Love Letters to Endo

By Dr. Hafsa Affendi

“You spend so much time in your profession it ought to be something you love” – John H. Johnson

Let us be honest, every one of us that has chosen Endodontics as profession has a love for saving teeth and a desire to alleviate our patients’ discomfort. As an Orofacial pain specialist who was mostly managing chronic pain disorders, the opportunity to acquire additional skills to manage acute odontogenic pain was beyond exciting to me. However, as someone completely naïve to the field of Endodontics with almost non-existent clinical knowledge of RCTs, the learning curve felt steep.

Today as a final-year resident I look back at the challenges I faced as a first-year resident and reflect on the suggestions I received from my faculty and peers, that helped me overcome the difficulties that a newbie in Endo occasionally encounters. While I am still learning, I would love to share some nuggets of wisdom that may help first year residents.

• Anesthesia and analgesia: As we know the first step to successful patient management is adequate anesthesia. Most endo visits comprise of patients experiencing dental pain and occasionally from that cohort of patients we encounter hot teeth that require additional anesthetic measures. Intraligamentary and intra-pulpal injections aside, practice intra-osseous anesthesia as well. Also, get your hands on different techniques like gow gates and akinosi blocks.
  Post-op analgesia is as important as pre-op anesthesia, know your analgesics well and prescribe them according to your patient’s health history for successful pain management.
• Microscope: ditch your loupes and rely solely on the microscope. I remain guilty of cheating during my first year by attempting to access and perform RCT under direct vision. While initially working with a microscope feels cumbersome, your back will thank you later and once you get hold of it your speed and quality of work will improve significantly. After facing difficulties with patient positioning and microscope’s indirect vision especially for mandibular molars, I practiced on typodonts to get comfortable with it and it greatly eased the transition.
• Access preparation: One thing that I wish I realized as a first-year resident was that access preparation and locating the canals is 60% of RCT. As a third-year resident I mostly do single visit treatments and compared to my first year of residency the difference lies in the speed of accessing the tooth and locating the canals. The key to refining your access prep is to practice as much as you can. I finessed my access preps by practicing on extracted teeth under microscope and for a naïve first year resident it helped tremendously.
• Learn from ‘everyone’ in the clinic: Every faculty has a unique style of working and you will find out with trial and error what suits you the best. Discuss challenging cases with different faculty and take suggestions from them, you will eventually incorporate bits and pieces of their recommendations and form your own practice style. Not only faculty but your seniors and co-residents can give you advice that could prove beneficial, this includes your assistants as well. Remember your assistants have worked with numerous batches before you and in certain circumstances they know exactly what instrument/ armamentarium will be required to assist you with the case. I personally have been bailed out of situations by being offered the right kind of clamp, ultrasonic tip or a specific instrument during the procedure.
• Last but not least ‘Diagnosis’: As time passes you will realize that clinical Endo gets better with repetition and technically with sufficient practice anyone can do it, what sets us apart is diagnosis. Do not perform a RCT if you are uncertain about the diagnosis, also never hesitate to spend additional time utilizing tools such as EPT, transillumination, tooth slooth, or performing an extraoral examination to determine non-odontogenic source of pain. As an orofacial pain specialist, I evaluate the patients for myogenous pain, arthralgia, neuropathic pain, neurovascular headaches etc. when odontogenic etiology is ruled out.

Above all it is important to enjoy your time and make memories during residency. We are all going to graduate as specialists, let us not forget to cherish every moment spent at the program which is perhaps the last step in our careers. You will have good days and bad days, but it is important to take it in a positive stride and keep evolving. Good luck with the journey!

Dr. Hafsa Affendi is an endodontic resident at the University of Michigan School of Dentistry. Follow her on Instagram at @rubber_dammit.