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Clinical Master Magazine

60 — issue 1/2015 Endodontics Article CUTTING ENDODONTIC ACCESS CAVITIES — for long term outcomes — Dr. L. Stephen Buchanan DDS, FACD, FICD, is a Diplomate of the American Board of Endodontics, he is a fellow of the American and International Colleges of Dentists, and he serves as part-time faculty to the UCLA and USC graduate endodontic programs. Dr. Buchanan holds patents on the Endobender Plier (SybronEndo), System-B and Continuous Wave obtu- ration tools and methods (SybronEndo), GT and GTX file systems (Dentsply/Tulsa Dental Specialties), LA Axxess Burs (SybronEndo), and Buc ultrasonic tips (Spartan/Obtura). Dr. Buchanan lives in Santa Barbara, California where he enjoys a practice limited to conventional and micro- surgical endodontics and dental implant surgery. He is the founder of Dental Education Laboratories, a hands-on training facility in Santa Barbara he has directed for 28 years. Errors accumulate during procedures. That's the reason botching the access at the start of a RCT is so much more de- vastating than say, problems that come from misfitting a gutta percha cone, just before finishing the case. Miss a canal and the case is going down, regardless of how brilliant the remaining procedure is carried out. Perforate the tooth and suddenly titanium starts looking better. Cut huge access cavities and expect to see relatively huge numbers of root- fractured teeth within 5 years of treat- ment. Simply cheat the access proce- dure by beginning the instrumentation of canals before a straight, perfectly smooth path has been cut to each canal orifice and be punished every time a file, an irrigating needle, an explorer, a gutta perch point, a paper point, or a plugger is taken into each of the canals scores of times. This is not a critique so much as an ad- mission of the ways that teeth and their root canal systems have taught me, usu- ally the hard way, to spend whatever time is needed to create perfect entry paths into canals, before I attempt to work in them. So why do I have to have a talk with myself before beginning every access cavity – even after doing this for 35 years - to be certain to hit the mark I know must be met, before it is safe to venture further? Zen and the Art of Endo Access RobertPersig,inhisbook,"ZenandtheArt of Motorcycle Maintenance,"1 described being deeply frustrated when a bolt stripped as he was attempting to remove the side covers to the engine of his mo- torcycle, before rebuilding it. The rebuild couldnotcontinueuntilhewasabletocir- cumvent this problem. He had expected tospendseveraldayscompletingthemis- sion, yet he was amazed at the fury he ex- perienced when faced with this conun- drum. The more he thought about it, the more mystified he became about his in- stinctual response, until he realized that hewastweakedbecausehehadgrosslyun- dervaluedthispartofthelongrebuildpro- cedure, thinking mostly about the more dramaticroutinestofollow,suchascrack- ing the cylinder case, honing the cylinder, replacingthepiston,andputtingitallback together afterwards. When he realized thatNOTHINGwasgoingtoprogressuntil he had successfully removed the side cover, he made removing that side cover a separate and important mission, an ac- complishmentthatwoulddeliversatisfac- tion in and of itself, if it could be com- pletedduringthenextseveralhoursspent. Then he was having fun again. So it is with endodontics. When we re- alize how critical the quality of our access preparations is to the remainder of the case, it feels like fingernails on a chalk- boardtoheadintoacanal,beforesecuring an ideal path into it. Aristotle got it right, excellence is a habit, not a charactertrait, sowhatdothehabitsofaccessexcellence look like in this twenty-first century? Failing to plan is planning to fail Atul Gawande, in his book "The Checklist Manifesto,"2 describes the importance of planning not just which procedure to do, but how every single aspect of that pro- cedure must be planned in detail, from start to finish, if consistently ideal results arethe goal. Doesthe preoperative imag- ing accurately describe the anatomical challenges, does the clinician have ade- quatemagnificationandlight,arethecut- ting tools adequate and well chosen, are the locations, angles, and depths of entry determined before beginning the proce- dure, have maximal safe cutting lengths been marked on access burs, are there procedures in place to deal with calcified canals that defy location, and so on. In other words, the Alfred E. Neumann atti- tude of "What, me worry?" is not appro- priate during this critical event. Con- versely, when each of these critical elements is included in the treatment

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