Single Versus Multiple Endodontic File Use

Transcription

1 Volume 35 No.12 Page 62 Single Versus Multiple Endodontic File Use Authored by John West, DDS, MSD Upon successful completion of this CE activity, 2 CE credit hours may be awarded. Opinions expressed by CE authors are their own and may not reflect those of Dentistry Today. Mention of specific product names does not infer endorsement by Dentistry Today. Information contained in CE articles and courses is not a substitute for sound clinical judgment and accepted standards of care. Participants are urged to contact their state dental boards for continuing education requirements.

2 Single Versus Multiple Endodontic File Use Effective Date: 12/01/16 Expiration Date: 12/01/19 About the Author Dr. West is founder and director of the Center for Endodontics in Tacoma, Wash. He graduated from the University of Washington Dental School and received his MS degree and endodontic certificate at Boston University, where he has been honored with an Alumni of the Year Award. He is an educator and clinician, and his focus is on interdisciplinary endodontics. He has authored several textbook chapters and is an editorial board member for the Journal of Esthetic and Restorative Dentistry, Practical Procedures in Aesthetic Dentistry, and the Journal of Microscope Enhanced Dentistry. He can be reached toll-free at (800) , via at or by visiting the website centerforendodontics.com. Disclosure: Dr. West is co-inventor of ProTaper, Wave One, ProGlider, and Calamus Technology (Dentsply Sirona). This is an article about doing the right thing for all the wrong reasons. It is also an article designed to move the reader into an action step that will positively change how he or she experiences the world of endodontics. The right thing refers to doing what is right for (1) the patient, (2) your office, (3) your staff, (4) your pocketbook, (5) your conscience, (6) your legal compliance, (7) your reputation, and (8) yourself. Let s begin with 3 understandings: 1. For most dentists, reading an article dedicated to single file use is a boring subject. 2. For some dentists, my message will not be compelling enough for them to change to the single patient use of endodontic manual and mechanized files. 3. For the clinicians who want to be at the top of their endodontic game and join the dentists of the future, this article invites the profound freedom you will experience moving from the constant fear of instrument breakage to the fun of improved endodontic performance and a new level of sustainable confidence. PERHAPS THE WRONG REASONS FOR SINGLE ENDODONTIC FILE USE Cross Contamination/Sterilization Considerations (Figure 1) All dentists are committed to protecting and reducing risk to patients, staff, and themselves. In North America, while most sterilization protocols are clearly spelled out by health organizations and the US Occupational Safety and Health Administration (OSHA) and are well enforced, sterilization of endodontic manual/mechanical glidepath files and mechanical shaping files essentially takes on 2 different forms in dental offices. The first approach is to reuse manual and/or mechanized files by manual cleaning, ultrasonics, and finally heat autoclave treatment. The second and less frequent approach is for the dentist to mandate single patient use of all files. 1 What does the literature tell us about endo dontic multiple patient use sterility? In a nutshell, 100% sterility between patient uses cannot be guaranteed. Perhaps the best summary of the literature is a joint publication by the American Association of Endodontists (AAE) and the Canadian Academy of Endodontics (CAE) Joint AAE/CAE Special Committee on Single Use Endodontic Instruments. 2 In their report, several key points were reported: 1. It is difficult to clean and sterilize endodontic instruments due to their many and small design flutes, which can act as bacteria and debris harbors. 2. Some countries have designated endodontic files, reamers, and engine-driven NiTi instruments as single use instruments (SUI). The mandate is to prevent the transmission of prion protein, the pathogen isoform of a common host cell receptor, which causes acquired iatrogenic Creutzfeldt-Jakob (icjd), a type of spongiform encephalopathy. No treatment or prophylaxis is available for this disease and its acquisition nearly always proves fatal At present there also is no universal standard for the preparation and sterilization of endo dontic instruments prior to reuse. Most current methods fall short of consistently rendering instruments surgically sterile. Disease transmission is associated with the reuse of endodontic hand and rotary files and reamers; however, it has not proven itself to be a clinical problem in endo dontic practice. Nonetheless, the threat of prion transmission via this route has become the basis for the decision to mandate that all such instruments be designated SUI in some countries. 4. While the prion protein has reportedly been transmitted to medical patients through exposure to blood, inadequately sterilized neurosurgical instruments and a variety of cadaverdriven materials, there has never been a confirmed case of 1

3 icjd transmitted through dental treatment. The report 2 goes on to state: The National Institute of Neurological Disorders and Stroke and the World Health Organization have estimated the worldwide incidence of icjd caused by all manner of transmission to be one per 1,000,000 people. It is, therefore, extremely unlikely that a prion disease could be transmitted from one patient to the next during endodontic treatment. However, The Special Committee does recommend that clinicians continue to adopt a vigilant and cautious approach in monitoring patient health, use acceptable methods to clean and sterilize endodontic instruments, and exercise sound clinical judgment in the selection of instruments for reuse. Finally, at the time of the above AAE/CAE Special Committee Report, there was no record of a case of icjd reported in the United States as of Weakened Files/Metallurgy Considerations (Figures 2 and 3) It is learned knowledge that if you use a file multiple times, you will break more files in the root canal system than if you use them once. And yet some literature would suggest a NiTi file can be used safely 4 times. 7 However, if you treat patients with single patient use, the chances of breaking a file especially when a smooth glidepath is prepared, a gentle touch is used, and each manufacturer s directions for use are followed (something often violated) is a very low risk. However, multiuse file systems are a risk that can be easily avoided, while at the same time, measurably improving confidence. When files are reused, the cyclic fatigue increases and the torsional resistance decreases Pecuniary Cost Considerations (Figure 4) The pecuniary cost of reusing files is very interesting. At first glance, and especially for easier root canal system treatments, it seems that reusing mechanical files would save money, especially when the dentist deems that these files were never really stretched, pushed, or appreciably taxed. To illustrate the financial cost of file reuse, I ran an experiment. I followed a typical family of 4 ProTaper Gold (PTG) (Dentsply Sirona) files (S1, S2, F1, and F2) from the finish a Figure 1. Multiple file sterilization consideration: (a and b) SEMs demonstrate retained presence of original bacterial matts at different levels along the file length and after 2 and 3 sterilization cycles. (SEMs courtesy of Dr. Carmen Bonilla, assistant professor, Nova Southeastern University, College of Dental Medicine, Fort Lauderdale, Fla.) b of one endodontic patient s treatment as if I were going to use them in a second endodontic patient treatment. At the Center for Endodontics in Tacoma, Wash, if mechanical files were to be experimentally reused, which they are not, we have calculated that the following 10 steps would be required: 1. Dentist determines that the files can be reused (60 seconds). 2. Files are collected by chairside assistant or asepsis coordinator and taken to sterilization area (60 seconds). 3. Chairside dental assistant or asepsis coordinator manually cleans files with 2x2 sponge and alcohol. Inspects to ensure flutes are clean (120 seconds). 4. Ultrasonic cleaning (60 seconds). 5. Heat autoclave. 6. Files are marked to reflect one use. This technique can create a nightmare, because any identifying mark for reuse cannot measure the amount of previous usage. For example, a file used in a calcified canal where considerable shaping is required would be more worn than a file used in a simple canal. Also, the damage from the number of uses in a multiple canal root canal system cannot be accurately assessed, compared to a simple single canal tooth where less damage or weakening would have occurred. For a growing number of dentists, the failure of being able to measure file fatigue is enough to disqualify a reuse mentality. The cost savings simply does not justify a risk that cannot be accurately evaluated. In a well-managed practice focusing on the highest performance level, efficiency and safety outweigh the apparent overhead savings. It is an illusion that these dentists are saving money. In addition, what could the dental assistant or asepsis 2

4 a b c d e f Figure 2. Multiple file use metallurgy deformation consideration. (a) SEM of new F2 ProTaper Universal (PTU) (Dentsply Sirona) file. (b) SEM of one use F2 PTU file. Note pristine edges are gone. (c) SEM of F2 after used 2 times. Note severe breakdown of file cutting edges. (d) SEM of new Twisted File (TF) (Kerr Dental). (e and f) SEM of TF file at 2 different distances from tip. (SEMs courtesy of Dr. Carmen Bonilla, Fort Lauderdale, Fla.) coordinator have been doing in place of this scrub work? There are still 4 more steps to our 4 mechanical file reuse experiment. 7. Place in banker sponge (60 seconds). 8. Deliver to operatory (60 seconds). 9. Set up for patient No. 2 (60 seconds). 10. Dentist discovers blades too dull (inefficient) or damaged (120 seconds). Now, Let s Do the Math! There is a dental assistant or asep sis coordinator cost for the 4 PTG rotary files (and, of course, this experiment is true for any 4 mechanical files) that we fictitiously followed. At an hourly rate of $15 per hour or 25 cents per minute adds up to about $2.50. The dentist s mean average wage is about $ For the purpose of this article, the average dentist in the United States makes about a $1.66 a minute. Based on this number, the cost to participate in and direct the reuse of our 4 rotary files is about 3 minutes and therefore about $5. Now add up the cost of distilled water for the sterilization unit, at least 4 pairs of gloves, 2 face masks, 6 ounces of ultrasonic bath, 3 sterilized endodontic sponges, one banker sponge, and electricity. This total is about $ Then add $2.50 (assistant production time) + $5 (lost dentist production time) + $10 (materials cost) = $ If the original 4 PTG mechanical files cost $40, then you mathematically save $ Is $22.50 worth it? The tradeoff distraction of multiple file use is potentially huge and is easily measured. Single file use creates an atmosphere and a culture for enjoying the canal preparations while knowing you are safer, it is easier, you are more confident, you are in control, you are more efficient, and you are energized by using the right tool for the right job. Your endodontics moves from fearful to fun. 3

5 a b c d e f Figure 3. Multiple file use breakage consideration. (a) New 558 fissure bur (Dentsply Sirona). (b) The 558 fissure bur often breaks after a single patient use, sterilization, and then reuse. The bur often breaks when refining an endodontic access. The dental assistant presents a new one while the dentist waits about 30 to 60 seconds, depending upon where the burs are located. This downtime is just like waiting for a new endodontic file. It can be aggravating, frustrating, and can disrupt the flow of an elegant and appropriately designed access outline. (c) Graphic example of multiple mechanical file uses (courtesy of Dentsply Sirona). (d) SEM of fractured NiTi file seen at 250x. (e) SEM of fractured NiTi file seen at 500x. (f) Multiple internal fractures seen in fractured NiTi file at 1,500x. THE RIGHT REASON FOR SINGLE ENDODONTIC FILE USE While sterilization and the safety from file breakage actually are good reasons and even the right reasons for single use, they are not good enough reasons, for reusing endodontic files. Another right reason to reuse endo dontic files seems to be a cost savings. Or is there a cost savings? My take home message: Do not reuse endodontic files ever. Previously used mechanical files need to be discarded. Do not attempt to resurrect them for an uninformed patient. The practice transforming benefit of single file use is ultimately energy, and energy directly translates to dollars. Endodontic Single Use Files Metaphor Remember when you were 8 years old and you got a new pair of shoes? You could run faster and jump higher! Not in reality, but you thought it was so. You experienced a newfound level of confidence. A new endodontic file series for each patient creates the same feeling of confidence, along with the added bonus of actually letting you perform better: Creating confidence knowing that your files have never been pushed to the limit is the big difference. In a reuse system, you never know when the overused file is going to show up. Please consider the following self-imposed test. Treat the next 10 endo dontic patients with brand new files. After each patient, prepare the used files in your usual way and then place them in a cup labeled John West Invitational. When endodontic patient No. 11 is treated, then raid the jar of used mechanical files. Go ahead, sterilize, and reuse them. What do you think you will notice? Your recently newfound confidence and energy level from using brand new files for each of your previous 10 endodontic patients will have vanished. Your fear of breakage will return and your peace of mind will be gone. The crapshoot returns. Will this be your lucky day, or your unlucky day? Everything is a choice, and you can choose your quality of the moment versus dollar cost. Personally, I would trade the energy and enjoyment over the apparent dollar savings any day. A quote that sums it up for me is, The journey is the destination! Comparing Reason for choosing multiple file use: 1. Could save money. Reasons for choosing single file use: 1. When you are treating an endo dontic patient, you know the mechanical treatment files are new. You feel a sense of boldness 4

6 a b c d e f g h i j Figure 4. Ten steps while following our imaginary 4 ProTaper Gold (Dentsply Sirona) files through a cycle for reuse. (a) At conclusion of endodontic treatment, the dentist carefully evaluates that the files fit the visual criteria for reuse. (b) The dental assistant gathers the foursome, taking them to the sterilization area. (c) Four files are carefully wiped off with counterclockwise rotation through an alcohol-laden 2x2 gauze. (d) Files are placed into ultrasonic unit. (e) Then, files are placed into heat sterilizer. (f) Files are removed and placed into appropriate sponges depending if one, 2, or 3 reuses. Keeping the color code legend is critical here. Other tracking devices exist but marking files becomes quite time-consuming. (g) Reused files are placed in banker sponges for delivery to the operatory. (h) Reused files arrive to operatory in banker sponge or delivery system of choice. (i) Reused files are placed onto dental cart tray for patient treatment. (j) Dentist discovers the files are dull and inefficient, or damaged and not safe. and control. This knowledge translates into confidence. The conscious and subconscious stress of reusing files is gone and the fun of endodontic shaping is priceless. 2. More efficiency. More confidence. More energy at the start and end of each visit. 3. Improved clinical results because the files cut and perform in the way they are designed. 4. Reusing files increases the probability of breaking files and having to refer to an endodontic specialist for repair. Retrieval or surgical correction is expensive and unpredictable and could cause a perforation in the removal attempt. The patient situation can go from bad to worse. Now all the saving numbers go out the window. Fracture is extremely rare in instruments used only once. 5. Single file use is now the recommendation of many manufacturers. If a patient were litigious, a claim involving cross-contamination or a broken file due to reuse could lead to a successful lawsuit. The first question that will be asked in litigation would be whether reused files were used, and whether the patient was informed that reused files were being used in the treatment. One lawsuit can cost thousands, raise insurance rates, and also include the cost of trial preparation and trial time. Then, all the apparent cost savings again go out the window. Saving $22.50 was an illusion after all. Also, if you need to refer your patient to an endodontic specialist, you have to do a lot of $22.50 savings increments to pay for their fee. 6. Multiple file use increases cyclic fatigue and decreases torsional resistance. 7. Resterilization increases file corrosion. 8. Tooth lifetime predictability is greater when files are not buried in the root canal system preventing 3-D cleaning, proper shaping, and 3-D obturation. 9. Reduce cross-contamination and accidental puncture followed by OSHA directed emergency room visit to be tested. 10. Multiple file use does not make economic sense. 11. Reputation. Once you break a file, don t be surprised to see a posted Yelp report that says something like: My dentist broke a reused tool in my mouth, requiring me to go to the emergency room. Now I have to see a specialist, and I might even need to have my precious tooth removed. The perfect bad storm! 5

7 CLOSING COMMENTS Multiple endodontic file use could save you $22.50 per patient. However, it could also cost you the joy of doing endodontics and the satisfaction that you are doing the right thing by giving patients what you would want if you were the patient. The single versus multiple file use choice is not about what you can get away with; rather, it is about the quality you can achieve. Are you about saving a few pennies, or are you about becoming and being an example of the quality dentist of the future? The bottom line here is that successful dentists of the future will find out what patients want and help them get it. What patients want is value, and they want what is right. They also want to trust that you are doing what is correct for their dental health, structure, aesthetics, and well-being. Optimally embracing tools and technology the way that they were both designed will help you ensure that patients get what they want to predictably and safely save their tooth. Single file use positively transforms the endodontic experience for the patient and the doctor.f References 1. Small group practice. Presented at: American Dental Association pre-conference; October 19, 2016; Denver, CO. 2. Hartwell G, Bowles W, Peters O, et al; Joint AAE/CAE Special Committee on Single Use Endodontic Instruments. Single use instruments [final report]. January 11, endoexperience.com/documents/caeaaesuistatement.pdf. Accessed August 25, Porter SR. Prion disease: possible implications for oral health care. J Am Dent Assoc. 2003;134: Walker JT, Dickinson J, Sutton JM, et al. Implications for Creutzfeldt-Jakob disease (CJD) in dentistry: a review of current knowledge. J Dent Res. 2008;87: Azarpazhooh A, Fillery ED. Prion disease: the implications for dentistry. J Endod. 2008;34: Cockcroft B. Advice for dentists on re-use of endodontic instruments and variant Creutzfeldt-Jakob disease (vcjd) [letter]. London, England: Department of Health; April Wolcott S, Wolcott J, Ishley D, et al. Separation incidence of ProTaper rotary instruments: a large cohort clinical evaluation. J Endod. 2006;32: Ullmann CJ, Peters OA. Effect of cyclic fatigue on static fracture loads in ProTaper nickel-titanium rotary instruments. J Endod. 2005;31: Vieira EP, Nakagawa RK, Buono VT, et al. Torsional behavior of rotary NiTi ProTaper Universal instruments after multiple clinical use. Int Endod J. 2009;42: Shen Y, Cheung GS, Peng B, et al. Defects in nickel-titanium instruments after clinical use. Part 2: Fractographic analysis of fractured surface in a cohort study. J Endod. 2009;35: American Dental Association, Health Policy Institute income, gross billings, and expenses. In: 2015 Survey of Dental Practice ADA; December 2015: Table 1. ada.org/en/science-research/health-policy-institute/data-center/dental-practice. Accessed on October 20,

8 POST EXAMINATION INFORMATION To receive continuing education credit for participation in this educational activity you must complete the program post examination and receive a score of 70% or better. Traditional Completion Option: You may fax or mail your answers with payment to Dentistry Today (see Traditional Completion Information on following page). All information requested must be provided in order to process the program for credit. Be sure to complete your Payment, Personal Certification Information, Answers, and Evaluation forms. Your exam will be graded within 72 hours of receipt. Upon successful completion of the post-exam (70% or higher), a letter of completion will be mailed to the address provided. Online Completion Option: Use this page to review the questions and mark your answers. Return to dentalcetoday.com and sign in. If you have not previously purchased the program, select it from the Online Courses listing and complete the online purchase process. Once purchased, the program will be added to your User History page where a Take Exam link will be provided directly across from the program title. Select the Take Exam link, complete all the program questions and Submit your answers. An immediate grade report will be provided. Upon receiving a passing grade, complete the online evaluation form. Upon submitting the form, your Letter of Completion will be provided immediately for printing. General Program Information: Online users may log in to dentalcetoday.com any time in the future to access previously purchased programs and view or print letters of completion and results. POST EXAMINATION QUESTIONS 1. Using modern technology and verification methods, it has been shown that 100% sterility between patient uses can be guaranteed. 2. Regarding Creutzfeldt-Jakob, a type of spongiform encephalopathy, no treatment or prophylaxis is available for this disease and its acquisition nearly always proves fatal. 3. When files are reused, the cyclic fatigue increases and the torsional resistance decreases. 4. The damage from the number of uses in a multiple canal root canal system can be easily and accurately assessed. 5. Reusing files increases the probability of breaking files and having to refer to an endodontic specialist for repair. 6. Single file use reduces cross-contamination and accidental punctures followed by US Occupational Safety and Health Administration directed emergency room visits to be tested. 7. Single file use is now the recommendation of many manufacturers. 8. According to the author s calculations, multiple endodontic file use could save clinicians about $10.00 per patient. 7

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