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2 December 2014
Endodontics: Specialty Observation Report
Endodontists are specialist in dentistry who focus on procedures
that involve the inner parts of the tooth, such as root canal therapy.
During my specialty office observation I was able to shadow Dr.
Michael J. Allen DDS, PC who is an endodontist in Roseburg, Oregon at
his clinic, Umpqua Endodontics. In the time that I was observing I
watched several treatment procedures, discussed the office team
members and their specific roles, examined their endodontic-specific
records, noticed their sterilization, disinfection, and infection control
procedures, and discerned the rationale for referral to an endodontist
from a general dentist.
In the course of my observation with Dr. Allen I witnessed six
procedures on six different patients. The first four appointments were
designated for patients who were either in for a check-up or were there
on referral from their general dentist for possible RCT or root canal
therapy. When a patient comes in for an evaluation for a possible root
canal the assistant begins the procedures. The first of these
procedures involves taking a radiograph of the tooth in question
followed by a sensitivity test. In the sensitivity test the assistant
performs a series of physical tests to determine what stimulation will
excite nerve endings of the tooth. The first test is to temperature
changes; this is done with a small piece of dry ice placed on the

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occlusal surface of the tooth. Another test requires the patient to bite
down on a block to determine if the tooth is sensitive to pressure.
Whether or not the pain lingers is an important factor in discovering
the need for root canal therapy. Lingering pain is an indication of a
dying root; in this case, a root canal would be necessary. If no crown is
present the assistant will test the sensitivity of the pulp with an EPT or
electric pulp test. Once these findings had been recorded Dr. Allen
came in, read over the findings, took probe measurements of the
pockets around the tooth, and examined with crown with an explorer.
With each patient the doctor then discussed their treatment options
that included either RCT or an extraction followed by an implant if the
likelihood of success with an RCT was not favorable. When the patient
made the decision as to what further treatment would be performed
the doctor would have them schedule another appointment for the
treatment. In the meantime, however, he would make the tooth as
pain-free as possible, either smoothing down a sharp amalgam surface
from a fractured tooth, placing IRM or Cavit, or prescribing antibiotics
such as penicillin or clindamycin.
The fifth procedure that I observed was an extraction of #5
followed by a bone graft for a future implant. Dr. Allen began by doing
a local infiltration injection all around the apices of #5 with 2%
lidocaine 1:100,000 epi. When the patient was still feeling pain, he
went back and used Septocaine for added anesthesia. The doctor used

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a curette, root elevators and extraction forceps to remove the tooth
and then went back with a large spoon evacuator to remove the
infection from the peri-apical abscess. Since Dr. Allen would also be
placing a bone graft he used a periosteal elevator to loosen the tissue
around the extraction and placed a semi-resorbable membrane under
the tissue. He then placed the synthetic bone graft material into the
newly excavated socket and compressed the material with a condenser
of sorts. The semi-resorbable membrane was folded over the graft site
and the tissue was sutured over the site with a synthetic suture
material. The patient was instructed to come back in ten to fourteen
days for the sutures to be removed. He was also given a prescription of
oxycodone and penicillin for pain management and infection
prevention. Once the doctor left the room the assistant went over postoperative protocols for the patient to follow at home.
The sixth and final procedure that I observed at Umpqua
Endodontics was a root canal performed on a patient who had
originally been to a general dentist for the root canal, but during the
surgery a file broke in a very narrow canal and therefore, a referral to
Dr. Allen was made. When the instrument separated in the
mesiobuccal root of #14 the general dentist stopped the procedure
and placed a temporary glass ionomer filling. After removing the glass
ionomer Dr. Allen used a root apex locator attached to a hand file to
determine the length in millimeters of the pulp canals. Once the

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lengths of the canals had been measured Dr. Allen used a SX Protaper
file attached to a high-speed hand piece in order to remove dentin and
any remainder of the nerve in the pulp canals so that he could reach
the separated instrument. He also used an ultrasonic to remove small
amounts of dentin. Dr. Allen did all of these procedures while looking
through a magnified lens in order to see the miniscule pulp canals.
Occasionally he would flush the area with EDTA
(Ethylenediaminetetraacetic acid) 17% and then dry the canals with a
paper point. The procedure took about an hour and forty-five minutes
to complete. Dr. Allen was very emphatic that this was a rare case.
Generally, when an instrument is separated it is either left in the canal
if there is no diseased pulp apical to it, or it is in an easier spot to
remove. Eventually, however, Dr. Allen was able to remove the piece of
file. Following the removal of the file the canals were flushed with
hyperchlorite chlorhexadine rinse and dried with paper points. The
apical one-third of the pulp canals were filled with gutta percha using a
Heat-n-Touch. An Obtura gun was used to back-fill the canals with gutta
percha, followed by the placement of MTA, an endodontic cement that
provides support and initiates healing, in the remainder of the canal. To
finish Dr. Allen placed etchant, a bonding agent and purple composite
followed by a piece of foam and a temporary IRM filling. Then, when
the patient is later seen by his general dentist for his permanent filling,

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the dentist will be able to remove the IRM and piece of foam and know
that Dr. Allen had stopped with the purple composite.
Endodontic offices, like Umpqua Endodontics, do not solely
perform root canal therapy. For instance, Umpqua Endodontics offers
root canal therapy, endodontic re-treatment, endodontic or apical
surgery, extractions, bone grafts, and implants. However, as indicated
previously, a lot of the appointment slots in an endodontist office are
taken up by referrals for root canal therapy and check-ups.
Umpqua Endodontics employs five staff members, three of whom
work in the operatories; two assistants work full-time with Dr. Allen, the
only doctor in the office. The other two employees work at the front
desk. The assistants are responsible for checking vitals and medical
records of patients, taking all radiographs, performing sensitivity tests,
assisting Dr. Allen during treatment procedures, performing all
sterilization, disinfection, and infection control procedures, explaining
post-op instructions to patients, and documenting all information in the
client charts. Dr. Allen is responsible for performing all endodontic
procedures, prescribing medications, and running the business side of
Umpqua Endodontics. The front desk staff is responsible for organizing
patient schedules, staff schedules, charts, and all outside
communication with fellow dentists and patients. Unlike some other
specialty dental offices, Umpqua Endodontics does not employ a dental
hygienist.

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Umpqua Endodontics only uses electronic records for their
radiographs since they have a digital x-ray machine. All other
documentation is made on paper charts. Specifically, they have a
generic paper chart that is filled out with the details for each specific
patient. This chart includes: medical history significant findings, the
tooth number of the suspect tooth, subjective findings by the patient
such as sensitivity to biting, pressure, hot or cold, objective findings
done by the assistant such as sensitivity to hot/cold, lingering pain,
EPT testing, and pain upon probing. These sensitivities are listed as
normal, mild, moderate, severe, or no response. Caries, extensive
restoration, and trauma are also listed along with how many
radiographs were taken and if there were any radiographic findings. A
diagnosis is then made, either pulpal or apical. Pulpal diagnosis
includes: normal, reversible, symptomatic irreversible, asymptomatic
irreversible, pulpal necrosis, previously treated, or previously initiated.
Apical diagnosis includes: normal, symptomatic apical periodontitis,
asymptomatic apical periodontitis, acute apical abscess, chronic apical
abscess, and condensing Osteitis. Following the diagnosis the doctor
indicates the treatment plan as RCT, retreatment, surgical endo,
extraction, or other. On the back of this sheet are more places for
documentation of a procedure. This includes the type of anesthesia,
irrigation, medicaments, obturation (GP, MTA, Sealer, Later or Vertical),
provisional (cotton/foam, cavit, IRM/ZOE, or RMGI) and restored

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(CMPST, Shade, AM, Surface, and/or Post.) The length of each pulp
canal is also recorded along with the size of the gutta percha tips to be
used, either .04 or .06. In addition, surgical procedures are
documented from the following list: 100 mg Flurbiprofen, Peridex
presurgical rinse x 30 seconds, Sulcular full thickness flap # ____ to #
______, mucogingival flap, apicoectomy, retro fill ____ MTA, biopsy,
simple or surgical extraction, suture ___4-0 gut or ____4-0 vicryl, I&D,
and irrigations, either 0.012% CHX or sterile water. There is also room
for further comments and prescriptions on this page.
Sterilization, disinfection and infection control procedures differ
in every office. At Umpqua Endodontics, they have their own set way of
doing things. After a patient is dismissed from an operatory and the
dirty instruments are taken to the sterilization room, the chair and
counters are first sprayed down with Birex and then wiped with Caviwipes. Once the chair and counters have dried they are barriered with
clear plastic, including special small plastics bags for the light handles.
The lines are only slurped with a Patterson line cleaner after a surgery
is preformed. In the sterilization room only an Ultrasonic and Statim are
used to sterilize instruments. They do not have an Autoclave. I like the
idea of spraying with Birex and then wiping with a disinfecting wipe
rather than wiping twice with disinfecting wipes. I think that this would
save time on clean up and lead to lower costs since half the amount of
wipes would be used. Unlike Umpqua Endodontics, we at LCC could not

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get away with using only one Statim and no Autoclave. We have too
many students and staff working at the clinic to keep up with the
sterilization demands if we only used a Statim.
A referral is made from a general dentist to an endodontist for
many reasons. The reason may be as simple as a dentist not liking to
do root canals or as complicated as a separated instrument being
accidentally lodged in a very narrow pulp canal. Other reasons include,
a complicated root structure, a complicated extraction, the need for a
bone graft, the need for an implant, or the need for endodontic
surgery. Dr. Allen made it clear that referrals were the vast majority of
his business, therefore, good relations between he and the general
dentists in Roseburg is crucial.
After my observations time at Umpqua Endodontics I was very
pleased with my decision to visit an endodontist for my specialty office
visit. I was able to see a side of dentistry that I have had little to no
experience with since I have never had or observed any endodontic
procedures. I enjoyed the complexity of treatment involved in a root
canal, especially when a separated instrument is involved. I was also
thrilled to see my first extraction, and not only that, but a bone graft as
well. With this new experience I feel as though I will better be able to
discuss treatment with patients who receive the news that they should
look into root canal therapy at our clinic.

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Contact: Loretta Strain (Dental Assistant) @ 541-733-9191 or
lorettastrain@yahoo.com