Your Endodontics Questions Answered! – PDP217

When Your Size 10 File is not going to length, what is happening?

Your apex locator isn’t giving you a zero reading. Your file is stuck. You’re wondering—have you ledged? Or could something else be at play?

In this must-listen follow-up episode, Dr. Samuel Johnson returns to tackle the biggest endodontic dilemmas left unanswered from part one. If you haven’t checked that out yet, go back and listen—it’s packed with insights on working lengths, apex locators, and even the role of consent in endodontics.

https://youtu.be/1E6pK2iOPjY

Watch PDP217 on Youtube

Now, in part two, we go deeper. We’re talking blockages, ledges, portals of exit, and the mysterious phenomenon of file gripping. Plus, Dr. Johnson takes on your burning questions from the Protrusive community—like how he responds to biological dentists claiming root canals should be avoided entirely. (Yep, we’re addressing that controversy head-on!)

Protrusive Dental Pearl: For a more visual learning experience, dive into the Pre-Endo Build-Up on Protrusive Guidance and see Jaz and Samuel’s insights in action.

Sonic Pro Ultrasonic Bath – 15% OFF before 30th April with coupon code ‘protrusive’

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Key Takeaway:

• General dentists often overlook the importance of taper.
• Removing too much dentin can weaken the tooth.
• GP cones can be unstable and affect the procedure.
• Reshaping GP cones can often resolve length issues.
• Pre-bending GP cones can help navigate tight curves.
• Biological dentists have controversial views on root canals.
• It’s essential to prioritize the patient’s best interest.
• Using endo frost can aid in manipulating GP cones.
• Consent should be informed and comprehensive.
• Communication between referring dentists and specialists is vital.
• Continuous learning is essential for dental professionals.
• Ultrasonic activation improves endodontic outcomes.
• Pulpotomy and root canal treatments have distinct indications.
• Building a supportive community can alleviate feelings of isolation in dentistry.
• Dentists should charge for their time and expertise.

Need to Read it? Check out the Full Episode Transcript below!

Highlight of this Episode:

• 01:03 Protrusive Dental Pearl
• 01:49 Common Scenarios and Tips for Young Dentists
• 05:30 File Gripping and Canal Anatomy
• 08:30 Master Apical File: The Common Dilemma
• 11:18 GP Cone Issues and Solutions
• 17:03 Addressing Root Canal Myths
• 23:35 Cracks in Teeth: Prognosis and Treatment
• 25:44 Ninja Access Cavities: Pros and Cons
• 28:21 Common Mistakes in Emergency Endodontic Treatments
• 33:51 Obturation: Overextended vs Short
• 34:41 UltraSonic vs Sonic Irrigants
• 36:15 Pulpotomy and General Dentistry
• 39:25 Building a Dental Community

As promised, here are the ESE Guidelines on managing cracked teeth.

Watch and learn from Dr. Samuel Johnson on Instagram and YouTube!

Don’t miss the first part of this series: PDP216 – Working Lengths and Troubleshooting Apex Locators

#PDPMainEpisodes #EndoRestorative #BreadandButterDentistry

This episode is eligible for 0.75 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes B and C.

AGD Subject Code: 070 ENDODONTICS (Emerging concepts, techniques, therapies and technology)

This episode aimed to provide deeper insights into troubleshooting endodontic challenges, particularly when files fail to reach working length. It explores common pitfalls, advanced techniques, and expert strategies to improve clinical outcomes in root canal treatments.

Dentists will be able to –

1. Recognize common endodontic challenges and strategies to navigate them effectively.

2. Evaluate the role of master apical files and resolve common dilemmas in achieving optimal shaping.

3. Identify frequent errors in urgent cases and improve treatment approaches.

Click below for full episode transcript:

Teaser: So your size 10 file is stuck. It's not going to length and you're not getting a zero recording on your apex locator. What do you do? Have you ledged? Or could there be another reason for this? This is where we answer that question leftover from part one.

[Jaz]
So if you haven’t watched or listened to part one yet, check it out. It was a great introductory episode. We talked all things, working lengths, apex locators, career and consent in Endo. So do check out part one. 

In this part two with Dr. Samuel Johnson, gosh, he loves Endo, doesn’t he? And it’s infectious, right? You can totally feel that. We’re going to talk about blockages, ledges, different portals of exit and a phenomenon called file gripping. Then Samuel answers all the questions from you guys, the Protrusive Community.

You guys asked some fantastic questions and it was a great pleasure to ask him all those. One of which what does Samuel think about those biological dentists who are suggesting that root canals are bad and that no one should have a root canal? I know, it’s crazy, but how does Samuel handle those kind of patients? We go deep in all the little facets and details of all things endo. Thanks again for all your questions, guys.

Dental Pearl
The Protrusive Dental Pearl for this episode is you need to see, if you haven’t already, you need to watch my pre endo build up video. It’s so relevant to everything that me and Samuel are discussing.

And that video was published just a few weeks ago as part of my POV clinical walkthrough series. You see my full video walkthrough of a couple of cases where I do a pre endo build up and do like a screen recording and interjection and running commentary of everything I’m doing. Very similar to wonderful videos that Samuel makes.

So I’ll put the link to that in the show notes if you haven’t already seen that. If you happen to be listening on Spotify or Apple, then do check out the video on the Protrusive Guidance app or just type in on YouTube, Pre Endo Build Up Protrusive. You will find it. Let’s not delay getting to the main part of the episode. I know you’re going to love this just as much as you loved part one. Let’s go with Samuel Johnson.

Main Episode:
Just talk about the common scenario that you want a young dentist to appreciate that when they feel encountered scenario. A great tip there is don’t force it. Slow down, retract because you don’t want to make it worse. And that’s a top tip already. 

[Samuel]
So I would say, have you reached zero or not? Cause you can get a canal. I’ve had one yesterday. I did distal buccal, which was 17 millimeters and in length. So if you have already reached zero and then at 18, you’re getting this hard stop. You have probably likely ledged it, but don’t panic.

I think we might move on later on to talk about managing ledges, but if you haven’t already reached zero with your apex locator, I think the best thing to do first is just estimate where you are actually within the tooth. So, you can estimate the working length in many ways.

You can use a radiograph, although, sometimes if you can learn how to draw how long it is on your radiographic software. It’s not perfect, but it kind of gets you in that kind. It’s a useful estimate, isn’t it? Another thing as well is, if you’ve got a multi rooted tooth, you say you’ve got a lower six and you’ve got a mesial buccal and you’ve got a mesial lingual.

If the mesial lingual is 19 millimeters or say the mesial lingual is 22 millimeters and you’re getting stuck at 18, you’re probably short. And also take a working length radiograph. I did say I don’t take them, but I do, do take them. Cause sometimes my apex locator is all over the place. And I don’t know why. And sometimes it’s good.

[Jaz]
This is the one that you said is not routinely advocated by FGDP, but sometimes when you’re getting erratic measurements and just to verify. That’s when you would take it with and you are doing it with a size 10 because obviously you’re stuck there. Is that right?

[Samuel]
Yes. Yeah, absolutely. So say you are near to the end. Okay, this could be a ledge. It could also be complicated anatomy that the x ray is not going to show these many portals of exit. And I would say a really really common sign that it is complicated anatomy, not a ledge is that you get that kind of sticky feeling.

So it’s a hard concept to kind of explain, but if you’ve got a hand file and you’re just sort of negotiating it to length and you’re hitting that hard stop, but then you get in that kind of sort of sticking feeling that is more likely complicated anatomy because you know that the file is sort of getting stuck, in the jammed in the hole.

[Jaz]
It could have been preempted by a Cone Beam CT, you think?

[Samuel]
No. So, the cone beam CT scan has many, many uses. And a great thing about a Cone Beam CT scan is that you can measure the tooth really, really well. It’s very, very accurate. But with a cone beam CT scan, it doesn’t show detail very well.

That might blow people’s heads, but it’s not the panacea of diagnosis, a Cone Beam CT scan. Although I take a lot of Cone Beam CT scans, we’ve got one in all three practices that work out. Very, very useful. What I would say as well is if you’re getting that hard stop feeling and you are near to the end, it’s probably likely that maybe the end of the tooth goes off to a 90 degree angle.

So you see this a lot with palatal canals and distal canals in lower molars. You can kind of sometimes see it on radiograph, where you see the large canal and it kind of flicks off to the end, or you don’t see the flick. You kind of see that kind of apical radiolucency where it’s kind of off to the side of the tooth or laterally to the tooth.

That’s essentially where the portal of exit is, again, to talk about how to manage those things. Maybe we’ll talk about that later, but if you’re not near to the end, it’s probably either a join or a split. So it’s where two canals are coming together, or they’re splitting apart, and your file just can’t reach around that kind of double curve, or it’s this concept of file gripping, which I’m-

[Jaz]
That’s the one I wanted to really expand on, because I think that can really catch people out. When we had a chat about this, I was like, oh wow, that’s right, tell us about file gripping.

[Samuel]
By the way, file gripping is, I don’t really know what it’s called really. It’s just something that I’ve just sort of made up myself when I say made up just the concept, maybe people do use file, I’m not too sure, but essentially, the problem is, is the file isn’t advancing, and you might think to yourself, well, I’ve got this kind of cylinder.

It’s a metal cylinder, which is a circle. And I’ve got this sort of perfect cylinder that I’m pushing down. There’s this tube, but in reality, it’s not like that at all. The inside of the canal space is actually oval. And there’s little places where you can get the file stuck and things, and you might be thinking that the tip of the fire is actually getting stuck, that’s the thing that’s not advancing, but actually.

It’s friction from further up the shank. So it’s essentially the canal space gripping onto the file further up. And you know this cause you find this more often in longer canals. So I’m going to exaggerate and do a bit of hyperbole. This is the best tip I could give you with a root canal if you’re starting out.

If you are getting, say you’re 18 on a canal, and it’s probably about 20, 22. The best thing for you to do, if you’re getting stuck, the best thing to do is not to jam it down there. You’re going to pull your hand file out. In fact, you’re going to measure first how far you’ve got with the rubber stopper.

You’re going to take it out, you’re going to measure it, it’s 18. You’re then going to get a higher diameter file. Okay. And this could be anything. So you’re using a size 10, you just get a 15. Personally, I like to use these glide path files and then I measure the higher diameter file, 17 millimeters. So 0. 1 millimeters away. And then I’m going to shape it with that. Then personally, what I do is I get my master apical file and then I shape it at 16. So listen, you’re not using more files than you would do. You’re going to be used this file later on anyway. So you might as well just use it to shape it up.

And what you’re doing is you’re releasing the grip of the canal further up the shank of the file, further up the file. And the amount of times this, this magical, the amount of times I do this every day, I’m not getting to length. I’m just shaping up further coronally up the tooth and then it slips.

But what I would say. Again, it’s that kind of temptation to get quicker, get quicker, get more efficient. Say you’re using a glide path file, you’re using a high diameter file and then you feel that this file is what I think I could probably just go a little bit further with this. Don’t resist the urge.

Just shape it a millimeter away because again, you’re gonna ledge, you’re gonna perforate. And if you ledge. It’s just a nightmare, isn’t it? It’s just, it’s one of those things that just makes you unhappy for the rest of the day.

[Jaz]
But I mean, that makes so much sense to move to a higher file. The only thing I didn’t understand there, Sam, just please explain to me is you mentioned that, okay, you go to a larger diameter. Like, so if you were using a 10, you’re going to go to a 15 a millimeter away, which makes sense. And then you said you’re going to go to your master apical file size, but how do you know where your master apical file is if you haven’t yet advanced down and prepped yet?

[Samuel]
Oh, Jaz. You’ve opened up a can of worms here. Again, another question I get asked all the time from newly qualified dentists is what should be my master apical file? And also I think this is a highly contentious issue in endodontics. So you get the sorts of dentists who use these huge diameters.

What I would say, it’s all about the taper. Okay. So it’s not really the tip of the file. It’s how much that file expands later on. So it’s essentially, it’s a contentious issue between endodontists essentially. And it’s all about the taper. So what I would say with the taper is that the tip of the file isn’t the significant point. It’s how thick it gets along its length.

[Jaz]
So for example, when we say 25, we know that’s the diameter at the tip. But really what I noticed when I used to hang out with endodontists is that they don’t, they never say 25. They say 25/04. The slash taper is so, so important, but as general dentists, sometimes we just see the big number, right? Which is the diameter. We don’t learn to remember which brand is what taper and that’s so, so important.

[Samuel]
So I’ll actually describe taper. So essentially the taper means that it’s usually a percentage value, the percentage that increases per millimeter. So, if you’re at the tip, a millimeter further up, it’s percent of that so-

[Jaz]
K file is 2%, right?

[Samuel]
Yes. Yeah. You can get really high diameter ham files and on the one hand, you can use a low tapered rotary file. It’s not going to cause much dentine. But it’s going to be more difficult to irrigate and also obturate. So at the moment, like I say, there’s a little bit of a bum fight between endodontists about how much you should be removing tooth tissue within the canal space. And then there are-

[Jaz]
Because the higher the taper, the more pericervical dentine you can remove.

[Samuel]
Exactly. And there is strong evidence to say, if you remove a lot of dentine, you’re going to weaken that tooth. I personally, I’ve gone through a little bit of a journey with this and people might say this is lazy, but I’ve just used Hyflex for so long. I know that it works. I’ve taken post op radiographs, a year after we know it works. The problem with Hyflex, of course, is it has got a relatively large taper.

[Jaz]
How much are we talking?

[Samuel]
It’s variable. So, I think off the top of my head, I think it’s averages about six to seven percent, but then you wave on golds between five and seven, I believe a primary is seven or six, but I think if you’re not into the nitty gritty of endo, I wouldn’t get too concerned about it.

[Jaz]
Okay, I mean, just the whole point of file gripping, for me, when I first experienced that, wasn’t actually with files. When I took my master GP cone, and I tried to get to length, I noticed that it wasn’t going, and that’s when I realized I was taught, actually it was the friction of the GP. That’s why I really understood when you taught me about file gripping, because it’s kind of the same thing happening with the GP.

And then what I learned was, and I think this is going back some years, Sam, so please correct me if I’m wrong, is that actually GP is not that stable and some people keep it in the fridge and stuff and it could be that issue that it expanded a bit or that my shaping wasn’t that good. I didn’t do enough shaping to allow the shape of the file to imprint onto the walls to allow my GP to go to length. What do you think is happening when we get GP gripping?

[Samuel]
Do you know that I always check the end of the GP. So I’ve got this little gutter cutter. So it essentially cuts the GP to a certain diameter. And every time I get a GP point out, say I use a 25 GP, I’m pushing that into this gutter cutter just to check, to see if the end is actually the correct diameter and I suppose in a way if the tip of the GP cone isn’t great, then obviously you’re going to get this kind of wide variation with the tape with a GP. So what I would say also as well is the dentists who like to do this kind of minimal prep dentistry, say they’re using like a 25/04 taper.

So that’s a thin taper. They’re using GP cones, which have the same taper, but the maximum diameter is a millimeter. So if you’re using a bioceramic, say you’re essentially filling the majority of the canal with your bioceramic because it flows nicely. And then you just enter this thin GP cone, which is not going to get stuck down the sides.

And this is going to allow for the endodontic bioceramic sealer to sort of flow around it. And I don’t know if people have ever noticed before, sometimes you’re going to get GP sort of touching the walls, but also if you fill the canal space with too much sealer, you kind of get that kind of buoy effect. Don’t you? It sort of floats up and down. This is really, really annoying.

[Jaz]
Okay. That issue is that GP isn’t as stable. And I think you’ve made that point where you’re having to use a GP cutter at all times. And then therefore what we get isn’t exactly that accurate. And therefore it might be the issue with the GP rather than not having filed enough.

[Samuel]
Yes. I think if I can’t get to length with my GP cone straight away, what I definitely don’t do is I think, oh, I’ll be alright. Just put it in. Be sound. But you know what? It’s everybody’s thought of. I’m not going to lie to you. Everybody’s thought it. You’re stressed. You’ve got this, that, and the other all going around.

But do you know what? This sounds blindingly obvious, but it isn’t in the patient’s best interest. Okay. What you want to do is you just want to pull a GP cone out. You just want to reshape and I would say 99. 999 percent of the time, if I just reshape with my mast apical file. Then, it’s going to go to length, but what I would say yesterday was a really, really good example of my GP cone not getting to length.

I just think there was an acute bend at the end and it was an upper six. I could get down the palatal really easily. I got down the DB really easy, but the mesial buccal was really, really difficult. And I shaped the other two canals with a 25 high flex, but I just could not get the high flex 25. Past this sort of, it must have been like maybe five millimeters away from the apex and I could just about get the size 20 past the apex.

What I did is the GP cone was still snagging and I don’t think it was this sort of gripping effect. It was essentially where there was like an acute bend at the end and another really, really great thing about it is you can pre bend hand files when you’re trying to get around a tight curve, but you can also pre bend GP cones.

Might say to me, well, GP cones are not stiff. So in this case, yesterday, what I did is I got some endofrost and I blasted the GP cone with endofrost. So it essentially froze the GP cone and I was able to manipulate around this canal. So that’s another really great tip is get your endofrost out.

[Jaz]
That’s a lovely little tip there. Fantastic. Great. You’ve answered a lot of these questions. I think if we go into overcoming a ledge. I think it’s a little bit too technical. I would love to instead go through the community questions if you’re okay with that.

[Samuel]
Absolutely. Sure.

[Jaz]
The one I want to start with is extremely controversial and I’ve just enjoyed this conversation so much with you and I, and I know enough about you now and your character that I think you’re going to have a fascinating answer more than anything is I would just love your opinion.

Feel free to say no comment if you’d like to. And that’s cool. Okay. These biological dentists. I think you know exactly where I’m going now, right? These biological dentists who are making all this hoo ha that root canals should be a no no. Like if a tooth needs a root canal, at that point, don’t even get the root canal, have an extraction because it’s dead matter in the body.

That’s the kind of terminology that they use. So Samuel, these biological dentists, I think you know where I’m going with this now, right? They talk a lot about root canals just being bad news. There’s something stupid thing I’ve read whereby 97% of cancer patients had this one thing in common, which is a root canal.

That’s like saying 100% of cancer patients drank water. Do you know what I mean? So like, A, do you ever get patients like this? And then B, I feel like as a profession and as it ends in the community, I know there are white papers, the American board is answering. I don’t know if the BES has had a position statement out, but I feel as though we need to like to put science first and there’s very dangerous advice sometimes to extract perfectly good root canals completely asymptomatic for this. Oh, it’s not biological. It’s not natural. Where do we even begin to talk about this?

[Samuel]
I watched that documentary on Netflix. It’s just absolutely mental. But I can say two things about this. The first one is, do I get people like that? Well, I take external referrals, internal referrals. I see these patients for a consultation before they even go for the root canal. And I would say if these types of patients, patients are probably filtered out before they get to me. What I would always say as well is that if you don’t want the root canal, just have it out.

It’s not really my kind of, if that’s what you believe, there’s no point arguing with people. You’ll notice if you do this job for long enough, that I suppose there’s the concept of you don’t care about patients teeth more than they do. If they’re consenting adults, if they feel like they want to make that decision, that’s on them.

If you start taking on people’s issues and problems and things like that. You’re not strong enough mentally to do so. And it’s something we see a lot of the time with new reception staff or new nurses where they say, Oh, so and so needs this and so and so needs that. And there’s a big kind of like, you essentially, again, I give people my opinion.

I do this friends and family test. If I understand that a patient’s quiet, they understand things and they say, well, what would you do when people say, what do I do? I always go, well, I love root canal. I say, if you want the root canal, I’d be made up, I’d be in the elements. But I also say, you’ve got to have the appetite to have this.

If you’re thinking to yourself, I don’t fancy this at all, then make, that’s the right decision. And this is essentially, it all goes back to consent. A lot of the time I’ve started new practices and the same question all the time. When would you go for a consult and when would you go straight to treatment?

We always go for consult. Because you’d be surprised how many people you can filter out where you do this kind of, you tell them all the risks, you tell them the costs and everything. And then they go, it’s not for me. And the other thing about consent is that if you’re a perfectionist, I can’t get rid of this perfectionism just yet.

But if you’re a perfectionist, you’re never going to be bulletproof medical legally. But it’s not about that. It’s about kind of telling the patient everything. And if it does go wrong, it goes wrong for me all the time. I do perforate teeth. I do fracture instruments. But when this happens, I sit the patient up and go, this has happened.

And then, but they’ve been told, haven’t they? So I think in answer to your question, I just don’t argue with people. I spread the facts out and say, what would you like to do? Again, I remember very early on in my, when I was doing my MSC in ENDO, I had a conversation with another dentist about trying to convince patients.

I just think I was what you’re about. You don’t convince people. Honestly, when you’re a new dentist. You’re just desperate, aren’t you, to kind of, to try new things out. You’ve done this new thing and, and listen, you’ve got 30 years of your career ahead of you. And trust me, this new thing that you want to do, you’ll have a hundred thousand ways and opportunities to do it. Never push things on patience. It’s bad news. Honestly, it is.

[Jaz]
So brilliantly said, and it reminds me of something that Lincoln Harris once said in one of his seminars I was with. And he said that, young colleagues will come to him and say, Oh, but I’m scared of it. I find it difficult to consent because when you give all the risks, it makes the patient want to say no.

Well, that’s the whole point of consent, right? Exactly. If the patient’s appetite for risk isn’t there for that very real issue, then that’s the whole point of consent. It shouldn’t be like trying to make sure that you just give them enough to make sure they say, yes, that’s not consent. Consent is making sure they own their problem, but they really want the solution, which you offer in which case is trying to save a tooth.

And if they believe this pseudoscience of unfounded claims, then so be it because you’re right. It’s sometimes, exactly. And as long as you just give those options, like here’s what I can do for you. I don’t believe in this pseudoscience. I don’t know if that’s the right term to use those patients or not, but you just need to respectfully, if they opt out, then that’s great.

[Samuel]
Learn not to judge people. I think that’s another thing as well, as I grow on with my career, I get more and more arrogant and I get more kind of thing, especially when I was newly qualified, I was a little bit unsure. And now I just know if someone comes to the door, I just, I see a problem.

I see it straight away, but I don’t judge people because that’s what makes our life rich, isn’t it? That people have different opinions and it’s not the end of the world. Let them get on with their lives. And if they want to do that, go for it. One time I saw a patient for an emergency. A lovely guy, really, really, salt of the earth guy, told him he had apical inflammation and he was hurting all night and blah, blah, blah.

So I said, right, I’m gonna numb you up, I’m gonna dress the tooth. I numbed the patient up and he was out of pain and he was like, oh, I’m out of pain now. And I was like, oh, yeah, yeah, but this was just to, and he didn’t understand it and then he just walked out. And the thing is, he was back for sure.

And he was all then nice, nice about it. But in the end, you can’t just get overly, like I say, don’t try and take on other people’s problems, obviously be empathetic, go the extra mile for people. But if they have made a consenting adult decision, don’t argue the toss with it because there’s no point.

[Jaz]
If there was one tip to give to any new practitioner of any discipline, it would be this, not to own the patient’s problem and care for your patients, be non judgmental, really actually, put the word care in healthcare is so, so important, actually generally care, but not more than their own teeth.

Some recurring themes in the podcast. That question, by the way, about these myths about root canal, that was from Megan. I just want to give a shout out to Zachariah, who actually introduced me to your channel, like some months ago. So Zachariah, thank you so much. I also have Ben who says he loves your YouTube videos and Ben has submitted so many questions that it’s insane.

Thank you, Ben. So I’m going to pick one. That’s going to be the most tangible. Okay. At what point if you spot a crack in a tooth during root canal treatment, do you decide the prognosis is too poor and would advise extraction? How often does this happen?

[Samuel]
Do you know what? I’ve boobooed a little bit because they’ve just released, I think it’s the ESE has just released a position statement on cracks. So what I would say is my advice given now is that it might be wrong, but in my opinion is that we used to chase cracks out. We now know that that is probably a bad idea because you’re just removing more and more tooth tissue. I was taught personally, if the crack doesn’t extend through and through. So say you’ve got a mesial distal crack and it doesn’t extend through the floor of the pulp chamber, it’s got a poor prognosis.

This is where consent comes in. And obviously it’s going to need some sort of cuspal coverage. Also as well, if the crack doesn’t extend into the canal orifice, but like I say, it’s kind of, it’s all about, we always go back to consent or any problems always go back to consent and it always goes back to tailoring your consent to the patient.

So, if you see someone for root canal, you just thrust them like a piece of paper and you get them in. That’s no good. That’s no good because it’s doing a disservice to the patient really. And you just give the patient the risk. Okay. And you’re never gonna know how they sort of value risk.

So if you say to them this tooth is in a real, really poor state, this could happen, that can happen. What do you want to do? Do you want to have a go? And some people go, yeah, some people say no. And then you just, I suppose in a way, if you’re sort of getting that sort of feeling that they’re not owning the problem, then maybe you’re going to lean towards maybe not doing the treatment, but I would say it always goes back to consent.

[Jaz]
But in terms of during your root canal, like you mentioned a feature is if the crack is extending into the orifice you’re thinking okay, this is a lot worse than I thought and yeah out and then again running across the floor by time you remove the restoration.

That’s like, okay, that’s maybe got a much poorer prognosis. And that’s a really good thing to go by. And we’ll put a link to that position paper on cracks as well. Another question that Ben asked just while we’re here is ninja access cavities. Okay, surely it would compromise straight line access and increase stress on files, increasing instrument fracture. Is it just an endodontist trying to impress on Instagram? Or do you think this has a future?

[Samuel]
It’s funny you should ask this question, actually. I’m about to do an access course. I do free lectures for HIW, which is the Wales Health Board, essentially. I’m going to do one on the 18th of February. It’s free.

So if you’re a dentist in North Wales, there’s still two places left and it’s on access and you know these ninja access I think the problem with these is yes you’re going to be putting major stresses on your tooth. This always brings me back to when I was a vt actually. My nurse was sort of tearing her hair out because I was always trying to do these sorts of minimal preps, but I didn’t really know what I was doing because I wasn’t very experienced.

If you’re using some sort of guided endodontics, we’re using the Cone Beam CT Scan and using jigs to sort of know exactly where to drill. I think by the time you’ve sort of drilled a ninja access and you’ve been looking around, you’ve probably not got a really true ninja access.

What I would say is if people aren’t aware of what a ninja access is, it’s essentially just making a hole just for your file to reach into the canal space. And the hole is really, really small, almost in the middle of the access cavity. I’m always a little bit reluctant as well to give my opinion restoratively because I’m not a restorative dentist, but I think in the main, if you’ve not breached the marginal ridge, so if you’re not breached the outer end of the tooth and you’ve just caught an access cavity right down the middle of the tooth, then it’s not going to need a crown.

It’s just going to fill it, and I suppose in a way it’s a kind of way off, isn’t it? Between, you know, putting major stresses on your files. Missing extra anatomy as well. And also there’s a strong argument to say that you need to remove all the pulpons to get rid of all the bacteria. How are you going to fill a tooth like that adequately? I’m not too sure.

[Jaz]
Cause if you’re preserving those ridges and stuff, they get in the way. But, ultimately there are very few teeth amenable to this approach. Usually got huge MOD amalgams.

[Samuel]
I was just about to say, how many teeth do you get? That virgin. You never.

[Jaz]
Exactly. So the type of case for that is, when you get to do it, I’m sure you guys get a nice little kick out of it.

[Samuel]
Exciting though, isn’t it?

[Jaz]
But I think you need to remove the old restoration explorer and stuff. By the time you remove the caries and stuff, you don’t need to do a ninja access. The floor of the pulp chamber is staring back at you. We’ll go for just two more questions, buddy. Okay, here’s a good one. Bernard asks, what would be the main mistakes that you’ve seen in patients referred from GDPs who have initiated endo to relieve pain as an emergency measure?

[Samuel]
That’s a really good question. Lovely question. Perforation, for sure.

[Jaz]
Perforation.

[Samuel]
Absolutely, yeah. It’s such a disappointing thing to do, to perforate, but it’s so easily done, and-

[Jaz]
I know that too well, my friend.

[Samuel]
Oh, I still perforate now. But granted, I don’t make the schoolboy era perforations anymore. The really easy ones, it’s usually with highly calcified teeth, but Sanja Banjera, I can never say his second name.

I think it’s Sanjay Bhanderi. He’s a Bhanderi, yeah. Lovely guy. Bhanderi, sorry. Yeah. He said something to me that I thought was really rang true. And he was saying, if you’ve never perforated a tooth, you’ve not done enough root canals. Absolutely. So I see a lot of perforations. I think when I did my MSC, I was told that you get a lot of dentists to ledge teeth and then they send it to you, I don’t really see that a lot of, I suppose, my referring dentists are pretty clued up on things.

And a lot of my dentists refer to me that they know that kind of, their sort of scope of practice essentially. Yeah. Another thing as well with referring dentists is referring teeth that are unrestorable. So there’s a huge kind of debate now between endodontists about, should you be checking the restorability of teeth or should you just be letting the original GDP to do that?

I think it’s down to how busy the endodontist is. So if you’re just starting out with your endodontic career, I think a really great practice builder is to say to your referring dentist, listen just bring them to me. I’ll see if it can be restored. I’ll do everything. I’ll put a core in then to GDP. That’s perfect. But I think as you start to get very, very busy, these kinds of treatments really, I’m now starting to ask my referring dentist just to see if it is restorable before it’s sent to me.

[Jaz]
Because the time it takes to actually get a removable caries cracks and explore, but get a lovely seal with your matrix band, build up a core. That can take up a significant amount of time. And so that needs to be respected. I remember not having an argument, but it was like a disagreement I had with an endodontist who used to work at our practice. Trey Endodontist, lovely guy, by the way, lovely, really sweet guy. But there’s one case where I’m quite good now at restoring dubious prognosis teeth in terms of the things I have at my disposal, vertical preparation.

The whole thing about supercrustal tissue attachment or biological width has totally changed over the years for me, right? So, there was this thing where I could restore it. He’s like, I don’t think this is storable. So we kind of locked horns about that, but eventually he did it. And this case has been going good for four years now, but it’s an interesting one sometimes.

And what I like to do now, by the way, is in those cases where it is a bit dubious, I do like to do my pre endo build up myself. Because I like to just, I charge the patient. Okay. Here’s an investigation fee. I will remove the restoration, I will clean it out, and then you’ll know by the appointment whether we should have this tooth out, or you’ll leave with a lovely seal, and the root canal, and the endodontist can do their lovely job and send it back to us. And I quite like doing that. How do you feel about that approach?

[Samuel]
I think another really, really important thing to sort of tell newly qualified dentists is when you said, I charge them, always charge them. Don’t get this thing into your head where you need to, you need to know your worth.

You need to charge for your time. I think the worry with checking the restorability of a tooth is if I think, or do you know, I would restore that, but I’m not too sure if another dentist would. So I’ve got a really, really good relationship with a lot of my referring dentists, a lot of the time, I still am restoring some teeth in one of the practices.

And if I just think it’s a bit tough that I’ll say to the patients, do you know what, if the dentist feels a bit, they can’t restore this, then I’ll do it for you. No problem. But you are on real shaky ground there because on the one hand, you’re kind of showing up the other dentist. And that’s not a good thing to do.

It’s not, not nice to kind of say, well, I’m better than you. Blah, blah, blah, blah. Another kind of issue is, if you are, and this is a really delicate thing to say now, is that as a referring dentist, you can’t be hoovering up work off of the patients. The referring dentist has sent you the root canal to do.

If then you start to like going, oh, I’ll do this for you. I’ll do that for you. It’s kind of like a gentleman’s agreement, isn’t it? Between referring dentists and referrers. You’ve got to have a really great relationship with these people. I used to refer to my root canals when I was early on to a place in Sandstone in the Wirral. It’s run by Kate Blundell. Anyone who lives in the Northwest knows Kate Blundell. She’s also-

[Jaz]
She taught my wife in Liverpool. And she’s a lovely lady.

[Samuel]
She’s the sweetest, kindest person you’ll ever meet. And she taught me a lot about referring to dentists, not directly, just how she sorts of conducted herself. And she used to send letters and say, this has happened. Do you mind if we do so? Essentially, it’s just always about communication. You see people on Facebook all the time, but people are arguing about it. Essentially, it all just boils down to communication, doesn’t it? We’re all mostly reasonable people. And I think that’s essential.

[Jaz]
A hundred percent. And that example I gave of me and the endodontist locking horns, it was actually in a courteous way. And he was looking out for me. He’s like, are you sure you want to do this Jaz? And I appreciate that.

[Samuel]
Maybe you should have listened to him.

[Jaz]
Well, it all is going well so far, but it was great for him to understand me as a clinician. And so you’re building that relationship with your endodontist is absolutely brilliant. Last question from your namesake, Samuel, Samuel Zhang. If it was your tooth, Samuel, which would you rather have extruded obturation or slightly short obstration? Which one would you rather have?

[Samuel]
Oh, I absolutely love this extruded. Oh, my God, that is so difficult. Well, I suppose we go back to the overextended and overfilled. I would say if it’s overfilled, so that’s where it’s out of the apex, but the whole canal space is filled, I’d go for that. Depends what’s out the end, if it’s a bioceramic, you know.

Perfect, even better if it’s through the apex and the apex has been destroyed by two larger ham files, probably go for short, but that’s a really good question. I couldn’t give you an answer on that.

[Jaz] It’s like choosing your favorite child or something. So, guys, those are amazing questions. Quick one from Rajeev. How important is sonic stroke ultrasonic activation of irrigants?

[Samuel]
Tell you what, if you buy an ultrasonic activator and you use it once. You will see all of the detritus, everything just sort of vibrating off the canal walls. And then your canal irrigant just starts to become really murky and nasty. And then you will never ever not do that again. And ever again. With the ultrasonic over the What was the other one? It’s ultrasonic and-

[Jaz]
He said, sonic or ultrasonic.

[Samuel]
So sonic, you can buy these like endo activators. You can buy them at dental directory for about 700 quid, or you can go on Amazon and buy one and they just buy the really expensive tips.

I used to use those, but I think the evidence suggests that ultrasonic is much better. You’ll also know clinically that you’ll see all this out. My irrigation protocol, rightly or wrongly is, sodium hypochlorite activated. So this is once we’ve shaped everything, we’ve done the comfort radiograph, everything’s all ready to rock and roll.

I’ll use sodium my chloride, I’ll activate it and I’ll use 17% E. D. T. A. And I’ll activate that. And then I’ll do a final rinse with sodium hypochlorite. And because the E. D. T. A. is going to remove all that smell, all that muck is going to open up all the tubules. You want to get it in there. So, I think the ultrasonic activator you buy the tip, they are all autoclavable It’s a really, really quick and easy way of just increasing the prognosis of the tooth. So definitely buy one for sure. Even if you’re a GDP.

[Jaz]
You’re totally right. When you see it for the first time and there’s no going back to not using it. I’m not gonna, I said that was the last question, but I’m just seeing these and I just-

[Samuel]
Keep going.

[Jaz]
Okay. All right. Lovely. So do you do many parts like pulpotomy kind of stuff or by the time they get to you the end of the line is the necrose kind of thing?

[Samuel]
So I do general dentistry. So when I went fully private, we gave the patients the option to stay privately with me. And then some people just couldn’t bear to see anyone else. I don’t know why, but I do do general dentistry. I enjoy general dentistry for sure. Like making crowns and things. And I think if I am being honest with myself and maybe I’m opening myself up really wide here, is that my dressing of vital teeth, it’s 50/50 for me. I am still on that learning journey, I think.

And I’ve had a few times where it’s been, it’s caught me out. Again, you go on like journeys, don’t you? As a clinician, you kind of work out this sort of new kind of thing that you’ve learned and you can start using it and then we get patients come back and you know, they’re not getting this kind of result that you’d wanted.

And again, I’ll say this ad nauseam, I’ll be really, really annoying. It’s all about consent. It’s all about communication with the patients. And like I say, if you’re NHS, if you’re in a kind of a healthcare system, which is just go, go, go, go, go, just get the whiteboard out, just draw it dead quick, tell them, and then let them make the decision again, it’s putting the responsibility onto them because once they’ve taken responsibility for the tooth, whatever happens, they come in and nine times out of ten, they’re going to be like, you did tell me blah, blah, blah, blah. So certainly for sure, I’m not doing these. I always get the difference mixed up between full pulpotomies and pulpectomy. I think a pulpotomy is where you-

[Jaz]
Remove the coronal.

[Samuel]
Exactly. And you leave this kind of, personally, I think if I’m down to that level, it’s a root canal for me for sure. But if it’s a pinprick exposure and the patient understands, I think the great thing, if you’re getting you for a general dentist, I’ve got this thing called well root putty and essentially it’s like a little box, it’s got 10 of these like little compule capsules full of bioceramic putty.

And essentially they come in these like little tiny sort of a silver lit sort of bags that you can sort of close up and say it’s a really, really great, great liner or a sort of material. I don’t use Dycal. I think the problem with the putty, of course, is it’s expense, but, you can buy this well root putty, you can kind of, as long as you’re obviously not using the sort of compule directly in the mouth, you just squirt it onto like a little pad and you’re manipulating it that way.

I’ve got a lot of great outcomes with that. So essentially, if you do like a tiny little pin prick and the pulp is really red and you can see that it’s alive and it stops bleeding as well, of course, that’s really important. Just pop a little bit of this putty over the top, bit of GI. Feeling on top, let the patient know.

And I suppose in a way towards it makes sense to do something like that, because the alternative, of course, is root canal or extraction. But you just need to involve the patient in the communication. Worst thing to do is to do a pull cap or direct pull cap, not tell the patient you come back in agony and you go, oh, well, this happened, that happened.

So, yeah, I’m on the journey with that for sure. And that is the greatest thing about my job in dentistry. You never, ever, ever, ever stop learning. My principal, my practice in Wrexham, he’s always doing something else. He’s always getting this out. He’s always, and I love that. I love watching him use different things and to be, he’ll kill me for saying this, but to be at the end of my career, he’s not at the end, but he kind of is. It’ll be like, be into it. And I went-

[Jaz]
That’s the goal. That’s the dream, man.

[Samuel]
I went to an endodontic sort of conference in Belfast and I was getting the plane home. I shared a taxi with a 70 year old dentist. She didn’t look 70. Put it that way. She looked fantastic, very glamorous, and she was talking about lasers and she was talking about this, that and the other. I didn’t know how old she was. And she was like, oh yeah, I’m in my seventies and only got my laser for like five years and her kind of passion for everything.

I was like, wow, it’s amazing, isn’t it? Most people don’t have jobs like this. Trust me. I’ve had a job before dentistry and I despised it. And count yourself lucky. And I know that doesn’t help for people who are having a hard time in dentistry at the moment-

[Jaz]
But anyone having a hard time, I think, take inspiration for our journeys and know that as long as you have a growth plan and some sort of direction you’re heading in, and sometimes education can be the catalyst for that, like you have experience as well.

[Samuel]
If you’re having a really, really bad time in dentistry, I know you’re thinking something now that you’re not saying out loud, and you might just feel you’re a bad dentist. And I can categorically say now you probably are a really good dentist. You just care too much. So I know in the past I’ve struggled slightly with certain things about dentistry, about being a perfectionist and I had a CBT and that’s kind of helped me.

Manage my anxieties and it kind of shows up things that I was blind to. And so I just want to say to you, you’re having a bad time. It will get better and just be really kind to yourself essentially. That’s what I would say.

[Jaz]
Well, one of the reasons we set up Protrusive Guidance is community. I think it’s so important to have a community of practice, as they call it, too, because we can feel so isolated. And what I love what you do, you’re building a community yourself. I’m fully supportive of that, Samuel. And what I love about our conversation, very candid, very honest accounts. I love educators and people like you who are real world, happy to talk about mistakes, happy to talk about, there’s always, they’re on a journey and you are just the embodiment of everything that we love in Protrusive, so I suppose we’ll say.

Thank you so much for sharing your time on this episode with us. It’s going to be the episode of the year in my opinion. And I’m so excited to get this in there. You’ve absolutely smashed it. Absolutely.

[Samuel]
Probably, I could talk for Britain. I could.

[Jaz]
There’s still about 40 questions from the community. There’s still about 40 questions.

[Samuel]
We could have a Joe Rogan three hour bad boy and I wouldn’t even stop for breath. Okay.

[Jaz]
I need to go for a wee desperately. So I’ve held it this long. So Samuel, thank you so much. Honestly, more power to you. Keep doing what you’re doing. And I’m going to get everyone to subscribe to your channel because it’s just so wonderful. Thank you so much.

[Samuel]
Great conversation, Jaz. Keep up the good work. I’ll see you soon. Okay.

Jaz’s Outro:
Well, there we have it guys. Thank you so much for listening all the way to the end. Wasn’t it brilliant? Isn’t Samuel such a great person? I love his outlook on life. I like his philosophy. I love that he loves Endo so much and we learned so much from him.

So thank you so much, Samuel. Do check out his wonderful YouTube channel. And of course, if you haven’t hit subscribe on our channel, then please do. Give a like while you’re there as well. If you’re listening on Spotify or Apple, please do subscribe. It costs you nothing and it means so much to me and the team.

Speaking of the team, I just want to say a big thank you to Erika for editing this. The premium notes team of Krissel, Nav, Emma, and our CPD queen, Mari. I really enjoy the Q& A aspect, so I will do a bit more of asking you guys. What are the questions that you want to ask our guest? So the only way to get involved with that is by joining the Protrusive Guidance app.

If you join the Ultimate Plan, you get access to all our masterclasses and premium clinical videos with CE. Head over to protrusive.co.uk/ultimate. It’s fully tax deductible and it’s one of the best value packages of education you will get. Thanks again for watching all the way to the end.

I’ll catch you same time, same place next week. Bye for now.