the patient: nerve tissue remains. These patients • Why they needed a crown? usually have noticeable swelling or • Was the patient experiencing chewing abnormal oral tissue with an abscess draining on the outer vestibule. discomfort before the tooth was crowned? • Was it done for cosmetic reasons? Ask the patient (i) when the treatment • Was it a replacement? was done, (ii) by whom it was done, and (iii) whether there have been multiple 2.6 Symptom Reproduction Techniques treatments. Symptom reproduction techniques include A tooth that has been treated and testing done to reproduce the pain, discomfort, re-treated may require apical surgery if or feeling the patient is experiencing. The main the tooth remains sound, or extraction and goal of this testing is to recreate the sensation the replacement with an implant. patient feels to ensure an accurate diagnosis. (b) Large composite and amalgam 2.6.1 Pulp Testing restorations are a red flag to both endodontists and general dentists. A tooth Pulp testing is the most important data that currently has a large restoration finding strategy for accurate diagnosis. Start each present means that there was at one time test by telling the patient (a) what they can expect a large amount of decay that may have from each type of test, and (b) what response you been sitting on top of the pulp, creating are seeking to achieve. inflammation. It also can be the case that the decay present may not have been (a) Explain to the patient the need to test touching the pulp; however, the vibration a vital tooth that is out of range of the of removing the decay may have created symptomatic tooth; preferably a tooth on substantial trauma causing the nerve to the opposite side–rather than the opposite spontaneously die. arch to avoid a referred-pain response. • Ask the patient how long ago the (b) Response seeking helps to establish restoration was prepared and placed. a baseline for individual reaction to stimulus. • Ask if the patient experienced lingering sensitivity after having the 2.6.2 Percussion new filling done. Percussion is a light tapping with your (c) Just as a pulp can spontaneously become metal mirror handle or the handle of a probe on inflamed if a large restoration was done, a tooth. It should be explained to the patient that the same is true for a tooth with a newly percussion (a) should not hurt; and (b) is not hard prepared crown. There are two important enough to fracture or chip a tooth. questions about newly crowned teeth: • Is the tooth in a temporary crown, or • In a new and permanent crown? 15

Chapter Two: Diagnostic Data Find a baseline tooth on the opposite side when tested.from where the patient is experiencing pain ordiscomfort. When tapping on your baseline tooth Observe all visual clues prior to applyingexplain to the patient that it: any pressure with the Tooth Sleuth™ by verifying that (a) there are no broken or partially broken (a) Should not hurt the patient; teeth and (b) that large fracture lines are not present. (b) Is exactly how the symptomatic tooth should feel as well If you see any of these abnormalities use your best judgment in either foregoing the biting/ It may be necessary to backtrack to this pressure test or gently testing these areas.baseline tooth to confirm how a normal toothresponds for accurate comparison. Apply the Tooth Slooth™ to each cusp of a tooth. Ask the patient to bite down firmly, and Perform testing on teeth adjacent to the apply pressure.identified symptomatic tooth. It is possible thatthe patient will be unable to isolate the sensation • Ask the patient if they feel any sensitivityto one specific tooth and may experience the or discomfort.sensation in all or part of the quadrant. • Determine if there is discomfort with • Lightly, but firmly, tap each tooth in your pressure or upon release testing quadrant Pain upon release is almost always indicative • After each tooth, ask the patient how it of a fracture and should be noted in the diagnostic feels record. • Keep specific notes of these responses in 2.6.4 Thermal Testing the diagnostic record Thermal testing is a simple, yet highly Responses frequently include effective diagnostic tool. A systematic approach to thermal testing is efficient and produces • Tooth ‘feels hollow’ reliable data. • Tooth ‘doesn’t hurt, but feels different • Does the patient experience pain/ from the baseline tooth sensitivity when drinking hot liquids (coffee, tea)? • Pain or discomfort • Does the patient experience pain/ • Ache sensitivity when drinking cold liquids (ice water)? The response to testing may be slightlydelayed and experienced after the fact of Consistent sensitivity/pain response tostimulus. The patient may note a sudden or slight extreme cold may indicate abfraction or abrasion,ache in the area of testing. which could be misidentified as an endodontic problem. If the responses are questionable orinconsistent, re-test to verify. The patient may report cold pain/sensitivity in the past that suddenly disappeared; and are2.6.3 Biting Pressure currently experiencing pain/sensitivity to heat. This is the crescendo effect. The crescendo There are a variety of instruments available effect is the sudden absence of pain because ofto test biting sensitivity or pressure. We suggest a nerve death. This set of symptoms follows theTooth Slooth™ that has a small flat area and can path ofbe applied directly to a particular cusp on a toothfor precise testing. 1. Cold pain/sensitivity First, use the Tooth Slooth™ on the baselinetooth to show the patient how they should feel16

The Art of Endontic Dental Assisting 2. Loss of pain/sensitivity 2.6.6 Cold Testing Procedure 3. Pain/sensitivity to Heat Explain to the patient what they should feel, and that it is normal to feel the cold on/in a vital Please note in the case of crescendo effect, a tooth. What you’re looking for is how long thepatient’s reaction to heat may be extreme. cold feeling lingers.2.6.5 Creating Ice Sticks for Thermal Testing Direct the patient to raise their hand when they feel the cold and lower their hand when the Cold stimulus testing is the only test that cold feeling dissipates.requires advanced preparation. The most accurateway to test cold sensitivity on a tooth is to use A within-normal-limits response is whenan ice stick, which can be easily created in (a) the patient raises their hand when they feelyour office. Endo Ice™ is commonly used but the cold stimulus and (b) immediately drops theirexpensive and often ineffective at accurately hand when the stimulus is removed.reproducing the patient’s cold sensitivity. It may be necessary to test the baseline How to Create Ice Sticks tooth a few times to make sure the patient understands this request. • To create ice sticks save all of the anesthetic carpules after any It is common for the patient to misunderstand procedures. the test procedure. Place the ice on the patient’s lips or gum so that they experience how it may • Sterilize carpules in your ultrasonic feel as the ice melts. Let the patient know that and autoclave just like any other you want them to identify the feeling of the tooth, instrument. not the surrounding tissue. • Place all of the carpules in a cup with Sensitivity is a highly individualized the open end up. experience. Prior to testing, view the 2D radiographs to determine if the patient has the • Cut strips of floss in about 3” lengths following anatomy: and fold them in half and insert them in each carpule with the folded end in • Normal pulp chamber first. • Small calcified pulp chamber • Fill each carpule with water (hint: use an air/water syringe for ease) and • Large pulp chamber then place in the freezer. Small or calcified pulp chambers are found When the Ice Stick is Frozen in older adults. Even in healthy vital teeth with small, calcified pulp chambers you may notice a • After the sticks are frozen, remove a lessened response or no response whatsoever. single carpule, Large pulp chambers are typically found in • Rub between your hands to warm younger people and elicit a very strong response. slightly Test a few teeth in order to receive your • Pull on the floss to remove the ice baseline response, instead of just testing a single stick from the carpule. tooth. • Wrap the ice stick between a 2x2 Teeth with ceramic crowns may need to gauze square so it doesn’t melt have ice applied longer to elicit a response as instantly from the heat of your fingers the tooth structure and pulp chamber is more protected. Teeth with gold crowns or amalgam restorations are thermal conductors and may 17

Chapter Two: Diagnostic Dataelicit a stronger reaction. Tell the patient that the feeling of warmth on the surrounding tissue is completely normal, but vital Recap of Cold Test Procedure and healthy teeth will not have any response to heat. If you have a patient with a very large pulp 1. Apply the ice stick directly onto the tooth chamber they may feel very slight warmth. and hold it until the patient raises their hand 2.7 Trans-Illumination 2. Remove the ice stick, and watch how Biting sensitivity (a) upon release, and (b) a long it takes for the patient to lower their large pocket, indicates a possible fracture. Trans- hand. Illumination is performed with a fiber optic light source that shows fracture lines present in the 3. Ask the patient if they experience tooth. lingering ache • The tip of the light source should be 4. A within-normal-limits response is when applied around all sides of the tooth in a patient raises their hand when they feel order to view any fracture lines. cold stimulus and immediately drops their hand when the cold stimulus is removed. • Note any findings in the data record and report to the doctor. 5. Note on data record teeth that do not feel the cold for 5 seconds or longer, or if 2.7.1 Trans-Illumination to the cold stimulus has a vague response Detect Cracks in Teeth compared with the baseline tooth. Trans-Illumination is the detection method2.6.7 Heat Testing Procedure that provides the most information, and graphically represents whether a crack is present. Heating testing is a simple, straightforward It is based on the principle that a beam of lightprocedure: The patient should not feel heat on will continue to penetrate through a substanceany tooth whatsoever unless it is the suspect tooth until it meets a space, after which the light beamwith an inflamed nerve. is reflected. This results in a light and a dark area of the tooth separated by a fracture line. Elements Free™ Set Up A dental mirror is used to see whether a • Turn on Elements Free™ after the pulp- fracture is present. A dental (surgical) operating testing wand is inserted into the unit. microscope is useful, particularly by turning off the light source and using only magnification • Activate the ring switch Various trans-illuminators are commercially • Mold a small chunk of a gutta percha stick available, but you could use a fiber-optic hand into a ball on the end of the wand piece with the bur removed (turn the water off), or composite curing lights (protect the patient’s WARNING: eyes as well as your own if using ultraviolet light) Use care when performing this test. The Trans-Illumination of teeth to detect thetesting wand heats to 200° F, and can severely presence of cracks should be performed in all ofburn your patient’s gums, lips, cheek, tongue, or the following instances:your fingers. • On the marginal ridges • Explain to the patient that the instrument is hot • Floor of the restorative preparation • Instruct the patient not to talk • To protect soft tissue, insert 2x2 gauze roll to pull the cheek away from the testing zone. A painful response indicates a dying pulp.18

The Art of Endontic Dental Assisting • The pulpal floor after endodontic access formal salutation and last name (Mr. preparation Jones). This formality demonstrates respect for your patient as well as enforces • Accessible proximal surfaces the professional relationship. • During surgical flap reflection procedures • Have the x-rays up on the computer screen. Trans-Illumination is particularly beneficialwhen performed after restorations are removed. • If possible, have the preliminary findingsMany fractures are not visualized without trans- also open on a computer screen forillumination. immediate reference.2.8 Diagnostic Charting 2.10 Transfer of Information Accurate data collection and organization is The dental assistant is in control of thethe paramount function of the dental assistant. In Subjective and Objective History gathered fromservice to the patient, it is the best guarantee of the patient, as well as the results of Imaging andproper diagnosis. As a responsibility to the doctor, Symptom Reproduction.accurate data collection (a) facilitates treatmentand (b) protects against malpractice claims. The secondary responsibility of the dental assistant is the presentation of (a) organized and • Dated, legibile and fully detailed charts (b) accurate communication of data to the doctor. are the documents relied upon by treating doctors, referring doctors, office staff, Begin with the most important information. insurance companies and courts of law. 1. Emergency conditions • Written records outlive and have greater evidentiary merit than personal memory. 2. Symptom reproduction results • Incomplete and poorly recorded data 3. Fracture identification in a medical record can be construed as substandard care or malpractice. 4. Time restraints or scheduling conflicts A variety of dental software programs help Preferably, this information should bekeep track of this information. However, if you communicated to the doctor before enteringwork in a semi-paperless office, paper back-up the operatory. Having the data record availableforms are helpful in completing data record. as suggested in Chapter 4: Consultation andInformation entered into a paper format can be Procedure Set-Up, for easy retrieval and reviewscanned into the patient record at a later time. helps to improve efficiency and reduce error.2.9 Operatory Preparation and Set-Up Up until this point, the dental assistant hasbeen the primary contact between the patient andthe office. To prepare for the doctor’s entry: • Move the doctor’s chair into the room so the doctor may sit down and talk with the patient eye-to-eye, or position the chair on the patient’s side in order for the doctor to immediately lower the chair back and perform the exam. • Introduce the patient to the doctor using 19



Chapter Three:Treatment and Financial Planning

Chapter Three: Treatment and Financial Planning3.1 Treatment and Financial Coordination situations you should present a multi-phase treatment plan, noting when the patient needs to Even though most offices have a designated return for each step.administrative and financial facilitator, it is oftenbeneficial for the assistant to be present during Conventional root canal treatment followedthese discussions with the patient. Assistant by a crown generally has a 3-step process.participation at this point gives the patient anopportunity to ask questions about treatment in (i) Phase 1 Root canal (the procedure)the context of timing, costs and contribution. (ii) Phase 2 Post procedure tooth preparation The following steps have occurred: (2 weeks later) (i) Diagnosis (iii) Phase 3 Seating of the permanent crown (1-3 weeks thereafter) (ii) Treatment recommendations 3.3 Understand the Patient (iii) Estimate of fees If the patient appears overwhelmed, confused (iv) Patient election to participate or anxious, you can present Phase 1 of the treatment plan only with a simple notation that Initially, patients may be distracted thinking Phase 2 and 3 will follow over a 5-6 week period.how they are going to pay for treatment. When This simplified approach gives the patient enoughmeeting with the financial/insurance facilitator, information to develop a mental timeline of thequestions frequently pop up when explaining the treatment plan. This helps reduce the anxietyprice for the benefit of a treatment plan. Insight caused by misunderstanding of the treatmentinto the specifics of the diagnosis and procedures process and the perception of “padded” billing forspecified in the treatment plan helps substantiate multiple office visits.the fees. This is also a time when the patient mayhave questions regarding insurance contribution Some people prefer to know everythingand timing of payment for services. “up front.” A precise, systematic description of the treatment process gives this type of patient a The assistant may present the treatment plan sense of control. If you have a patient that wantsand costs and, thereafter, introduce the patient to to have all of the information and all of the feesthe financial/insurance and scheduling facilitator. prior to beginning any treatment, this is perfectlyThe assistant may remain in the room while the fine too. It is suggested that a written schedulefinancial/insurance facilitator and scheduling of treatment showing all phases be provided socoordinator discusses these logistics with the that the patient can (a) see all of the visits andpatient. The assistant can help by addressing procedures (b) the price and (c) timeframe. Thisstatements such as, “I don’t need any fillings; the helps create an accurate expectation of whatdoctor said I only have a small spot of decay…” will be accomplished during each visit, and thewhere clarification of the treatment plan helps the financial obligations for each phase.patient understanding the fee. Phasing of the treatment plan should be by Alternatively, the patient may meet with the recommendation of the doctor and should beassistant after consultation with the financial/ according to priority. Why repair a few electiveinsurance facilitator and scheduling coordinator cosmetic composites before treating a tooth withto answer any clinical questions that may have an inflamed and dying nerve? The answer is, youcome up when discussing insurance contribution, would not! If the doctor does not have a treatmentscheduling and payment obligations. phase preference after treating the first initial root canal, than you may time each phase of the3.2 Treatment Phases treatment according to convenience. For example, all necessary treatment that is on the upper right The patient may need multiple teeth treated,or have a complicated treatment plan. In these22

The Art of Endontic Dental Assistingshould be done at one time, if possible. If a crown treating a minor or incompetent) stating that thewill be permanently seated and additional work person to be treated is agreeable to the servicesis required, then you may want to combine that proposed. (See Forms Appendix)appointment with another, to save your patienttime and lessen their commitment to come toyour office unnecessarily. By identifying the bestindividual approach for a patient you, may noticethat long appointments are incredibly difficultfor some and they prefer to have shorter multiplevisits or, in the alternative, fewer more lengthyvisits. Feel free to explain that either alternative isavailable to your patient—knowing is better thanguessing.3.4 Consent Forms ~TheProcedure Consent Form Once the patient has signed the FinancialAgreement (terms of payment), they will alsoneed to sign the Procedure Consent Formfor the specific procedure. This is a writtenacknowledgment of “informed consent” that (a) diagnosis and treatment plan has been fully discussed with the doctor, including the anticipated outcome, possible complications, and alternative treatments available, and (b) patient voluntarily gives permission for the treatment as recommended by the doctor as described in the treatment plan. Consent forms are legal documents thatmay be presented as evidence against claims ofmalpractice, misrepresentation, fraud or omission.The use of Procedure Consent Forms developedas a response to case law, Schoendorff v. Societyof NY Hospital; 211 NY 215; 1914, pertaining to“battery” described as “… the unwanted touchingof someone else.” Further, this case stated, inpertinent part, that “Every human being of adultyears and sound mind has a right to determinewhat shall be done with his own body; asurgeon who performs an operation withouthis patient’s consent commits an assault, forwhich he is liable in damages.” Written informed consent must be obtainedfrom the patient or the patient’s guardian (when 23



Chapter Four:Procedural Set-Up

Chapter Four: Consultation and Procedure Set-up4.1 Consultation and Procedure Set-Up 1. Zirc™ locking trays and boxes a/k/a ZOBE™, (Zirc Organizational Box of Consultation set-up is simple. Regardless Efficiency). This is a color-coded systemof your practice environment, I recommend that of tool organization that can help identifyyou use Zirc™ locking trays so that the entire the set-up by procedure type, treatingconsultation is ready ahead of time; including, (a) doctor, etc.instruments and (b) disposables. Pre-prepared,systematic tray set-up keeps focus on the patient 2. Another organizational system is the useand procedure. (See Figure 4.1) of a rolling cart that can be taken from one operatory to the next. This allowsInstrument tray set up items include: all of the instruments, disposables and general supplies to be easily accessible, • Auto-clavable cassette with the capacity eliminating time to retrieve items from to hold five instruments various locations. (See Figure 4.2) • Mirror 4.2.1 Doctor Organizational System • Explorer Work Station: • Large instrument cassette • Probe • High-speed hand piece • Slow-speed endodontic hand piece • Tooth Sleuth™ • Bur block with necessary burs • 2 Ultrasonic hand pieces • Locking cotton pliers • Ultrasonic block with ultrasonic tips and a • Elements Free™ heat test tip wrench • Stropko™ air/water syringe tip • Gutta Percha • Bite block • Endo benderDisposable tray set up items include: • Finger ruler • Lubricant • Tray sleeve Set up these items on a flat workstation for • Tray cover the doctor. Use the tray on either a separate or combined station to set-up all of the instruments • Patient bib and bib clip that are in the cassette. (See Figure 4.2.1A) • Head rest cover or chair cover 4.2.2 Doctor Instrument Checklist *Ice stick upon testing and no earlier. Cassette: • #3 size Crystal HD mirror4.2 Conventional Root • DG16 endo explorer (straight) • DG16 endo explorer (bent–by you or the Canal Treatment Set-Up doctor using the endo bender) In the same manner as setting up your • Shepherd’s hook explorer or pig-tailconsultation tray, you’ll also want to prepare foryour root canal procedures. The most difficult part for most assistantsthat are new to endodontic procedures is theamount of instruments, disposables, and generalsupplies that are needed. When beginning thisset-up process, it may take you as long as 20minutes to prepare and then take down a room.With system-based organization, this process willbecome much more efficient. Assistant organizational systems aresuggested as follows:26

The Art of Endontic Dental Assisting explorer–whatever your doctor prefers • Flat composite instrument• Probe• Large spoon excavator • 4-5 Pairs of locking pliers*• Medium spoon excavator• Small spoon excavator *Why so many locking pliers? If your doctor• Plugger composite instrument is treating a molar with four canals they will need to have one plier for each of the gutta percha cones, and an extra plier for general use. (See Figure 4.2.2A)Figure 4.1– Consultation Tray Figure 4.2.1A– Doctor’s InstrumentsFigure 4.2– Assistant Box shown with Locking Lid closed Figure 4.2.2A– Doctor Tray closed 27

Chapter Four: Consultation and Procedure Set-Up4.2.3 Assistant Instrument Checklist 4.2.4 Obturation Tray Locking Box: It is recommended that these trays be in each • Locking box individual operatory permanently or added to • Mirror (preferably a #5 as you will only armamentarium brought into each room at the time of set-up. These trays function more as storage need this for retraction) trays rather than working trays. (See Figure 4.2.4) • Buchanan Plugger™ #0 (yellow) • Buchanan Plugger™ #1 (red) Obturation Tray: • Buchanan Plugger™ #2 (blue) • 3 pairs of locking pliers • Pre-gauged and cut gutta percha cones at 20, • Spatula 30, and 40* • Endodontic suction • Stropko™ air/water syringe and tip • Untrimmed gutta percha cones • Rubber dam • Rubber dam frame • Paper points gutta percha cones • Rubber dam clamps in a box • Rubber dam forceps • Auto-fit backfill cones • Rubber dam punch • Apex locator hook • 20-60 sized Gutta Core™ carriers • Apex locater rod • Monoject syringe tips with blunted and • Elements Free™ backfill cartridges vented needles • Gutta gauge • Kerr pulp cap sealer • Mixing pad • Scalpel (cutting gutta percha) Additional Items: • Scissors • Apex Locator • Heat Pluggers in Heat Plugger caddy ( See Figure 4.2.3A-E) *You will want to prepare the gutta percha cones ahead of time for your doctor. This tray has all reusable/disposable items. When the procedure is complete, wipe down everything. Place a new tray wrap and cover. Place all of the items back in the locking tray for the next procedure. Check inventory of the tray on a regular basis, and restock monthly. You are now prepared for any obturation technique.28

The Art of Endontic Dental AssistingFigure 4.2.3A– Top layer of Assistant Box (Assistant Figure 4.2.3D– Assistant Cassette openedCassette) Figure 4.2.3E– Assistant Cassette closedFigure 4.2.3B– Middle layer of Assistant Box Figure 4.2.4– Obturation TrayFigure 4.2.3C– Bottom layer of Assistant Box 29

Chapter Four: Consultation and Procedure Set-Up4.2.5 Restoration Tray • Composite gun • 2-3 Composite Carpules (temporary and permanent) • Curing light • Cavit™ (temporary filling material) This tray should be wiped or sprayed cleaneach time, re-wrapped, and placed in an operatoryor stored with other boxes and trays for the nextuse. (See Figure 4.2.5)4.3 Procedural Preparation Activity Figure 4.2.5– Restorative Tray Prior to each procedure, there are twoadditional organizational practices to beaccomplished besides the box and traypreparation. This is the preparation activity ofdisposable components.4.3.1 Estimation of Lengths Figure 4.3.1– Assistant Endo-Ring with sponge and files Before the procedure begins, estimate howlong each canal may be. This helps the doctorhave an idea of the canal length prior to entry,and also helps you determine the correct file sizebefore the procedure. A default file size to use isa 25 mm length adjusted to your specific canals’length. (See Figure 4.3.1) 1. Open the patients’ CT scan and use the measuring tool associated with your machine’s software to measure the tip of the root to the tip of a cusp. 2. The length will display on the screen. Note in the patient record. 3. Write each canal length down on a Post- It™ note and place in a visible spot during the procedure, such as on a microscope or TrueVision™ 3D camera. On the note have the canals and lengths listed as shown in the illustration below. 4. Note that these are ‘estimated’ lengths. Figure 4.3.2– VistaDental ™ Syringe and Anesthetic Warmer30

The Art of Endontic Dental Assisting4.3.2 Fresh Sodium Hypochlorite and EDTA • Does the tooth have a ceramic crown? If so, prepare a diamond bur for the doctor Preparation of fresh monoject syringes filled to cut an access through the crown.with sodium hypochlorite and EDTA. (See Figure4.3.2A) Please note that the monoject syringes • Is it a virgin tooth? If so, prepare thecannot be prepared ahead of time and stored in smallest round bur for preparing thethe procedure tray. The EDTA will eat through access cavity.the plastic, and the sodium hypochlorite is mosteffective when it is fresh. The earliest a monoject Along with placing the bur in the high-speedsyringe can be prepared is the morning of or hand piece, also place a 15/06 Vortex Blue™evening prior. rotary file in the slow-speed hand piece. Turn on the syringe warmer and keep the The 15/06 Vortex Blue™ rotary file issodium hypochlorite warmed immediately the most common rotary file used to beginbefore and during the procedure. Heat increases negotiation and cleaning. Therefore, it should bethe efficacy of the sodium hypochlorite. Do placed in the endo hand piece.not warm the EDTA solution. Include extramonoject syringe tips (store in your procedure Finally, have two separate ultrasonic handbox) in case one of the tips becomes bent, pieces prepared–one with a BUC-1™ tip; andclogged or unusable. the second with a BUC-2™ tip fastened on for immediate use. These hand pieces can then be4.3.3 Lubricant traded out through the procedure more easily than unscrewing the ultrasonic tip and tightening a A single-dose lubricant such as ProLube™ new tip on.should be placed on the doctor’s tray with the tipcut off for immediate use. Single-dose lubricant 4.3.6 Rubber Dam Punchtubes can be stored in the procedural tray for easyaccess and storage. A single-dose lubricant tube Prepare your rubber dam and clamp ahead ofshould be enough for a single tooth. Your doctor time for quick isolation when the patient is numbwill begin using lubricant once the access has and ready to begin treatment. The simplest andbeen completed. Lubricant is also helpful when most foolproof method to punch a rubber dam isdetermining the working lengths of each canal by using a rubber dam punch guide. Mark theusing the apex locator, as well as facilitating rubber dam with a Sharpie™ where to punch itmovement of files to the apex. for a particular tooth. Another way to punch the rubber dam is to place the rubber dam on to the4.3.4 Water Check for Doctor and Assistant frame, hold it up to the patient’s mouth, locate the working tooth and place your finger on the Check the water levels on both the doctor outside of the dam and mark the area. Then,and assistants’ side. Ideally, this should be done remove the dam from the frame and punch theat the beginning or end of each day. Confirm that mark.there is plenty of water for the duration of theprocedure. Once the dam is punched, drape it over the frame by tightly securing the four corners of the4.3.5 Bur, Rotary File, Ultrasonic dam to the frame while letting the middle areasTip and Hand Piece drape loosely. Once this has been done, you can now apply the clamp, keeping in mind that While setting up for the procedure, take the “loop” should always face the back of thenotice of the condition of the tooth that will be patient’s mouth. (See Figure 4.3.6A-B, next page)worked on. 31

Chapter Four: Consultation and Procedure Set-Up4.3.7 Rubber Dam Clamp Selection 4.3.8 Anesthesia There are many different types of rubber Anesthesia preparation should be the finaldam clamps available, but you will only need the activity of procedure set-up. You can easilyfollowing 4 sizes, which are the most common keep the disposable items such as the anestheticclamps for all procedures.* (See Figure 4.3.7) carpules and needles in your procedure locking box along with the topical anesthetic and cotton • 12A–This is a molar clamp with a serrated applicators. (See Figure 4.3.8) inner edge. A simple way to distinguish between this clamp and the 13A, which The Wand™ is a mechanized anesthesia is also a serrated clamp, is to mentally delivery system that measures out the anesthesia picture the large edge fitting on the buccal to patient comfort. Whatever the system used in side of a molar. This would mean that the your practice, prepare the syringe ahead of time 12A would only function on a lower right with the correct needle and pre-load the correct or an upper left molar. anesthetic carpule. • 13A–This clamp is the same as the 12A Warming the anesthetic makes the injection with a serrated inner edge, but has a much more comfortable for the patient. Simply larger edge on the opposite side, making place the most commonly used types of anesthetic it perfect for a lower left or upper right carpules in the syringe warmer at the beginning molar. of the day. The anesthetic carpules can be rewarmed without affecting potency. • 12A–This clamp has smooth inner edges with both sides equal. This clamp is used for all bicuspids. • 9–This clamp is used for all anterior teeth. This clamp may also be used when doing a split-dam technique as the long loops help pull the rubber dam material further apart. *Remember that the clamp “loop” shouldalways be closest to the back of the patient’smouth.32

The Art of Endontic Dental Assisting Figure 4.3.6B– Rubber dam items: forceps, punch, rubber dam, foldable frame, and clampsFigure 4.3.6A– Rubber Dam Punch Guide Figure 4.3.7– Rubber dam clamps (1. 9A- Anterior, 2. 2A- Bicuspid, 3. 12A: Lower right, upper left, 13A: Lower left, upper right) Figure 4.3.8– Anesthesia Tray 33

Figure 5– Endodontic File Box Files listed by size (left to right): Top section: 15 K-File (21mm), 6 (25mm), 8 (25mm), 10 (25mm), 15 (25mm), 20 (25mm), 30 (25mm), 40 (25mm), 50 (25mm), 25 red broach (25mm) Bottom section: All 25mm: 15/04 Vortex Blue, 15/06 Vortex Blue, 20/06, 20/04, 30/06, 30/04, 40/06, 40/04, 30/08, 40/08

Chapter Five:Assisting During Procedure

Chapter Five: Assisting During Procedure5.1 Anesthesia Figure 5.2– Rubber dam on foldable frame with clamp placed Whether applying topical or block injectionanesthesia, place the topical anesthesia in a 5.2 Isolationfolded 2x2 gauze nest. This will keep the patientfrom (a) tasting the topical, and (b) keep it from Five to 10 minutes after the administrationrunning down the patient’s throat, which may of anesthesia, check to confirm that the patientincrease saliva production. is numb. Do this by pulp testing the tooth with (a) gentle percussion and (b) an ice stick. If the Alert the doctor that the patient is ready for patient tests normally in the baseline quadrant,anesthesia. Stay with the patient to repeatedly and can no longer feel any testing on the workingsuction if necessary. tooth, the patient is ready for the procedure. (See Figure 5.2) In states where it is legal, a hygienist mayadminister anesthesia pursuant to the doctor’s • Place any suctioning devices such as thedirection. Isolite™ or other mouth-props prior to placing the rubber dam.5.1.1 Topical Anesthesia • Prepared rubber dam, clamp, and frame, • Begin by putting a small amount of using the rubber dam forceps to place topical anesthetic on a cotton-tipped around the working tooth. applicator. • Double check to ensure stability of the • Place the cotton-tipped applicator clamp approximately one tooth before the tooth on which you will be working. • Use the shepherd’s hook explorer to fold the rubber dam over the winged parts of • Example: If working on #12, place the the clamps. cotton-tipped applicator above #11 as the nerves to each tooth run slightly anterior • Floss between each contact to snap the to the tooth itself. rubber dam material into place.5.1.2 Nerve Block 5.3 Access • When working on the mandible, the Once your patient has been fully isolated, the doctor may perform a block injection. doctor is ready to begin treatment. • Nerve blocks are used for pain treatment 1. High Speed Hand Piece: The doctor and management. By injection of nerve will begin by using the high-speed hand numbing medication, the entire quadrant piece that has been prepped with the pre- may be rendered without feeling. selected access bur. • Place the cotton-tipped applicator all the way to the back of the patient’s mouth above their lower molar. This is where the doctor will access the lower nerve pathway to perform the block injection.36

The Art of Endontic Dental Assisting2. Water Spray: During use of the high- Figure 5.3– The assistant keeps the high-volume suction speed hand piece, it is important to use close while the doctor is accessing the tooth. a high volume suction to evacuate water from the patient’s mouth. (See Figure 5.3)3. Saliva Ejector: Frequently, the patient will experience the sensation of drowning. Use the saliva ejector to alleviate discomfort. If the patient becomes anxious, tell the patient that the rubber dam protects against ingestion of debris and water. Reassure the patient that it is okay to swallow--it is only saliva.4. In creating the access cavity, the doctor will use the LAxxess™ diamond bur. This bur has a pilot tip like a router that can come off very easily. Be mindful that if it does come off, you can evacuate it quickly and discreetly. Let the doctor know that they need to replace the bur with a new one.5.4 Negotiation Figure 5.4A– The doctor uses the Apex Locator to measure the length of the working canal. The assistant holds the Upon completion of the access cavity Endo Ring file sponge ready for any new files the doctor may need. • Add lubricant to the cavity, and • Unwrap the apex locator for use. Figure 5.4B–The assistant notes the working length of each canal on a Post-It™ note to refer to throughout the procedure. If you are sitting on a chair that has an armin front, the arm can be used to rest the apexlocator. Be careful not to drop the apex locator. 1. Hook the lip clip attachment on the patient’s cheek on the opposite side of the working tooth, being careful not to disturb the rubber dam. 2. Place the rod attachment on the patient bib so that it is easily available for the doctor. (See Figure 5.4A) 3. When begins using the apex locator and telling you the working lengths, write them next to each canal on a blank Post- It™ note. (See Figure 5.4B) Also, the doctor will tell you the referencepoint—the reference point is spot from whichthey are measuring. The reference point istypically a cusp tip or, if the tooth has beenground down or flattened, a high point such as themesial high point. 37

Chaprer Five: Assisting During Procedure When all of the canals have been measured and Figure 5.4C– While the doctor is working and not needingnoted on the blank Post-It™, remove the estimated suction, the assistant reorganizes the Endo Ring file spongeworking lengths Post-It™ and replace it with the and double checks each file to ensure it is not unwinding,reference point Post-It™. Save all Post-It™ notes bent, or broken. If it is, immediately throw the faulty filefor reference when writing the clinical notes after the into the sharps container and replaces it with a fresh new file.procedure. Figure 5.4D– The doctor chooses a new file from the • Check that every file is returned to the ring assistant’s Endo Ring file sponge. sponge. • Check for bended, broken ends, or unwinding files. If the file begins to unwind, replace with a new file. • Discard broken, bent or kinked files. Place them into your sharps container as you would a needle, or set them to the side on gauze to dispose of them in the sharps container later. • Replace any broken, bent or kinked files. (See Figure 5.4C) After the doctor has (a) measured the actualworking lengths of all the canals, and (b) the actuallengths have been noted, ask in which canal the doctorwill be working. After verbal confirmation, measureall of the rotary files to the canal working length bymoving the stop on the file to the correct measurement.(See Figure 5.4D) • The doctor may go through a series of rotary files in cleaning and shaping. • The doctor will use EDTA irrigation during this process. • Always keep the 90-degree endo suction on the occlusal surface as close as possible to the access cavity. This will ensure that any irrigation used does not eat through the rubber dam and, in turn, will not go into the patient’s mouth or digestive track.5.5 Cleaning the Smear Layer Figure 5.5B– Doctor removing the smear layer and EDTA is used through the cleaning and shaping preventing blocking out by using EDTA irrigation.process. It is a chelating agent, removing the smeared Block out means there is debris that prohibitslayer that can block out the canal system. (See Figure5.5A, p.40) 38

The Art of Endontic Dental Assistingthe doctor from becoming patent. Patent means 5.7 Irrigationgoing to the end of the root canal. If block out occurs, When all of the canals have been gauged,the debris-filled canal cannot be effectively cleaned, the doctor will begin the irrigation process.and bacteria may be present. As the doctor uses the Irrigation is the most important processes ofEDTA, lubricant will be added as needed. the entire procedure. Irrigating with sodiumWhile the doctor is using the shaping files, note at hypochlorite for at least 30 minutes ensures thatwhat length each canal becomes patent. For example, all bacteria is killed, and the root canal system iswrite that the mesial canal is shaped to a 30/06. This clean for obturation. (See Figure 5.7, next page)way when it comes time to gauge and obturate, you Due to the 30-minute irrigation time, yourcan easily tell the doctor the shape of each canal. (See office may choose to complete this root canal inFigure 5.5B) two separate visits. Following irrigation is the best end point in this situation.5.6 Gauging After all the canals have been shaped, the doctor 5.7.1 Two Visit Approachwill gauge the canals to confirm that shaping iscomplete. The file size that the doctor uses to begin is • If this is the case, the doctor will insteaddetermined by the shaping file. If the finished shape place calcium hydroxide in each of thein the canal is a 30/06, the doctor will use the 20, 30, canals, which will kill any bacteria thatand 40 file. linger over the next few weeks until the patient returns for the completion • The 20 will become patent (go to the end of appointment. the root canal) • After the calcium hydroxide is placed, • The 30 will bind at length a sponge and temporary restoration can be put into place. The patient can be • The 40 will stop short (about 1 to 1 ½ mm (a) scheduled for a second appointment short) and (b) given appropriate post-operative instructions. This means: • The 30 would be the correct size.• The 20 is too small and slips through. 5.7.2 Single Visit Approach• The 40 is too large because it stops short. If the doctor does decide to irrigate usingThe doctor should not twist or rotate the gauging the 30-minute single visit approach, you mayfile at the end of the canal otherwise the microscopic be asked to irrigate the canals with sodiumrazor-like flutes will cut the apical portion of the canal hypochlorite. (See Figure 5.7.2)to a larger size. 1. Place a stop on the end of a 30 GAPre-measure all of the gauging files as you did blunted and vented tip needle so that youfor the rotary files, according to each of the canal’s are a safe distance from the apices of theworking lengths. canal (typically 3-4 mm shorter than theThe final file used in gauging will be the smallest shortest canal’s working length).file that slipped through the first time so that the doctor 2. Use warmed sodium hypochlorite whilebecomes patent. This pushes through any remaining suctioning with the 90 degree suction withdebris that could bind during obturation. the free hand 3. Fill the tooth with fresh irrigation solution. 4. Do not let the irrigation solution overflow 39

Chaprer Five: Assisting During Procedure while being careful not to suction all of Figure 5.5A– EDTA the solution out of the access cavity. Figure 5.7– Monoject Syringe Irrigation filled with Sodium 5. Freshen the solution every 5 minutes over Hypochlorite the 30-minute time period. Figure 5.7.2– Freshening the Sodium Hypochlorite irrigation 6. After completion of the 30-minute solution (done approximately every 5 minutes for 30-40 process, alert the doctor. minutes) 7. Continue freshening the solution every 5 minutes until the doctor returns to finish the procedure.5.7.3 Ultrasonic Approach* The doctor may decide to use the Irrisafe™tip after sodium hypochlorite has been added tothe canals. (See Figure 5.7.3) • The Irrisafe™ tip will be placed patent through each canal (so as not to cut and ledge while in the canal system). • The doctor will then ultrasonically treat the canal. • A small stream of bubbles will appear indicating that the ultrasonic irrigation solution is active. • If ultrasonic irrigation is used, irrigation is shortened by half the time. *The dental assistant is not legally allowedto perform this technique. Figure 5.7.3– The doctor uses the Acteon™ ultrasonic unit to use ultrasonication in the presence of Sodium Hypochlorite to eradicate the canals of bacteria.40

The Art of Endontic Dental Assisting5.8 Obturation spatula off of the mixing pad 2-3 inches high without dropping. Obturation is the three-dimensional fillingof the pulp chamber and root canal system with • Often when you’re mixing it will feel toofiling material (usually gutta percha and sealer). hard to mix but continue working it untilIf the doctor is cone fitting, the preparation for it becomes thick and creamy.obturation may begin during the irrigationprocess. Carrier Cement Mixture • Cone fitting can be done in the presence If the doctor is using carriers, you will want of sodium hypochlorite. to make your mix much thinner. • Cone fitting is never done dry so the • This is done with equal parts Kerr Pulp doctor can experience actual tug-back of Sealer™ powder and Kerr Pulp Sealer™ the cone. Tug-back is how the cone will liquid, or 1-scoop to 1-drop ratio. resist and bind at the tip after the correct size and length is chosen. Tug back, like • This should string up about one inch the gauging process, ensures that the before falling onto the mixing pad. sizing is correct. • If this is done after completion of irrigation, the doctor will finish by irrigating with EDTA. This removes the smear layer and the tooth will then be ready for drying and obturation. • Suction the entire access cavity once EDTA has been used. (See Figure 5.8)5.9 Cement Mixture Figure 5.8– The doctor rinses with EDTA irrigant after finishing irrigation with Sodium Hypochlorite. The cement mixture is critical to the entireprocedure. A perfect root canal can be ruined Figure 5.9– Mixing the cement for Cone Fit Techniquewith improperly prepared cement. The powder toliquid ratio is key to perfect cement. (See Figure5.9) Cone Fit Cement Mixture. Cement mixture for cone fit obturationneeds to be extremely thick; so thick that you’llthink that you need to scrap it for a new batch. • Mix 2 scoops of Kerr Pulp Sealer™ to one drop of Kerr Pulp Sealer™ liquid. • If using the EWT (extended working time), the cement will be pliable for hours, although you should not prepare this ahead of time. • The cement, when lifted by your mixing spatula, should stay connected to the 41

Chaprer Five: Assisting During Procedure5.10 Paper Points Figure 5.11A– Doctor dipping the Gutta Percha Cone into the sealer. While the assistant mixes the cement, thedoctor will use paper points to dry each canal. 1. The doctor will also confirm lengths with paper points by placing each paper point into the canals initially and then removing them with locking pliers. 2. The doctor will then press the wet tip of the paper point with the finger to bend it back, and measure the unbent portion all the way to the locking pliers. 3. This paper point length will be the length in the canal. 4. The working length may fluctuate slightly if there was an impediment present that the doctor worked around, shortening the working length of the canal. 5. After the tooth is fully dried and the cement mixture is prepared, the doctor will then begin obturation.5.11 Cone Fit Technique Figure 5.11B– Obturating with the Elements™ Free unit with the appropriate sized Buchanan Heat Pluggers™. If the doctor is using cones to fill the rootcanal, they will: (See Figure 5.11A) Figure 5.11C– Doctor using the Buchanan #1 (red) Plugger™ after searing the cone at the orifice with the Elements™ • Coat the cone with cement; Free unit. The assistant holds both the Buchanan #2 (blue) • Place cone in the canal; Plugger™ as well as the Elements™ Free unit to pass to the • Remove the cone; doctor depending which they will need next. • Coat cone again with cement, and place. After all cones are placed, the doctor willuse the Elements Free™ heat tips to sear eachcone off at the orifice. (See Figure 5.11B-C) 1. After this is done, the doctor will use the larger end of the corresponding heat plugger to compact the softened gutta percha at the orifice. 2. The assistant will pass the hand plugger and heat plugger back and forth in rapid succession. Be prepared to have the hand and heat pluggers readily available. 3. The doctor will then use the heat plugger again, first in a single downward packing stroke, and then will go back to the corresponding hand plugger, and then repeat in each canal. 42