Tips for treating patients with limited mouth openings
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One of the most difficult aspects for the clinician in doing root canal treatment is gaining access in patients who have limited mouth openings or small mouths. Common scenarios include treatments in children and the elderly or patients with trismus due to space infections or temporomandibular joint disorders. Nonetheless, if root canal treatment is indicated, one must find a way to perform it, no matter the clinical limitations.

Here, are various clinical tips and tricks that will help clinicians in the above scenarios. Various endodontic instruments that are currently available and recommended for use in patients who have limited mouth openings will also be discussed

Small Hand Mirror
Visibility in endodontics is essential.For nearly all teeth, direct vision will not suffice, as the opposing arch obstructs one’s view. Many clinicians tend to use a standard size 5 mirror, which is quite large and unnecessary. This could be an issue in patients with limited openings and when a handpiece or fingers holding files take up space over the tooth. As such, a size 3 mirror would be small enough to gain access into small mouths and sites with limited openings while being large enough to see everything needed for carrying out root canal treatment.

Hold Hand Files at 90°
Many clinicians hold hand files with the file directed somewhat along the axis of their fingers (index and thumb). Doing so makes it almost impossible to gain access when the opposing arch is in the way and there is a limited mouth opening. Instead, one should hold the hand file at approximately 90° to the direction of his or her fingers. This should be considered in just the same way as any endodontic handpiece that holds a NiTi motorized file at 90° to the shaft of the handpiece.

Mechanized NiTi Files With Controlled Memory
NiTi mechanized files with controlled memory have been available for several years. These are files that could be curved, and instead of bouncing back to their original straight position, these files remain curved. Hence, the same way that it was recommended to pre-curve stainless steel hand files to more easily gain access into tight spaces, it is strongly recommended that mechanized NiTi files with controlled memory be used

Electronic Apex Locator
Taking radiographs in patients who can’t open their mouths easily could be a challenge. It would also unnecessarily lengthen the procedural time. While pre-, mid-, and post-treatment radiographs are required, it would be helpful if the number of mid-treatment confirmation films could be reduced. This is best achieved with the use of an electronic apex locator.

Gaining access into tight spaces because of limited mouth openings or small mouths is an important challenge to overcome in endodontics. Fortunately, there are many clinical tricks and tools available that help in managing this challenge. Pre-curving stainless steel and NiTi files and using a handpiece with a small head, along with a small hand mirror, can only make it easier for a dentist to perform root canals in such scenarios.