The Conversion of a Scope Cynic
A 20 year Retrospective
When the Endoexperience web site was first created in 2000, I originally had included a page that suggested that the use of a Surgical Operating Microscope (SOM) in endodontics was unnecessary and I questioned its routine use. I had been in specialty practice for 14 years, had a high degree of success and saw little need for this expensive piece of equipment. At the time I believed that the mandatory Postgraduate SOM certification was nothing more than a method to increase SOM sales. I also had some questions as to why this technology was so readily accepted without support from the literature. I also commented that the presence of a microscope could be used as leverage “against” the referring Generalist. The Endodontist could now say that optimal Endodontic treatment could only be delivered by using state of the art equipment, and that this included the SOM. I wrote that the subliminal message to “non SOM equipped dentists” was that they were second class, were ignorant, and that they just “didn’t get it”. It was a cynical attitude.
The reaction to this page was swift and dramatic. On the rxROOTS internet forum, several clinicians, (such as the father of Microscopic Endodontics Dr. Gary Carr) were very critical of the piece. They wrote that I could not treat what I could not see, that I had no concept of what a huge difference it made and that I could never reach my potential as an endodontist without one. There was much browbeating, name calling and at the same time very much encouragement from those on ROOTS. I finally saw the light, literally. After attending two scope courses at ROOTS Summits I and II, it became apparent to me that I was wrong. I made arrangements for immediate purchase of my first Global SOM with upgraded Starlite light source and I haven’t looked back.
I now believe that it is impossible to do the highest quality endodontic treatment without an SOM. It may be politically incorrect to say so but I believe that teeth such as molars should NOT be attempted by those who work without one. The difficulty with recommending that clinicians treat “easy” teeth and think about referring out the more difficult cases is the fact that many teeth that were initially thought to have been “easy” were actually much more difficult than anticipated. Rather than ledge the canal, break a file or make the case more difficult to treat prior to referral, perhaps it is best to decide whether you truly wish to perform the treatment yourself, rather than refer it out after the case has been made much more difficult to treat by these initial unsuccessful attempts .
For those that ARE willing to raise the bar of their practice ( Not just in Endodontics!) the SOM offers many advantages in visibility, magnification, light and ergonomics. Many of these attributes are not readily appreciated this device routinely. Then you will wonder how you worked without it!
Some initial impressions of a scope novice:
1. The light source is incredibly bright. My staff sometimes complain that they have difficulty seeing “away” from the field after they have been looking at the area for a few minutes. An assistant ocular would probably prevent this. Sunglasses are helpful if your assistants do not have their own ocular and work with the scope for long periods of time. A less expensive alternative to the assistant ocular is mounting a video camera on the scope and porting out the video to a monitor that is directly opposite to your assistant. This “Poor man’s Assistant Scope” is a way to allow your assistant to see what you are seeing, which is an important part of working together under scope magnification.
2. There is a tendency to go to “high power” immediately in order to “see better”. This is a mistake. Skills must be developed at lower magnifications. In many instances it is better to observe the field at lower magnifications to gain “perspective”. ( You also have more light at lower magnifications). Then shift to higher magnification when close inspection of a specific area is required.
Staff have some major trepidation when confronted with this new technology. It requires a whole different set of assisting skills. Staff must be brought along slowly, as they regard the scope as a tool that will “slow us down” (i.e./ put more pressure on THEM) rather than as an augmentation to treatment. The truth is that once you become proficient, the scope saves you a lot of tie.
3. Clinicians who are used to running multi-op practices (frequently filled with emergency toothaches) occasionally find themselves working alone while other ops are being prepared or patient’s seated. This breeds a bit of “laziness” in staff because the dentist sometimes reaches for instruments while he is alone in the operatory. When using a scope, this is not possible. The clinician’’s hands must be stationary in the operating field. Bur changes, file changes, suction and irrigation that may have been performed by the dentist alone in the past now cannot be done this way. Much greater staff discipline must be obtained and this takes time.
5. Scope Photography is a whole art by itself. It requires time to focus the image. After almost 20 years of scope use, I’m still struggling at times with deeper focus images and depth of field issues.
Although I had only been using the scope for a relatively short time when I first wrote this piece, its advantages are obvious. Visibility is greatly enhanced and I now saw much of what I missed earlier.
For example, I am noticing how “wet” prepared canals remain, even after attempting to dry them with paper points. (You need alcohol and Stropko syringes for proper drying!) Additional canals (such as MB2 and more!) are easier to find. Canals that looked “clean” superficially frequently have tissues, fins and canal branches deeper in the canals that can only be seen with a scope. Most importantly, the SOM offers the ability to see changes in dentin coloration (as a clue to where orifices are). You can also see bubbling of NaOCl as it interacts with tissue, it is essenial for removal of broken instruments, etc. With specialized micromirrors the SOM allows for close examination of retropreparations at angles impossible to view with the unaided eye or with loupes. The list goes on and on.
SOMs are the future of dentistry for those clinicians who truly want to see what they are doing. Back in the days where amalgam was our only option and margins where checked with a dull explorer, it was easy to neglect things that we could not see. In the era of bonded restorations, precise margins, and high quality dentistry, this attitude IS passe. I believe that dentistry will eventually be divided into those who truly can/want to see and those who don’t.
One final question to ask yourself – Who would you rather have doing your restorations or Endo – someone who is or is not SOM equipped?
I owe much of my rethinking to the gang on the (now defunct) rxROOTS.com and to Dr. Gary Carr, and for that I will always be grateful.
One organization that has dedicated itself to the use of the SOM in Dentistry is called AMED – The Academy of Microscope Enhanced Dentistry. The clinicians in that organization are truly world class operators and if you have an interest in getting trained to use the SOM properly, that is a good place to start.
See AMED for further info.
It had been almost a year since my first SOM was installed. I ran into a big problem: I realized that I couldn’t see as well in my other non-SOM equipped operatories. The difference was dramatic and obvious. On the occasions that I had to work in this 2nd op, I found myself cursing the fact that I simply couldn’t see what I needed to see to do a good job. That operatory was “handicapped” by the lack of the SOM. So on July 31st a second SOM (Seiler Revelation. My conversion as a “scope cynic” appeared to be complete.
I subsequently purchased a Global G6 which has gone into my #1 operatory. It is a fabulous scope and by far the best of the 3 that I now own. For more information about it please see the product section of this website. I am extremely happy with the G6 and wish I had one in each op! If you are considering an SOM, I strongly recommend that you do not “cheap out” and go with less expensive model. These instruments are your “eyes'” and if you want to do the best endodontics possible, you need to make an investement that will allow you the best visibility possible. It truly is the LAST place you should be looking to save money. If you can’t see it….you can’t treat it.
2021 Update – Some 20 years has passed since I wrote that initial piece and incorporated the SOM into my practice. Now, I cannot imagine practising without one. I eventually sold my Seiler scope ( I was never happy with the ergonomics and design of that Revelation model) and purchased another G6. It has been flawless. Going “full Global” in all ops has solved all reliability and ergonomic problems.
One factor I have come to appreciate more that ever is the need for good seating and proper arm support. The Jed Med chairs ( See the product section of this website) are terrific. They are rugged, solidly built and have very comfortable over the past 20 years of use!
Ultimately, we each make decisions that define us and the way we practice. Dentistry is both and art and a science. For those who wish to do their best work, it only seems logical that being able to see as well as possible will make you the best clinician you can be. The question we all have to ask ourselves is : How can I be my best? The SOM will allow you to explore that possibility.