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NORTHWEST ENDODONTIC SPECIALISTS
CLINICAL HANDBOOK
Welcome to our team! This handbook will introduce you to our clinical area, increase
your knowledge and skills for each procedure, and ensure that you reach your maximum
potential as rapidly as possible.
The clinical area deals with the actual treatment and interaction with patients. We strive
to provide the highest quality dental care to our patients with the greatest degree of
compassion and efficiency.
TABLE OF CONTENTS
Defining Dental Assistant Responsibilities
Prior To Seating A Patient
Entering New Patient Exams
Opening patient exams
Seating A Patient
Doctor Introduction and Anesthetic
Root Canal Procedure
Dismissing A Patient After Treatment
Charting
Anesthetic
Files, Gates Glidden Burs, and Compactors
Engine Drill Files
Rubber Dam
Radiographs
Developing Radiographs
Prescriptions
Surgery
Apicoectomy / Retrofill
Suture Removal
Incision and Drainage
Root Amputation / Hemisection
Extraction
Crown Lengthening
Glossary of Endodontic terms
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DEFINING DENTAL ASSISTANT RESPONSIBILITIES:
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Assist the doctor in all clinical procedures.
Familiarize yourself with each patient and their scheduled treatment.
Chart all appropriate data during the exam and treatment.
Take, develop, and mount x-rays.
Take every opportunity to educate the patient on dentistry and their treatment.
Help maintain schedule flow by monitoring the doctor/treatment progress. If
running ahead or behind schedule, notify the schedule coordinator.
Maintain maximum operatory function by keeping it adequately stocked.
See to clinical equipment and instrument maintenance through proper preventive
maintenance, cleaning, and sterilization.
PRIOR TO SEATING A PATIENT:
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Review patient record. Verify that consent for treatment has been completed.
Review medical history for necessary precautions. Highlight medical alerts using
red alert stickers. Record all medical history information provided by the patient on
the patient information sheet. If there are no medical precautions, write ‘WNL’
(within normal limits).
Record patient information onto computer – CDR. Verify that the spelling of the
patient name is correct.
Make sure the operatory is completely set up for treatment. All equipment should
be turned on and ready to go.
ENTERING NEW PATIENT EXAMS
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From Schick technologies main screen, press ‘new patient’ icon box located at the
top left of screen.
Record new patient information from chart onto computer. Enter patients last
name, first name, and chart number (ID number). To move between fields, press
TAB/ For example:
Last name
First name
ID number
Date
3.
Smith
John
11432
(automatic)
When finished recording patient information onto computer, press ENTER.
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HOW TO OPEN PATIENT EXAMS
If the patient is a returning patient (has previously been into the office for exam and/or
treatment), search the computer memory for previous exams.
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From Schick technologies main page, press the ‘open’ icon box located second
from left at the top of the screen.
Enter the first letter of the patient’s last name.
Using the arrow keys, scroll up or down alphabetically to find the patients name.
Once you have located the patient’s name, press ENTER.
Note: not all returning patients will be registered in the current computer memory. Our
files are historically compressed (filed by date) and may have been transferred to CD or
disk. If search does not produce the patients name, enter the patient as a new patient
exam.
SEATING A PATIENT
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Call the patient by their first name and escort the patient to the operatory.
Indicate to the patient where coats and purses, etc. may be placed during treatment.
“Sally, there is a hook in the far left corner if you would like to hang your coat.”
Introduce yourself to the patient. “My name is Molly. I will be assisting Dr.
Goerig with your treatment today.”
Gather diagnostic information from patient. Listen intently to the patient, they will
give you the diagnosis. Record diagnostic information onto patient information
sheet. See diagram next page.
Take initial x-ray on computer.
Notify the doctor that the patient is ready for exam.
Return to patient and see to their comfort. Offer the patient a magazine. All
conversation should be directed toward the patient needs. If the patient has any
concerns about treatment or is apprehensive, note this on the patient information
sheet. Address patient fears; be careful not to negate the patient’s feelings.
DOCTOR INTRODUCTION AND ANESTHETIC:
Doctor will enter the operatory, glance at the patient information sheet and make
the appropriate introduction. (If the ‘N” is circled, this indicates to the doctor that
this is a new patient. If the “N” is crossed out, it indicates that this patient has
previously been into the office.) The doctor will then address any patient fears, if
indicated. It is very important that any patient apprehension has been
communicated to the doctor. After fears have been addressed and introductions
have been made…
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Put the patient chair back.
Adjust examination light and doctor tray for doctor use.
Record all diagnostic tests onto patient information sheet.
When patient has given verbal consent to recommended treatment, pass topical
anesthetic and 2x2 gauze to doctor.
Receive topical, pass anesthetic syringe. For all mandibular (lower) teeth, Citanest
Plain (black) carpule and yellow needle should be used. For all maxillary (upper)
teeth, 2% Xylocaine (red) or 2% Polocaine (brown) carpule and blue needle.
Prop the needle cover onto cotton pliers for recapping.
Receive the anesthetic syringe and recap immediately.
Pour a cup of water for the patient and offer tissue for the patient to rinse.
Turn engine drill on.
Place the appropriate bur in the handpiece:
i. Porcelin crown – round diamond
ii. Temporary – 1158
iii. Decay – round bur* in slowspeed
iv. Calcified – round, L-N bur, and have sonic ready
* Round bur size should correlate with tooth size. For example, if molar, a
large bur (8) would be appropriate. If bicuspid or anterior, a smaller size (4 or
6) is more suitable.
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Explain to the patient that doctor allows the anesthetic to soak for ten minutes.
Offer the headphones and explain how they work.
Ask if the patient has any questions regarding insurance. In most cases, financial
arrangements have already been discussed with the insurance specialist/front staff.
Occasionally, however, the patient may have additional financial concerns. If so,
explain to the patient that you will submit their treatment plan to the front desk and
our insurance specialist will be in to answer their question(s).
Submit completed route slip to the front desk. Request that someone “go over fees”
with the patient if necessary.
Fill out final card and coin envelope for final x-rays.
Return to patient.
Transfer diagnostic findings into patient chart.
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ROOT CANAL PROCEDURE:
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Hand Dr. anesthetic with new carpule. Use2% xylocaine (red) or 2% polocaine
(brown) for second injection.
Receive anesthetic; pass rubber dam and forceps.
Place safety glasses on the patient.
Use the air/water and suction to maintain clear visibility for the doctor as he opens
the tooth.
When Dr. uses RC Prep, hold the file holder in your left hand angled toward the
tooth. Replace files in order onto sponge as they are used. Always inspect files for
unwinding or bending; discard and replace as this occurs.
Maintain a wet working environment as Dr. uses gates glidden drills. Wash tooth
between sizes. When Dr. has finished using the gates, wash and dry tooth.
Place lip clip (apex locator) on the corner of the patients mouth opposite side of
working area. Pass probe (straight end) and finger ruler to Dr.
As Dr. reports measurements, record them onto pt information sheet.
Pass engine drill to Dr. Hold engine drill files with left hand angled toward tooth.
Support engine drill cord away from patient.
Measure hand files to lowest reported length.
Turn on Obtura and touch-n-heat. Always place lever switch on touch-n-heat on
"touch”
Suction and stay close when Dr. uses sodium hypochlorite.
As Dr. begins to place engine files into tooth, place lead drape over patient.
Measurement X-ray will be taken. For Dr. Goerig, position x-ray head within reach
of Dr.
When Dr. has positioned x-ray head and is beginning to exit operatory, press red
floor pedal.
Press x-ray button located in hall. All hall buttons are marked with room number.
After Dr. OK’s x-ray, remove x-ray head and lower lead drape. (Fold lead drape
over patients lap.)
Continue with engine drill files.
When Dr. has finished using engine drills, suction as he rinses the canals with
sodium hypochlorite.
Hold file block as Dr. instruments canals. Record master cone sizes as they are
reported by Dr. and place appropriate sized cone to measurement onto grey file
block. As each cone size is determined, reset files to next greater length.
Suction as Dr. uses sodium hypochlorite. Pass cotton pliers as Dr. pulls back on
syringe.
After Dr. has placed paper points into each canal, position air/water syringe over
points and dry into canal.
Hold measuring file block with gutta percha points and sealer towards doctor.
When gutta percha is in place, another check x-ray will be taken. Put compactor
into slow speed. Position Obtura on endo cart arm, tip facing away from Dr.
X-ray.
Pass touch-n-heat, suction as smoke rises, have 2x2 ready.
Receive touch-n-heat, wipe with 2x2. (Dr will take Obtura from arm of endo cart.)
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Wipe obtura tip as indicated by Dr.
Pass slow speed handpiece (with compactor).
Wipe excess from compactor tip, pass 5-7 plugger.
Receive 5-7, pass touch-n-heat.
Receive touch-n-heat, pass 5-7 plugger.
Pass Obtura.
Have ready to pass 5-7 plugger and glick; Dr. will choose the one he wants. If Dr.
chooses 5-7, pass Obtura. If Dr. chooses glick, pass alcohol soaked cotton pellet.
Restoration of tooth is determined and placed.
Pass rubber dam forceps.
Wash (rinse) patients mouth.
Final X-rays are taken. Initial x-ray will be taken on computer. After Dr. approval
of computer x-ray, change settings on x-ray wall mount for final x-ray. Pass snap-aray with double film to doctor.
DISMISSING A PATIENT AFTER TREATMENT
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Remove lead apron from patient and raise patients chair.
Review post op instructions and give patient written post op sheet (Completion of
endodontic treatment).
Prepare a prescription for the patient if the doctor has indicated the need for one.
Verify and/or amend route slip to reflect actual treatment.
After Dr. has approved final x-ray, escort patient to the check out counter.
Inform front staff personnel that patient is ready for a walkout statement.
Signal to Dr. that patient is in the process of checking out.
Complete patient record.
Return to operatory to assist with preparation for the next patient.
CHARTING
As with many aspects of dental assisting, writing patient records is a meticulous duty.
All patient records should be admissible as evidence in a court of law. Therefore, details
are very important. Ultimately, Dr. Goerig is responsible for what is written into patient
records. With these details in mind, an example chart write up is provided on the
following page.
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Insert chart example here
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CHARTING CONTINUED
The following outline should be used to ensure thorough documentation of each
procedure:
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Pt referred for (what treatment?)
Reported symptoms (Hot/Cold/Pressure) / how long?
Diagnostic test results
Recommended treatment
Pt consent
Details of treatment rendered:
a)
Hyperemic / Necrotic upon opening
b)
Special findings (pulp stone, fracture, resorption, calcification)
c)
Restorative filling material placed where (occlusal cotton/cavit in
tooth access)
d)
Post op review (oral and written)
e)
Rx
f)
Additional recommendations (crown, post build up, perio work)
7. Notes about pt (pt listened to country music on headphones)
8. Notes in reference to next appointment (if applicable)
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ANESTHETIC
The following chart represents some of the types of anesthetics used in our office:
Name of anesthetic:
Citanest Plain 4%
Duranest 1.5%
Polocaine 3%
Xylocaine 2%
Xylocaine 2%
Color code:
Black
Orange
Off-white
Red
Green
Qualities:
Same pH as tissue, fastest onset, no epinephrine
Longer acting, 5-10 hour duration
Used with Stabident system
1:100,000 –used for RCT
1:50,000 – controls bleeding in surgery
FILES/GATES GLIDDEN BURS/COMPACTORS
The files are the basic cleaning and shaping instruments used in endodontics. They
smooth and enlarge the root canals. The file handles are color coded to indicate the
progressive file size. You must be thoroughly familiar with the colors and corresponding
sizes. There are two types of files, standard and Hedstrom files. The standard files are
used for most procedures, while the Hedstrom files (which look like a Christmas tree) are
used occasionally. Files also come in varying lengths; 19mm, 21mm, 25mm,and 31mm.
The standard length used in this office is 21mm and 25mm hand files. These hand files
will be placed in the blue file holder in progressive order from file size #6-50 to include
two #15 files. Each file will have rubber stops. The #2,#3, and #4 Gates Glidden burs, a
size25/04T condenser, a 25mm #10 file, and a Vortex® Orifice Openers 16 mm (25
tip/10 taper) are all placed in the blue file block for sterilization. 25mm file blocks,
indicated by a black ring around the top of the file block, have files size #6-60 with a
25mm compactor in the center of the block.
ENGINE DRILL FILES
A series of Edge Endo engine drill files are used for the efficient cleaning and shaping of
canals. Engine files are placed in the blue file holder in order of sequence, 15/02 Endo
Magic file/ and Edge Endo X7 files in sequence 20 tip 04 taper/25 tip 06 taper and 40 tip
04 taper. A number written on the top of the sponge indicates the number of usage for
each series. When the series has been used for two cycles, the files are discarded,
replaced with new files. The sequence and files are listed below.
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Dr. Goerig’s Technique
Coronal Access #330, #1158 burs and #8 Round slow speed.
Locate canals with DG16 endodontic explorer.
Use a Vortex® Orifice Openers 16 mm (25 tip/10 taper) or a 17mm Endo Magic #1(25
tip 06 taper) to find and open orifices.
Then use #2, 3, 4 Gates Glidden
Apex locator measurement using a #10 file with RC prep in canal.
#15/02 taper Endo Magic files with RC prep in canal to get to length.
Irrigate with 6% NaOCl
Use Edge Endo X7 files in sequence 20 tip 04 taper/25 tip 06 taper and 40 tip 04 taper.
Develop apical seat with steel hand files in canals larger than size 40.
Tulsa Vortex® Orifice Openers Run at 350 RPM Torque 400 Ratio 8:1
File number Tip size
taper
length
catalog type
Color
25
10
16 mm
VOS251016
Red
Edge Endo files 855-985-3636
File number Tip size
taper
X7
20
04
X7
25
06
X7
40
04
Run at 350 RPM Torque 400 Ratio 8:1
length
catalog type
Color
21/25mm
X7
Yellow
21/25mm
X7
Red
21/25mm
X7
Black
Endo MAGIC Traditional files from Endo solutions 800-215-4245 Run at 350RPM
File number Tip size
taper
length
catalog #
Purpose
1
25
04
17mm
815-3013
Orifice openers
2
15
02
21mm
815-3001
Calcified canals
2
15
02
25mm
815-3002
Calcified canals
6
25
04
21mm
815-3103
Orifice openers and remove
gutta percha and Thermafil.
6
25
04
25mm
815-3104
Orifice openers and remove
gutta percha and Thermafil.
Simplified obturation
Select a numbered gutta percha (GP) cone to the last file that fit passively in the canal
(i.e.. #35).
Coat GP cones with Roth 811 sealer and place in canals.
Verify GP length with an x-ray.
Sear off cones at the orifice with a hot instrument (Touch and Heat).
Place a 21-gauge Obtura needle into orifice and inject pushing needle out of the canal.
Place a 04 taper #25 or 45 condenser in a slow speed handpiece, run it full speed and
place it into each canal. Go in and out of the canal 4 to 6 times and slide it off the wall.
Remove excess gutta percha from the orifice and pack the canals with a #5 endo plugger.
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RUBBER DAM
With very few exceptions, the rubber dam should be used to isolate the tooth during
endodontic procedures for both safety and efficiency. The rubber dam prevents
accidental swallowing or aspiration of instruments or medications by the patient. Also
when properly placed, the rubber dam decreases contamination of the tooth by oral fluids
and provides a clean and dry working area.
The rubber dam unit includes the clamp, rubber dam, plastic frame, clamp forceps, and a
punch. The rubber dam is placed on the frame by the assistant and punched for the tooth
to be treated. Clamps are selected and placed on the dam, and forceps are attached to
clamp. Many times four teeth are isolated for teeth that will require build-up restorations,
and usually the entire anterior arch is isolated for an anterior tooth.
Clamp selection depends on the individual tooth size and structure. Refer to the chart
below for basic clamp selection:
UL/LR molars
UR/LL molars
Anterior
Broken to gingiva
Bicuspids
If clamp slips…
Size 12
Size 13
Size 9
Size 9
Size 9
Size 9
RADIOGRAPHS
During the root canal procedure, three to four CDR images will be taken. These x-rays
are taken for diagnosis, to confirm a working length (optional), and to confirm accurate
gutta percha point position. A final CDR image and a traditional x-ray (using ClinAsept
double film packets) are taken for each procedure. The lead apron will be placed over the
patient for all x-rays taken, both CDR and traditional.
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Parallel x-rays are preferred for diagnostic evaluation and final x-rays. The use of
the RINN is encouraged.
Measurement x-rays of the molars are taken from the distal angulation, premolars
are taken from the mesial, and anterior teeth are shot straight on.
Educate the patient on the benefits of CDR images.
A plastic sheath is always placed over the sensor. For maxillary teeth, a finger cot
also placed over the plastic barrier to aid in stabilizing the position of the sensor.
PRESCRIPTIONS
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You should be familiar with the different types of prescriptions that may be prescribed to
our patients. A current list of prescribed medications is posted on the information board
located in the lab. Premedication guidelines are updated as necessary and posted
alongside the general medication list. The medications are divided into three categories :
analgesics, antibiotics, and anti-inflammatory. Analgesics are pain medications.
Antibiotics are used to help minimize infections. Anti-inflammatories help reduce
inflammation and throbbing pain.
SURGERY
Occasionally, surgery is indicated in addition to non-surgical root canal treatment.
Some of the surgical procedures you should be familiar with are:
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Apicoectomy and retrofill
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Periapical curretage
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Reparative surgery of resorption or perforations

Root amputation

Hemisection
APICOECTOMY AND RETROFILL
Prior to seating patient, display most recent CDR image on computer. Soak suture
(attached to hemostat) in saline. Review “Prior to Seating a Patient” instructions listed
previously in this manual.
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Seat and drape patient.
Verify health history.
Review and have patient sign the surgery consent form. Explain the surgical
procedure and advise patient of the risk of parasthesia using the tooth diagram.
Inform Dr. Goerig that the patient is ready for treatment.
Dr. Goerig will discuss the treatment with the patient. Record
i. any precautions Dr. Goerig may advise of the patient into the
patient’s record.
Recline the patient.
Pass the topical anesthetic, 2x2.
Receive topical, pass anesthetic syringe.
Receive anesthetic syringe. Re-cap and change carpule.
Place patient in an upright position.
Allow patient to rinse his/her mouth.
Ask if patient would like to use the headphones during the procedure and offer
patient various CD’s to choose from.
Ask if the patient has received an estimate for treatment. If necessary, submit
treatment plan (route slip) to someone at the front desk and allow for fee
discussion.
Dr. will allow 5-10 minutes for the anesthetic to soak.
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Recline patient.
Pass anesthetic for Dr. to verify numbness.
Receive anesthetic, pass folded (square) 2x2 and saliva ejector.
Pass Bard Parker. Suction right alongside incisal edge. Follow blade.
Pass Minnesota retractor.
Pass surgical handpiece with #8 round surgical length bur.
Keep the surgical site clean, irrigate frequently.
Pass ultrasonic. Dr Goerig will prep for retrofill.
Have second assistant mix IRM when indicated by Dr. Goerig.
Suction while second assistant assists with retrofill.
The second assistant will pass IRM to Dr. Goerig on a 31L, have endo plugger
ready to exchange.
Receive 31L, pass endo plugger. Continue with this exchange until Dr. picks up
burnisher.
Place lead apron over patient.
Take CDR x-ray. If Dr. indicates, a regular double film x-ray may be taken at this
time. Remember to change settings on X-ray machine.
Pass surgical handpiece with football finishing bur.
Pass suture.
Retract for Dr. as needed.
Have scissors ready, cut sutures (1/8 inch) when indicated.
Suction as Dr. washes patients mouth. Have 2x2’s ready (soaked with water).
Clean off any surgical traces from patient’s mouth or teeth.
Hold flap tight to bone, pressing toward the teeth, for five minutes while reviewing
postoperative instructions.
Have Dr. Goerig sign the prescriptions.
Raise the patient slowly to an upright position.
Make duplicate copies of the prescription.
Give patient written postoperative instructions, ice pack, and the prescription all
enclosed in a care bag.
Ask patient if they have any other questions.
Escort patient to side reception area for receipt and scheduling for suture removal
appointment.
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SUTURE REMOVAL
Most commonly, three to five days following a surgical procedure the patient will return
to have the sutures removed. Place a suture removal pack in the operatory, review ‘Prior
to Seating a Patient’ info.
After the patient is seated, ask how the area has felt since the surgery was done. Record
reported information on the patient info sheet. Inform the patient that you will remove
the sutures and then Dr. will be in to verify the healing process. Inform Dr. once the
sutures have been removed. Dr will examine the area, review post care instructions.
Usually at this point the patient may begin to brush softly in the area, running their
toothbrush under hot water to soften even more so. Be sure to record any
recommendations from the Dr to the patient in the patients chart. This entire process
should take less than ten minutes.
INCISION AND DRAINAGE
A patient with swelling and accumulated fluid may need to have the area incised to allow
for drainage. You will need to have the following:
1. Anesthetic
2. Bard Parker
3. Curette and 31L
4. Gauze
5. Air/water syringe and suction
Dr. Goerig will make an incision to allow for drainage. Simply suction as the area drains.
When indicated, place 2x2 gauze over incision area. Pack approximately ten 2x2 gauze
in a coin envelope and give to patient to bring home. In most cases, the patient will
reschedule to have root canal treatment completed. If the general dentist has not already
given the patient a prescription, an antibiotic prescription will be given.
ROOT AMPUTATION / HEMISECTION
A hemisection involves cutting the tooth in half to include the coronal portion.
A root amputation involves removing one (or more) root(s) leaving the coronal portion
intact. A special instrument pack is located in the lab for either of these procedures.
EXTRACTION
Occasionally Dr. Goerig will extract a tooth for a patient. A special instrument pack is
located in the lab. Post operative instructions for extractions are located in the surgical
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closet in Op 2. In addition to the pack, you will need a suture. Sutures are not used in
every case, but it should be available should Dr. Goerig ask for one.
CROWN LENGTHENING
In addition to temp replacement and extraction packs, a crown lengthening pack is also
located in the lab. In addition to the pack, you will need a Bard Parker and a suture.
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