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!

25th MDA SCATE 2018 @ PWTC & Dr Ashwin's Rubberdamology @ The Dental Academy

Group A mini reunion @ Nau's 

(This is so overdue)

I’m not going to apologized AGAIN for not updating as frequently as I used to in the past. Not that I was busy, it was more of laziness and the lack of motivation to write. These days I noticed I have somehow developed a pessimistic outlook in my clinical judgement and execution, often expecting the worst outcome. The dental graduate that used to be so optimistic and confident in her work has overtime wither away. Sometimes I questioned why did I chose this field previously. I still in the midst of sorting out this confusion within me.

Ok, enough rant on my emotion rollercoaster, this blog entrée is about the events I attended earlier this year.

MDA SCATE Jan 2018
(WhatsApp msg)

Finally on some magnification!

Rach

Jom Pergi Conference MDA? - Syasya 

I replied “Ok”. And hence I paid a few hundred ringgits to renew my MDA membership and signed up for the conference.

“Going to conference again? Why you dentists always have to attend so many conferences?” asked my mum.

I pretty much looked forward to SCATE ever since joining the private sector. Coop up in the clinics 6 days a week doing intricate meticulous work and meeting the demands of patients can lead to isolation and professional burnt out.  For me, dental conference is not only one of the means for continuous professional development but also a good opportunity to take a break from the clinic. It is where active learning for dentist happens post-graduation. There will be brewing conversation about the trends and advances in dentistry, exchanging clinical experiences and ideas, trying the latest gizmos and getting a good discount to restock clinical supplies. Some also view this as a good opportunity reunite with friends and batchmates.

Photo credits: Syasya

There are two major annual dental conferences held by the MDA; SCATE in the beginning of the year and MIDEC around mid-year. As compared to MIDEC, I noticed that the lecture topics in SCATE usually are tailored for the junior dentists.

There were two to three lecture sessions lined up every hour. We had to choose between the mundane and the remarkable. I took interest in the full mouth rehab presentations. I was amazed and humbled by the treatment plans and clinical work presented. One good take home message was advances like the Digital Smile Design and Chairside CEREC technology still rely on basics taught in prostho, cons and perio. Fundamentals are still important. Besides that, I found the lecture on Managing Dentinal hypersentivity most useful. The sensitive toothpastes in the market all contains different active ingredients and its effectiveness may varies for each individual. Patient should be encourage to try out different sensitive toothpaste to find the one that works the best for them and stick to that particular one.

I wasn’t only attending lectures but also went around scouting for materials and instrument I needed in the trade exhibition. The exhibition hall was filled with set up booths, some with tall kiosks with banners advertising cool new instruments, appliances and materials that you had never heard of with impressive multimedia presentations. And of course drs are not oblivious to the ‘bribery’ each booth has to offer. It’s common to see lines forming while drs giving away their personal contact info in exchanged for the latest merchandise (often toothbrushes and toothpaste). You can hear some murmur that this year givings weren’t as good as previous year. Others were simply handing out souvenirs (like an innocent pen or tote bags) stenciled with their brand logos together with paper brochures or catalogues. I felt somehow the exhibition hall was strategically placed as we have to navigate ourselves to dining area through the maze of sales booth. Probably they hope that on your way to teatime or lunch your attention will get caught with the big fancy ads or by a smooth tongue salesperson. Some companies prepared hands on kiosk for the drs to try out the various products. Also, some booth had a crowd swarming around a projection screen with a man dressed in suit and headset microphone giving a short lecture and demo.

As Joe and I were strolling down each alley, we were lucky enough to stumbled upon a supplier who was giving a demo on BioLase laser. We signed up for the hands-on session on the second day. Together with 3 other drs, we were introduced to a transparent glass high tech looking device in front of us. The sales rep gave a 10 mins PowerPoint presentation and have us all put on the yellow bug eye looking safety googles before the demo. Next thing we know, we were happily carbonizing away tomatoes and sausages. Gingivectomy would have been such a straight forward procedure instead of using traditional blade. One of the participating dr had a traumatic ulcer and offered for us to use the laser on him. We were lucky enough witness the effects of the laser on a real traumatic ulcer without any LA and the results were instant. All 5 of us were sold that afternoon. 

By the third day the meeting rooms were no more than half filled and the crowd was inside the exhibition hall instead of the lecture halls. You could sense the enthusiasms for actual learning have tapered down. Among those attendees, a large chunk either dozed off or left early to stroll the trade show. For me, I left the conference early to get some rest before the start of another new week.

Dr Ashwin's Rubberdamology Feb 2018

A few weeks after SCATE, I was lucky enough to book a spot for Dr Ashwin’s Rubberdamology hands on session @ The Dental Academy. We all know that the usage of rubber dam is the gold standard for isolation for any restorative work but many just brush off the idea in the name of inconvenience. Those who are reluctant often claimed that patient disliked it and it takes too much effort and time to isolate a tooth for just a simple filling. Personally, I find that the dam actually gave me a piece of mind to work especially in the lower posterior regions. Instantly, you do not need to worry about the cheeks, tongue and the pooling saliva. It makes clinical dentistry more awarding and stress-free.

I had a bad experience back in final year of dental school when I had to place a dam on a 12 y/o patient with the lingual wall of tooth 36 at equigingival level. The clamp kept popping out and the interdental gingiva were so traumatized. I put off the idea of using the dam after that. Ever since then, the last time I ever placed a rubber dam was on the typodont model during our final exams. However, I always wanted to be comfortable in placing the dam on patients and this course really gave me that confidence.  The confusions on to use wing or wingless clamps; heavy or medium dam sheets; to dam first, clamp first or the dam and clamp together technique were answered. According to Dr Ashwin, is best to give Local Anaesthesia prior to placing the rubber dam as it can ensure a comfortable experience for you and your patients. Also, you would not be able to clamp the tooth if significant buccal or lingual wall is missing so build up that wall first before placing the dam. He also showed some crown cases done with Vertical Tooth Prep and introduced the Thermacut bur used in DME cases; both were new concepts to me. We all were also given a set of his famous rubber dam clamps kit to bring home. I think by far that was the best hands on course I ever attended and those who are struggling with the dam should really sign up if there is a next one. 

ps: 

A miracle happened!
(Will write a post on my experience of the exam later)