Toothbrushes Review - from a dentist perspective

Toothbrushing have become a daily routine in modern day life and yet most of us don’t give much thought about the toothbrush we buy.

For a long time, I been wanting to write a post about toothbrushes and oral hygiene products that I have personally tried and were effective. I got to admit the urge to write this is highly influenced by those Youtuber skincare review videos which I frequently binged on. After googling, I noticed not many dentists have ever shared about their honest opinions of toothbrushes and their designs. Ever since learning about oral hygiene maintenance back in 3^rd year of dental school, I always love to explore what are the new toothbrushes available in the local market. Personally, I do believe that the manual toothbrush is good enough when designed appropriately. By using it in the right technique, it can be our greatest weapon to keep those plaque at bay. An electric toothbrush is not any superior. I know some people are more motivate to brush with them thinking technology is helping them to do a better job at cleaning. However, I want to make it clear that spending large amount of money on a toothbrush doesn’t equate to improving your oral health. Any tool used in the wrong manner will not bring out the desired result.

Modified Bass Toothbrushing Technique (Pic taken from Pinterest)

I truly stand by the Modified Bass toothbrushing technique as it can really clean all surfaces IF your teeth are in the right alignment. However, the selection of toothbrush design itself is important and many dentists just overlook this aspect when giving their patient oral hygiene instructions. I know and have seen people are often confuse when they are at the oral hygiene section in supermarkets or pharmacies, trying to pick out the right toothbrush. You can almost read it on their faces; hard or soft bristled? Blue or red? Should I get that one with the rubbery tongue scraper at the back? – so here are my personal opinion of good toothbrush designs that one should look out for. 

1.       Only Bristle that are Soft or any softer than that.

Remember the aim of toothbrushing is to remove food debris or plaque are that loosely bound to the teeth surfaces. We are not trying to remove stubborn stains or tartar that certainly won’t budge even though you brush with all your might.  It is fairly common to hear patient saying they feel brushing with a soft bristle doesn’t feel like they are doing effective cleaning and that’s why they continue to use the hard bristle. It is also this same kind of patient that will present with many cervical abrasion lesions (the holes that you create on the neck of the teeth when you brush) in their mouth. Irony the patient is losing good teeth structure while they are making the effort to clean their teeth to prevent decay. There are 3 contributing factor to this: You are using too hard bristle; You are simply putting too much force when brushing; You are brushing with the wrong technique.

Colgate Slim Soft Flex Clean toothbrush

Recently I have discovered a new kind of soft toothbrush from Colgate (picture above) where the bristle made of silicon (usually the bristles are made of nylon). The toothbrush when used with a gentle force already feels like you are brushing with a hard toothbrush and therefore, I felt that it will be good for those who are really used to brushing hard. However, the down side of it is that the bristle are not thin, so if the patient wants to use this toothbrush, they must floss afterwards.

2.       Thin Plastic casing that holds the bristle.

The width of the plastic that encase the bristle makes a huge difference when cleaning the upper back teeth. I only notice the significance of this part on the toothbrush after my upper wisdom teeth were erupting. Using such toothbrush in combination with not opening your mouth too big, you can reach those narrow areas of the upper molars nicely without hurting your cheeks.

 

Systema Super Thin Charcoal Compact toothbrush boast of a 3mm plastic encasing

DentalPro Ultra Slim Compact C22 toothbrush also have similar thinner head

 

3.       Longer Bristles

Longer bristle can facilitate to clean the lingual surfaces of lower anteriors (inner surface / tongue surface of lower front teeth) better. It is also more effective for those who have gum recession (shrunken gums) where the teeth are slightly longer.

Oral B Pro-Dense Gum Care toothbrushes do have bristles are longer than the usual by roughly 0.5mm. The overall size of the toothbrush head is also small and compact with the only design downfall in my opinion is the thick plastic casing.

4.       The length of the brush head should cover 2-3 teeth at once, not any lesser or more than that

You are not brushing an elephant’s teeth; you don’t need such long or big toothbrush. As our teeth are arrange in a curvature and the toothbrushes head are usually straight, a longer toothbrush head won’t be able to cover all the surfaces and may even hinder you from reaching those deeper areas. However, the head of the toothbrush also should not be too small/compact that you can only brush a tooth per time.

5.       Wider Brush Head

Especially when brushing the buccal (tooth surface towards the cheeks and lips) or lingual (tooth surface towards the tongue) surfaces, not the entire tooth surface will be cleaned if the brush head is too narrow. A wider brush head will increase the area of coverage, hopefully able to simultaneously cleaning from the coronal 3^rd to cervical 3^rd of the tooth.

Darlie Wide Clean toothbrush is a good example of wider brush head toothbrushes. However, this good feature is somehow compromised by the center elevated bristle which hinders the adaptation of the side bristle to clean effectively when used in a 45 degrees angulation on the buccal or lingual surfaces.

PERIOE Wide Edge toothbrushes from Korea also had similar wider brush head design

The above 5 points are crucial for me when I judge whether the toothbrush will be effective. I’m aware that companies have been trying to upgrade and improve this close to 100-year-old oral hygiene tool. One of such attempts is to in cooperate some rubbery bristle which claims to help polish the teeth and massage the gums as you brush. Having tried those toothbrushes, I don’t find that they are as effective as those with just regular nylon bristle. Also, I find toothbrush with charcoal, green tea, gold or silver particle infused bristle a little gimmicky.

 Unbeknownst, people still tend to choose their toothbrushes mainly base on the look and the packaging. As we live in a social media driven world, I know many are attracted to trendy toothbrushes (e.g. One Morning, Curapox) seen on the Gram with various color combinations and quirky designs.

One morning toothbrush

 Size wise and bristle I think it’s good but I find the shank to be not rigid enough to help you adapt the toothbrush to the surface of the teeth. Probably would be useful to train those patients who apply heavy pressure when brushing as such force will certainly cause the shank to bend away from the tooth.

The popular Curapox 5460 claimed to have more bristle packed into your toothbrush helping you to cover more surfaces while brushing. However, I noticed they have used same length bristles which seems more ineffective to adapt nicely against the convex and concave surfaces on the tooth.

Jordan Clean Smile do share similar design to Curapox 5460 with slightly longer brush head

As majority of our toothbrushes sold here in Malaysia are still made of plastic, I do share the concern they are that not eco-friendly. (Imagine your toothbrush when you used as a kid is still lying somewhere in the landfills) There is an increase interest among the public to switch to bamboo toothbrushes but I have yet to try any of them to give my thoughts in this post. Not just the brush but the plastic that is used in the packaging is also a concern that oral hygiene product manufacturing companies should look into. So far, only Jordan Green Clean toothbrush is a good example of an eco-friendly toothbrush in Malaysia with even its packaging made fully with recycled cardboard.

Jordan Green Clean toothbrush claims to be made of 100% Recycled Plastic with 100% BioBase Bristle packaged in a 100% recycled cardboard box. That’s a lot of 100% promises but if they could just make the toothbrush head slightly thinner, then it would be 100% marks for me!

There are also special toothbrushes with thicker handles for people who have dexterity issues.

Ci 803s toothbrush (left) have thicker handles for patients with weak grips.

Before I wrap things up, I want to specially mention this toothbrush I bought during my last Korea trip. Initially I was attracted to the contra-angle shank and wonder will it work like our dental handpieces. Surprising, the kind of shank actually also do help you get about the back teeth. However, such design is not available at the moment in Malaysia stores.

Contra-angled shank toothbrush I found in Korea

So far, my top 3 manual toothbrushes available in Malaysia are:

1. Systema Super Thin Charcoal Compact toothbrush

2. Oral B Pro-Dense Gum Care toothbrushes

3.  DentalPro Ultra Slim Compact C22

I hope my observations and honest opinions shared here can not only help the general public, dental practitioners but also toothbrush designers.

If you have read till now, I would like to know what are your thought process when come to picking a toothbrush and what have been your favorite brush so far. Please feel free to leave me comment. I would love to hear from you.

Reflections: Letter to My 18 year Old Self

Have you ever wondered what you could have done differently if you can turn back time? As I’m going to start another new phase of my life soon, I thought it would be appropriate do a self-reflection post for the past 10 years. Honestly, I have always wanted to try write one of these ‘advice to my younger self’ letters.

Me at 18

I know it’s a fact that I have changed and grown in many ways. What I valued at 18 and my perspective of life is really different now. After graduating, I realized I have kept myself a prisoner in a cocoon for far too long and wished I could have challenged myself a little more.

At 18, I was still in the carefree stage of life and the reality of the future has not hit me yet.  I hope by sharing this letter it will help to give some value to those who are aspiring to become dentists.

So here it goes – a letter to RC at sweet 18

********************************************************************

Hey Rei Chiel,

It's me, you from 10 years later. As I recall, you must have just left college and about to spend 9 months idle before you start dental school.  These 9 months are very precious time which you can invest to grow your general knowledge and they are I-M-P-O-R-T-A-N-T. Spend more time reading and read far and wide. Take heed of your mother’s nagging to be interested in world issues, economics and business. She meant it well and you will thank her for it because from where I am now, I regret not knowing much more.

Ever since young you have been obsess of becoming a dentist and quite determined at least finishing your tertiary education till a postgraduate level in orthodontics.  However, I know you ACTUALLY don’t really know what you are diving into. Dentistry has many dimensions and if you plan it right, can turn out to be a rewarding career. You not only need to be a good clinician but also learn how to be an entrepreneur (which you will learn nothing of this in dental school).  There are so many roles to juggled which makes this field interesting but yet daunting at the same time.  It would be good if you seek out of opportunities to shadow a dentist before you go off to India. Don't be fooled by those cliché quotes in line with "Follow your passion and you will never work a day in your life" Life is more dynamic than that and passion can change over time. You won’t always be happy as a dentist. There will be days you will drag your feet to work and have to face stresses you did not even think about before. The work you are about to do is very tedious and precise. You will have to manage patients (human beings) of different temperaments and limiting anatomy (e.g.: small month openings, macroglossia, hypersalivation). You will also have to work with unmotivated staffs and having to juggle between being nice or strict with them. You will face many things that are beyond your control but don’t let all these weighs you down. Just aim to be better than yesterday and encourage those around to do the same.

This is a life long journey of learning. It is a fact that you will not be well equipped to handle every case when you first join the workforce. There will be times you aren’t the most confident and when things don’t go as planned for example you broke a root tip and unable to retrieve it, you will feel like a failure. You may even lose sleep thinking about your patients. IS OK REI CHIEL. There will be hiccups and please don’t beat yourself too much. Rather than allowing introspection overtake your mind, take steps to improve and relearn. One key thing while at university, don’t be scare to make lots of mistakes while you have the lecturers to hold your hands. Playing it safe while in dental school will only be at your disadvantage in the future when you have to work alone. Build your experience and mistakes can be your best learning tool. Those who were fighting for the chance to learn aren’t inconsiderate of others; they see the value in experiencing it first hand in order to help others next time.

Keeping yourself spiritually and mentally fit is also important. Daily, you may meet patients that come in and tell you they hate being here, they were traumatized in the past, they dread the sound of drill, demanding for a discount or even asking you the entire spectrum of dentistry. It can get quite toxic and drains your energy. It is crucial you identify with these frustrations and struggles. Pour them out with your close friends and don’t bottle up. Rely on God’s word to draw strength and encouragement. In time of extreme anxieties, run to the Lord in prayer. Also, do not develop the habit of comparing yourself to others. With the bloom of social media (For you, I guess it is still the era of MSN messenger or is it Facebook messenger?) many people will start to look for validation through these platforms. You will see how your friends (especially those who aren’t dentist) are doing well: enjoying their work and living life to the fullest. You will feel like you are so constricted in the clinic premise 6 days a week, not progressing much in your work or life. Don’t compare yourself with others! What they do with their life is none of your business and you shouldn't measure yourself against them. Behind the scene, people are striving for what they want. Remember you are not trying aim for the worldly successes (power, riches, fame) but living your life serving God and your neighbors. Learn to count your blessing everyday and give thanks.

Also, try to shed off your shyness. You will have lots of opportunities in the future to meet with great people and many a time you lose out because you don't dare to initiate the conversations. Listening to other is good, but you got to also learn to form your own opinion about things and not be the silent listener. Be more vocal, thick-face and be interested in others.

I know you are very idealistic that this stage of life and is having a rosy picture of the future. You are not fickle minded about your decisions and want to strive for your goals. You like to know that you have everything planned out and what’s coming next. However, I hope you do realize that life is an unpredictable journey. There is no such thing as a perfect life. The next 10 years WILL BE a roller-coaster ride but you will also be surrounded with many good Samaritans by your side. It is you that need to stay humble but yet bold. Be curious and seize the moment. Don’t be disappointed if things don’t turn out the way you wanted because in every disappointment comes an opportunity to experience something different. That is more valuable and helps to shape you into a better person. Live like today’s your last and strive for the best to help others in need.

I love you,

Your 28 years old self

My Take on the MJDF exams

With God’s grace, I was able to complete the MJDF examination last august. Before I forget the details of this whole roller coaster ride, I would like to share my experience and some thoughts about it.

So what is it all about?

MJDF is short for the Diploma of Membership of the Joint Dental Faculties (MJDF) by the Royal College of England (RCS Eng). It’s an exam that allows dental graduates to demonstrate their competencies in knowledge and skills they have learned. It is not an exam that enable you to earn the license to work in the UK (that would be ORE by GDC) but more to confer that the person is of a certain standard. This membership is often compared to MFDS offered by Royal College of Edinburgh but is slightly unique as it provides membership to both Faculty of Dental Surgery (RCS Eng) and the Faculty of General Dental Practice (UK) upon successful completion with the price of a single membership for the first six years. And so, this allow the members to benefit from both faculties before making the decision to join either faculty. After 6 years, you may continue to remain as a member of both faculties (paying separate membership fees for both) or choose which of the faculties to join that suits your career direction. In short, the FDS is dedicated more for specialist dentistry while the FGDP on the other hand support those that are in primary care. Both faculties do organize CPD and courses from time to time, some which are free but they are mostly held in the UK. You can also access to publications including standards in dentistry and journals like the Primary Dental Journal or Faculty Dental Journals for free.  

Received a copy of the PDJ and brochures from FGDP 

Do I really need it?

This is not really something that I was exposed to when I was at dental school and I believe many dental graduates do have the same confusion as me. Most dental graduates in Malaysia take this exam for career advancement to pursue specialization or simply to enhance their skills.  I noticed it has become a trend among young dental graduates to take the exam; many that were influenced by friends and colleagues without really know the purpose of it. Some then stop at part 1 of the examination and let it expire after 5 years. I think is important that one should first map out a 10 years career and personal plan, to see if the examination is worth investing their time and money. There is certainly lots to revise and the exams fees isn’t cheap. Furthermore, it is rather expensive to maintain the membership (about £136 per annum) while not reaping much of the benefit being an overseas member. In my opinion, the best to plan and start preparations for the exam when they are still in their final year of undergrad. I do find it beneficial because it makes you question again things you have studied in dental school and reinforce the knowledge. Moreover, some universities do prefer that applicants for their postgraduate program to have a primary fellowship and this certainly will come in handy. Locally, from the information I gathered so far, a successful completion of the Part 2 examination from either MJDF or MFDS is also a requirement to apply for the HLP government scholarship.  Ultimately it boils down to your career goals and priorities in life.

How does it go?

This examination is divided into two parts. Usually dental graduates opt to take MJDF Part 1 and then switch over to take the MFDS Part 2 as many seniors have claimed that this is the easier route to obtain a primary fellowship. However, I choose the road less taken and did MJDF Part 2 instead. Therefore, I will be just writing more in details of both the MJDF Part 1 and Part 2 process, styles of questions, some favorite topics and recommended reading materials. I will link another blogpost which describe the Part 2 MFDS in detail here so you can make the comparison for yourself: https://www.helpingdentists.com/2017/10/mfds-part-2-guide.html

I shall be sharing the following information from a past international candidate point of view and it may not be applicable to those who plan to sit for the examination in the UK. I did both my examinations in Kuala Lumpur which was held in University Malaya. Of course, you may also opt to do the exams in other overseas venue like in the UK or Cairo.

MJDF Part 1

This is a 3 hours paper consisting of 150 single best answer questions. I’m not sure about the passing criteria but all questions carry equal marks and there is no negative marking. Candidates will be tested a variety of topics related to basic dental knowledge one should know as a general dental practitioner. International candidates preparing for the exam tend to miss out their revision on law and ethics. Far too often they get shock when asked for example the CPD requirements of a Dental Hygienist or taking consent from a mentally unsound patient etc. I would recommend candidates to read from the following books:

-          Oxford Handbook of Clinical Dentistry by David A. Mitchell

-          Master Dentistry Vol 1 & 2

-          PasTest MCQs for Dentistry

I strongly advise candidates to go through the question banks from PasTest and Master Dentistry as some of the question that appear in the examination were quite similar. You can also use those questions to gauge your preparation and give you an idea the types of questions that may come from a particular topic or specialty. If you want more practice, you may obtain past year questions by joining some study groups on Facebook. I will just link the group that I have joined here: https://www.facebook.com/groups/Mjdfpart1/

In Malaysia, the examination is held twice a year, first in April and then October. From my experience, one should eat well before they sit for the examination as you will have some kind of adrenaline rush as you scroll down the 150 questions in 180 minutes. It feels like running a marathon. I remember I was famished toward the end of the paper and slightly dizzy as I left the hall.

I used about 6 months of my “gap” year (while waiting to be absorb into the MOH) to prepare for the exam. Upon completion of the Part 1 examination, you are given a time limit of 5 years to pass the part 2 examination. You will not be awarded any certification of passing the Part 1 exam but just a written letter to prove of your success. Only after completion of the Part 2 then you will be presented with a prestigious certification from the Royal College of Surgeon England.

MJDF Part 2

The MJDF Part 2 exam is only held once a year in the month of August.  Again, it’s a 3 hours practical exam which comprises of 14 stations in a single circuit. Of that 14 stations, there will be 11 examined stations and 3 preparatory stations. You get 9 mins to answer in each station with 1.5 mins of reading time. A case scenario will be presented in front of the stations for you to digest during the reading time and after which you shall begin. As compared to MFDS, there is a mixture of stations where you may have to actively perform the clinical skills tested or demonstrate good communication skills with a stimulated patient or directly be asked a series of structured questions by the examiners in the station. Usually each station will have 2 examiners, one from the UK and another a local. The questions are formulated to either test your clinical skills or clinical knowledge. You will be given a long time (9 mins) before facing the preparatory station and usually you will have to jot down notes of the case given. There may be rest station in between, depending how many candidates are participating in that session and how the examination board design the circuit.

 

The Registration counter for Part 2

It took me about 1 year to prepare for this examination. Thanks to the heads up from my friend Komi, I got to join the preparatory course organized by RCS Eng at FOD UM in early April. I’m not sure if RCS Eng will make this will be an annual event, but it was definitely helpful. We were given examples on how questions will be framed and were involved in a short mock exam.

As it’s an ‘unconventional’ paper and the RCS Eng have recently changed the exam structure, there really isn’t many past year question banks available. However, I highly recommend to read the following books to get a glimpse of the types of case scenario and questions that can be asked:

-          Clinical Problems in Dentistry by John Laszlo

-          Clinical Problem Solving in Dentistry by Odell

-          PasTest OSCEs for Dentistry

The books I used 

I would also suggest that candidates who took a long break after completing Part 1 to refer to the books used back then. The knowledge from Part 1 is still necessary. You can also join some Whatsapp group to get feedbacks, tips and some past year questions from previous candidates. Some of them are generous to gather and compile a list of questions that were asked. That is certainly useful and would shed some light on how much you need to prepare. You may also find the follow document shared by Dr Reena Wadia from the UK useful: http://reenawadia.com/wp-content/uploads/2015/11/fgdp-mjdf-part-2-2015-handout1.pdf Also, it is IMPORTANT for candidates to keep abreast with the latest standards of care and guideline from the RCS Eng and FGDP which you can assess through their websites. You may use materials for MFDS Part 2 in your preparation as the various case scenarios there can be quite similar to those asked in MJDF Part 2.  

I would agree that candidates should have some clinical experience as it would help greatly while preparing for stations which primary focus to assess candidate communication skills.  It will be good if you have a study partner with whom you can do some sparring and practice answering questions verbally. I find it was a struggle for me to communicate my answer effective and fluently as these days I hardly use English when I converse with my patients. Regrettably, I took it for granted and should have practice speaking out more. In terms of communication skills, candidates have to distinguish whether they are speaking with a patient (avoid jargons) or they are speaking to another colleague where proper scientific terminologies must be used. Common scenarios will be like to handle an angry patient, explaining a suspicious lesion, obtaining an inform consent for a dental procedure (applying Glick’s competency), obtaining full patient history, explaining conditions like aphthous ulcers, lichen planus, Sjogren syndrome, apologizing for procedural mishaps, convincing patient the safety of dental amalgam or dental radiograph radiation exposure.

Another important part of the exam is managing medical emergency in the dental practice. One of station will definitely be there to assess how candidate handle a stimulated emergency. Honestly, this is one of the most stressful station for me. It was my first time to see a complete set of emergency drugs and I become overwhelmed when I have to search for GTN from the bunch of drugs laid out before me. I was also worried that I would need to handle the oxygen tank. From my experience, you need act a little for this station. You need to pretend as if you are single handedly handling the case even though there will be an examiner observing you in that station. It will be a little confusing whether to involve the examiner as in a real scenario he/she would be helping you. I highly recommend reading Laszlo’s book and guidelines from Resuscitation Council (UK) when revising the medical emergencies.

As I mention earlier, there will be some active station that will test your practical skills. A few examples of the possible questions are: like fabricating a temporary acrylic crown, isolating a tooth with a rubber dam, suturing, writing a referral letter, labelling structures in radiographs, designing for a partial COCR denture, finding the working length, extraoral examination, taking a biopsy sample, mounting a full mouth PA films. Remember, they just testing your clinical competence and reasoning expected of a general dental practitioner and so you need not worry that you will be questions on things that are beyond that level.

Personally, I felt I did not do well for my part 2 exam as I was inarticulate in my answers. I wasn’t the most confident that day and after finishing the exam, I walked out of the venue in a dejected spirit. I did not dare to check my results when it was release. I couldn’t believe my eyes when I saw the word ‘passed’ and was literally jumping for joy.

How do I sign up for it?

You will need to create an account in the RCS Eng website and then sign up for the exams there. You will need to fill in some details and pay the fees for the exam once you submitted your application. For the local administration fees, you can either send in a cheque or pay with your credit card or cash in UM. Usually they allow you to do it on the exam day but make sure you call them first to confirm. Applicants for Part 1 then need to mail a certified copy of their primary dental degree certification and their registration documents to the MJDF examination department of RCS Eng. They will not send you a confirmation email that they have received the documents and so it is better you write to them if you are worried. 

As for MJDF Part 2, all you need to do is just log into RCS Eng and sign up for the examination. You don’t need to mail any documents as they already have a record of it. Comparatively, MJDF Part 2 is cheaper than MFDS Part 2 and so if you are really tight on budget, you may consider taking this paper instead.  

I hope my insight will be beneficial to those who are thinking of taking the exam especially on MJDF Part 2 as so far very few have shared their experience on the net. Please feel free to share this post to your friend who are contemplating between MFDS and MJDF. Don’t be shy to drop me a comment below if you have any doubts. I will be glad to help out.

Have a nice day and thanks for reading. Stay tuned

Dr Yoshi Terauchi's The Art of Safety Canal Instrument Removal workshop @ 11th MES-SES Biennial Joint Scientific Conference 2018

Back in November, I had the opportunity to attend a full day workshop entitled ‘The Art of Safety Canal Instrument Removal’ by the world-renowned endodontist in instrument retrieval, Dr Yoshi Terauchi. I first came to know about him during one of my discussion of managing separated instrument with Dr Alok when I still in undergrad. I am aware that Dr Yoshi do host workshops in Japan but they are way too expensive. It was a dream came true when MES announced that he will be coming to town and I quickly sign up for the course minutes after registrations were opened. Sadly, of all days, my GPS went haywire that morning and I was about an hour late! I was frustrated that I missed out the initial part of the lectures but thankfully he was still warming up in his presentation. I thoroughly enjoyed the lecture he gave as it was generous with visual diagrams and video demonstration to help us understand and convince us of the points he made. We first learn in depth how unwanted mishap in endodontics happen in the morning and then the art of retrieving separated instruments in the afternoon.

My learning station

We were asked to willfully create a ledge in an acrylic block and learn how to bypass it. The importance of prebending the # 10 K File was stressed over and over again. I must say the SybronEndo Endo-Bender is one neat instrument for that but it comes with a heavy price tag. After that exercise, we were required to separate (break) the NiTi file in the block! (We were provided with the TF Adaptive Motor and Files to practice and it sure feels like driving a BMW- Endo style) Learning to break the instrument intentionally really help me understand how such mishap happened clinically and how to move on from there. Sometime our emotions can get the worse of us and we have a mental block to handle the situation.

Recipe to break the file

Successfully separated the new file

Keep Calm and retrieve the instrument with – TFRK technique!

The Terauchi File Retrieval Kit 

Each participant was then given a TFR kit (that we can bring home!).  Dr Yoshi 99.7% success rate in retrieval made me ponder on one thing which I never gave much thought about in Endodontics: ‘PREDICTABILITY’. I continue to see this theme running through the MES conference ‘How to make your work predictable?’ – through an established protocol with evidence. Dr Yoshi continue the afternoon by introducing the TFR kit and the 3 main factors in instrument retrieval: Motivation, Profit, Predictability. He presented to us his usual recipe and systematic approach to handle separate instruments. I’m not sure if I can share the photos of his slides here without his permission but here is a youtube video link if you want to learn more: https://www.youtube.com/watch?v=o6Ah2kaOeMI

We then practice his technique under magnification on Tru Tooth models which have a broken instrument is already present in them.

I was lucky to get to practice on this Zeiss OMI PROergo model!

Struggled with this tooth

Out in 10 sec

The following is just a brief summary of some take away points from this workshop and the MES conference lecture:

On Ledges

-          Don’t try to run when you haven crawl. Ledges can easily be created with large stiffer files like #20. To bypass irregularities and create a glide path for your rotary files, use a #10 K file with 30 degrees bend on the apical 1-2mm, push and pull in an up down motion about 50 times till the files is super loose. Note if you precurve the file too much (5mm from apical end), file become straighten when inserted into the canal.

-          If a ledge is formed while negotiating the canal, locate the ledge under magnification, enlarge the canal to the ledge, pre-curve the negotiation file, and use it with push-pull motions. the key to success in bypassing the ledge is to push a file in an inner direction rather than straightforward. Do no rotate the file, just try to hug the inner wall and maintain the precurvature of the tip.

-          If the ledge is not visible, first enlarge the canal with #3 GG bur till level of the ledge. Locate ledge on the outer wall. The opening to the canal is always on the inner wall, opposite to the ledge. Place a precurve # 10 file to get into the original canal. Then you can use SM1/path files in pecking motion at 100 rpm (slower rpm easier to get into the ledge) to bypass the ledge

SM1 file with 100 rpm 

Successful bypass the ledge

       On instrument retrieval

-          Try to think positively when you break the instrument. ‘Its ok, now I can practice instrument retrieval and it is a predictable procedure’ Psychological factors will affect your ability.

-          We need the motivation to carry on our work so never short change yourself. You are providing dental treatment for your patient health not at the expense of your own pocket. Charge you patient enough to make yourself happy and feel it’s worthwhile. No free lunch in the world

-          Location of the coronal end of the fragment is important to assess the difficulties of instrument removal. Before curvature & visible file: easy. Beyond curvature & not visible: difficult

-          The method of retrieval depends on degree of canal curvature and length of the broken instrument. More than 30 degree curvature or > 4.5mm length of broken instrument might need the use of the Yoshi Loop. Always start to use the ultrasonic first, make sure the instrument is dancing before proceeding with the loop. (The mean length of # instrument is 2.5-3.5mm, more commonly with large files)

-          Separated instruments are usually lock in at the its coronal 3^rd. No dentin will be surrounding the middle and apical 3^rd. The concept essentially is to create space in the coronal 3^rd on the inner wall (careful not to touch the instrument) with ultrasonic till you see the instrument is dancing before move on to retrieval. Never touch the tip of the ultrasonic on the instrument as there is a risk of file extrusion or secondary # of the broken instrument.

-          Always refer to axial view as axial view of CBCT is similar to what you see under DOM.

-          To assess/diagnose look only at the coronal portion of the # instrument, measure the length need to remove dentin. The longer the instrument, the longer it will take as more coronal 3^rd length to remove

As a whole, I was really inspired by Dr Yoshi who dedicated his career in providing a solution with simplicity and predictability when facing with such stressful mishap. I do feel that the time for the workshop was a little short and I would love to have more time to work on the extract tooth that I brought along for the course. It was really sweet of him to agree to drop by Malaysia on his birthday to teach and share his experience and technique with us.

Please continue to stay tune as I have a couple of things I have stored up in my drafts that I plan to share. I will try to be more discipline and get them finished. Till next time, take care!