Dental News - The perceptions of a David in a land of Goliaths

Dr Barry Lee Musikant, USA

Tue. 26 January 2010

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When you are competing against giants in a field that has become tremendously lucrative for these giants, one could easily be convinced we are out of our depth and should beat a hasty retreat lest we encounter their true wrath. It is undeniable that we are exposed to the all-encompassing marketing power of these giants.

We recognize their ability to dominate the endodontic education in the schools (both undergraduate and graduate), the commercial exhibits and lectures at all the major meetings, the majority of the articles published in the trade journals all nicely capped off with an army of salesmen who make sophisticated pitches to the dentists to buy one or another of the expensive rotary NiTi systems.

We, on the other hand, have one over-riding advantage: We work with the simple but powerful idea that we have a safer, far more cost-effective and efficient way to perform endodontics that is so strongly based in common-sense logic that for those who expose themselves to these alternative concepts, the acceptance rate will be extremely high. We don’t have to see a lot of people to convince a small portion they should adopt our approach because the logic and application of our approach is readily accepted by a large percentage of the far fewer dentists we do come in contact with.

We have no other choice than to think this way, and it has done very well for us these past several years. We created an endodontic system that meets our needs because the products that have been heavily promoted in the marketplace did not. It is an absolute essential that the instruments not break. For us, there is no compromise on this point. I don’t want to know they won’t break if I only use them once, use them lightly with several iterations of recapitulation, not use them in highy curved, dilaceated, bifurcating or merging canals.

I want to know these instruments used in the recommended fashion will not break, period. This was not a requirement before the use of rotary NiTi because while breakage occasionally occurred, it was a rarity. Once I used rotary NiTi, I appreciated the greater tapered shaping, but this advantage did not outweigh the trepidation I had when using them. Moving forward in time as only a narrative allows, we came up with a system that incorporated the shaping associated with NiTi, but without breakage as a worrying side effect. I clearly remember giving a lecture at a fairly large dental meeting introducing our concepts. After the lecture, one of the dentists I was friendly with asked a younger dentist if he was interested in the system. The dentist responded he wasn’t interested in what I was talking about because it could not possibly be true. If it was, everyone would be using it.

The dentist’s response was an insight into human nature. What I gathered from this remark is:

1. If it sounds like it is too good to be true, then it is most likely not true. Having come to this conclusion, there is little follow-up to see if by chance it actually is true. It is more comforting to simply dismiss it. This reaction is even more true when a dentist’s focus for new endodontic systems is already filled by one of the expensive systems offered by the major manufacturers.

Against the exposure of my single endodontic lecture, the dentists attending the lecture have seen and heard about rotary NiTi systems at other lectures, articles, testimonials all from well-known opinion leaders as well as the ever-present salesmen who are convincing the clinicians to go with their latest system. It is hard not to pay credence to a flow of information that appears to be coming from diverse sources, but in reality is being centrally choreographed.

2. Once an expensive system is paid for, it is only natural the dentists would want to defend their decisions, that they made the right choices to make their efforts better and more productive. For many dentists, increased usage makes the dentists more familiar with the rotary systems’ limitations and they begin to take the precautions that are necessary for safe usage. It is an unusual phenomenon of rotary NiTi that the more one learns how to use these instruments, the more selectively they are employed. Case selection becomes an important part of treatment.

One should be very clear, however, that case selection has become increasingly necessary simply because there are many situations that can lead to instrument separation. I cannot think of another innovation in dentistry where the more one learns how to use the instruments, the less they are used. Now depending upon your point of view, one could look at the selective use of these instruments as a study in sophistication, that only the best and most trained dentists will use them safely and this is somehow a plus. Learning how to use a system that is defined by a narrow window of success, may appear to be a study in professional growth. I look at it as just the opposite: the need to expend a great deal of energy in mastering a system that will produce results that are (at best) no better than those attained by simpler, far less expensive and far safer approaches.

I teach many dentists and when a dentist comes to me to learn, I always ask them what they are presently using. The other night I was teaching a dentist from Virginia who came to our NYC endodontic office. She has been using the GT rotary NiTi system. I asked her if she fears separation and she said she’d only broke one instrument in the past few years.

Despite that single incidence of breakage, she now takes extreme precautions not to separate an instrument. I then asked her how she handles curved canals and she said if they are mildly curved, she will use the GTs in a double sequence (otherwise known as recapitulation) after shaping the canals up to a 15 or 20 via K-files. If the canals are more than mildly curved, she sends these patients to the specialist.

As an endodontist, I have no problem in having patients sent to me, but from an academic point of view, I don’t like systems whose vulnerabilities are so obvious they force a dentist to refer. It should not be the vulnerability of the system that determines whether a referral is made or not. Not being able to negotiate calcified canals, or failing at finding them, is a good reason to refer. Fear of instrument breakage should not be a reason.

Ironically, these referrals are made because of the fear of breakage of rotary NiTi. However, the endodontist has the same concerns, and he will use alternative means to shape the curved part of the canal at least up to the point where the concern for instrument breakage has passed. Certainly, if the specialist attains safer results using a more cautious approach, the dentist can also adopt this approach. We teach a far safer approach and those using it find the shaping of canals not only to be safer, but so highly efficient the need to ever transition to rotary NiTi is not necessary.

I have read a number of articles about the less distorted shaping rotary NiTi produces, but these results are always in comparison to the use of K-files used with a twist-and-pull stroke. When K-files are used with a balanced force technique, the results of non-distorted shaping favor the K-files.

The results will favor stainless-steel instruments even more when the instrument is a relieved reamer rather than the traditional K-file and it is negotiated to the apex using a tight watch-winding stroke or used in the 30-degree reciprocating handpiece. With the understanding that both the tight manual watch-winding stroke and the 30-degree reciprocating handpiece virtually eliminate all the torsional stress and cyclic fatigue that causes rotary NiTi (and for that matter, stainless steel) to break, we are addressing the basic concerns of dentists.

Solving these basic problems gives the dentist the ability to become more productive by turning out superior work on a greater variety of cases than he would have attempted in the past. Extending the dentists’ skills by the invention of systems that produce compatibility between the metal and what is asked of it, is what progress is all about, and despite being Davids, it is worth battling the Goliaths. I suppose you have to be a dentist to appreciate that last remark.

Your wallet and your stomach lining will appreciate the change.

About the author

Barry Lee Musikant, DMD, is co-director of dental research and co-founder of Essential Dental Systems (EDS). The company’s roots stem from the desire for product improvements to the items of focus in lectures and daily practice. His research and business partner is Allan S. Deutsch, DMD. Musikant and Deutsch have a combined 60-plus years of practice experience. Contact them at info@edsdental.com.

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