Karen Potter, DDS

In our Cover Story, we find out how Sonendo, CBCT, and other technologies have helped Dr. Karen Potter to create a single-visit practice.

This tech-savvy endodontist discusses her practice’s focus and the role technology plays in allowing her to provide an improved patient experience

What made you decide to concentrate on endodontics?

I was born and raised in the beautiful seaside community of San Clemente, California. I came from a “dental family,” as my father was a generalist and my mother was a dental hygienist. I worked in my dad’s dental office during summers and learned about providing the highest quality dental care there. In our small community, I learned that I had to always do my best by people and stand behind my work. After graduating, I moved to Los Angeles to pursue degrees in Spanish and Natural Sciences at the University of Southern California (USC). I graduated magna cum laude and moved to University of California, Los Angeles (UCLA) for dental school where I developed my interest in endodontics. I loved the idea of saving natural dentition, alleviating patients’ pain, and having a small practice where I could spend one-on-one time with all my patients and give them compassionate care at a painful and daunting time. After graduating summa cum laude from UCLA, I earned my Certificate of Endodontics at the University of Iowa where I realized my passion for endodontics and vowed to be a lifelong teacher and student. I learned that endodontists have an important role because people highly value maintaining their natural dentition. I pursued Board Certification in 2011 and returned to San Clemente to practice. After starting my practice, I established a Vision Statement that guides my decision-making every day. This Vision encompasses providing the most compassionate, thorough, and skillful endodontic treatment possible using the most advanced technology and best customer service.

Dr. Karen Potter with a patient

Are you tech-savvy? What types of technology are beneficial in your practice?

While I do not consider myself “cutting edge,” I think that I am tech-savvy. My interest in technology began when I first graduated from my residency in 2009. My first associateship position was in Leawood, Kansas, with Dr. Paul Jones, who was one of the first endodontists to utilize CBCT. I was astounded by the amazing assistance that technology gave me in my diagnosis, treatment planning, and practice of endodontics and vowed to thoroughly investigate upcoming technologies throughout my career to make sure I was providing the best quality of care. When Sonendo®, the manufacturers of the GentleWave® System, began promoting their technology around 2015, my interest immediately peaked. Sonendo’s headquarters is 10 miles from my office, so I was introduced to the company early on. Like other practitioners, Sonendo’s claims of canal-cleaning capability and efficacy made me skeptical. As more research came out, I got more intrigued. Finally, several of my endodontic colleagues had adopted the technology and were raving fans. That’s when I transitioned my practice to a GentleWave practice, and I’ve never looked back. The combination of CBCT and the GentleWave System has made my practice a primarily single-visit practice with a high emphasis on dentin preservation. My goal is to save as many teeth as possible by saving as much dentin as possible. By knowing my anatomy preoperatively with CBCT and then by conservatively cleaning those spaces with GentleWave, I have been able to provide more efficient and thorough care.

How do you encourage the patient to prioritize saving natural teeth?

An endodontists’ job is to try to save natural teeth or to identify when it is not in the patients’ best interests to save their tooth. Encouraging patients to save their natural teeth starts at the referring doctor’s office. It is important for endodontists to have relationships and communication with dentists about the value of saving natural dentition. Some doctors just want to pull the tooth if it seems that the endodontic treatment failed, or if the tooth seems questionable. My role is to educate the generalist about which teeth truly have a hopeless prognosis as well as which teeth we can save with advanced technology and skill. I do this through giving CE courses to my referring doctors and through sharing my knowledge of endodontics on social media. Instagram has been a great way to share cases and knowledge with dentists and non-dentists alike! I started sharing cases on Instagram about 3 years ago, and I will never forget how many of my non-dental friends said, “I never knew in all these years what exactly you did for a living, or what an endodontist is!” I knew then that social media would be an important platform for me to share my passion for endodontics and try to educate the general population that it is important to save natural teeth when possible.

What are some challenges that you have faced as an endodontist?

One of the challenges I’ve faced as an endodontist is insurance reimbursement. As endodontists, we give the patients an invaluable gift — saving their natural dentition. Many of my patients recall their parents being edentulous at a young age. They don’t want to be in the same boat! As our field has advanced technologically, insurance reimbursements have not matched the increasing cost of practicing. Because of this, I am mostly a fee-for-service practice. I feel that my patients need to be treated with quality time and care, and I do not want to feel pressure to shorten my treatment times just to keep afloat. My Vision is to provide VIP service with the greatest technology to every patient, and I want autonomy from insurance companies to allow me to do so.

Another challenge I’ve faced is seeing a decrease in referrals as older dentists retire and new dentists buy generalist practices. It is only natural that a newer doctor would want to keep procedures in-house to help build rapport with patients and also avoid sending out possible production income. While this is expected, I have learned to be a resource for new generalists to help them provide the best-quality endodontic care possible. My goal is to be there when they need me and help build them up so that when they are tired of doing endo, they send it over to me! I act as a resource by giving CE courses, taking calls when they’re on vacation, helping them answer questions about tough cases, and even stepping in on a difficult case. Generalists know they can trust me to do the work with the best quality, expertise, and technology available when they’re ready to pass on those procedures.

Figures 1A-1E: 1A. Tooth No. 19 had pulp necrosis and acute apical abscess with buccal swelling of the attached gingiva and a 12 mm pocket on the buccal at the site of the swelling. 1B. Treatment was completed using the GentleWave protocol: Neither hand files nor rotary files were able to negotiate past the distal canal apical bifurcation. ProTaper Gold S2 file was used 1mm short of length on the mesial root and to the level of the bifurcation on the distal root. Canals were obturated with gutta percha and BC Sealer HiFlow. 1C. At the 4-month recall, the patient was asymptomatic, all swelling was resolved, and apical bone was healing. 1D. Preoperative CBCT showing apical and lateral root pathosis. 1E. CBCT at 4-month recall showing substantial apical and lateral bone healing

How have you traditionally attained your goals in cleaning and debridement of the root canal system, and how has new technology changed that?

Many of our teachers have said, “You could fill the canals with anything, and if you’ve disinfected them properly, they’ll heal.”  Basically, it’s what you take out of the canals, not what you put in, that will lead to healing. Endodontists strive to come as close to complete disinfection as possible (reduce bacterial load below a clinically relevant level) so that the apical tissues around the tooth can heal. Traditionally, we have done this using bleach, chlorhexidine, EDTA, calcium hydroxide, and activation techniques. These traditional techniques relied on files to open the canals to a certain size to allow for the fluids to penetrate the deeper areas of the teeth. Certain canals could not easily be reached, which is why we would leave medication in canals for weeks or months to hopefully diffuse to these areas. With these techniques, we have a high success rate. However, it can be cumbersome for the patient to return to the office multiple times, and we often remove unnecessary amounts of dentin. Nowadays, more practitioners use technology such as laser and GentleWave to achieve these goals more efficiently and without removing unnecessary tooth structure. I have adopted a GentleWave protocol that allows me to treat 99% of cases in a single visit without using intracanal medicaments and without enlarging canal sizes. The mechanism of action of the GentleWave delivers degassed irrigation fluids to all reaches of the root with instrumentation as small as a 15 file. This allows me to provide quality endodontic care in a single visit with minimal instrumentation.

How has your practice promoted patient convenience?

One of my goals is to provide prompt treatment. I try to leave space for emergencies when I’m in the office, and I routinely come in on my days off, if needed, for patients in pain or patients who need IV sedation. I am also able to be more efficient since implementing the GentleWave protocol. I am currently treating most cases, even retreatments, in a single visit. To have a complete procedure done where the patient can leave and get the tooth restored right away is a huge service.

Another goal is to provide pain-free treatment: It’s inconvenient for patients to return because they can’t get numb or they’re having postoperative complications. I get the patient profoundly numb by using infiltration and nerve block as a primary technique with supplemental techniques as needed. While I’m doing initial anesthesia, I use a facial massager on the patient’s cheek to help relax them and distract them from the injection. Leaving the facial massager on the bolus of anesthetic after injection also helps distribute the fluid to the desired tissues and can even push the fluid into the mental foramen if anesthetizing a mandibular premolar tooth. Patients have responded well to this technique. Pain-free treatment also includes not sending the patient away with severe postoperative pain. I always administer ibuprofen or acetaminophen to my patients before they leave the office, so it’s in their system before the anesthetic wears off. Also, using the GentleWave System provides a lower incidence of postoperative pain and flare-up. Instead of maintaining mechanical patency throughout the procedure by pushing the tip of a file (and any debris in its way) through the apical foramen, I’m staying short of the apical foramen and trusting the GentleWave to maintain patency. I call every patient the night of the treatment to check in, and since I’ve been using the GentleWave, I rarely have any problems with postoperative pain.

There are no “easy roots.” Even a tooth that at first glance looks like it may be straightforward can have a surprising complexity.

How does your GentleWave® System promote minimally invasive endodontics?

When I first started using GentleWave, I thought of it as supplemental irrigation and not its own protocol. Thus, I instrumented to normal sizes and ran the GentleWave at the end of the procedure to maximize my disinfection. However, as I learned to trust the technology, I started to shape my canals smaller to preserve natural dentin and lead to better fracture resistance. Now I am able to confidently shape most canals to a 15/04 file size, and some larger canals maintain their natural shape altogether. GentleWave also helps me promote minimally invasive endodontics because many times I can see on a preoperative CBCT that the canal anatomy joins with another canal. In these instances, I no longer shape that branch of the canal to a complete size, just make enough space for my fluids to penetrate and let GentleWave do the rest. This will save me time by not troughing a tight MB2 canal, for example, that I know joins in with the main canal. I trust the technology to debride the canal space, and I preserve all of that additional dentin that I would have traditionally removed to get a file down.

What are the main drawbacks to manual instrumentation during RCT?

For my first 12 years as an endodontist, I would pick my way through canals, pre-bending files and hoping I could find the right pathway. I would also trough down pericervical dentin to try and locate and treat canals. This technique was time-consuming and fatiguing for my hands and wrists. Once I could get a small file to length, I had to hope that my bend in the file would find a pathway down one of the many apical foramina at the root apex. Even then, I could not feel confident that my rotary instruments would scrape more than 50% of the canal surfaces or that my irrigation fluids would disinfect these spaces due to the dreaded vapor lock. With particularly tortuous canal morphology, my file could snap and be left behind in the canal. By utilizing GentleWave, I minimize my use of hand and rotary instruments and rely mainly on chemical debridement for treatment so I don’t have to worry anymore.

How does the GentleWave® Procedure help patients who have complex apical anatomy?

There are no “easy roots.” Even a tooth that at first glance looks like it may be straightforward can have a surprising complexity. This is why I take a CBCT on every case that I treat. I want to make sure I know what I am dealing with before I even touch a handpiece. Most teeth are quite complex, particularly in the apical third. GentleWave helps me treat complex apical anatomy by cleaning the spaces that I could never reach with a file. So often do I see a 2-1-2 canal configuration on a maxillary first molar MB root, which in the past, I would stress out about and medicate the canals, even though my calcium hydroxide would likely never reach that second ML branch. Now I remove the bulk of tissue that I can from the main canal and trust GentleWave to do the rest of the cleaning. GentleWave removes the risk of me, in my imperfect humanity, taking a file into spaces that I may destroy and lets me maintain what’s natural by barely (or not even) touching those spaces.

What would you tell a colleague who is reluctant to try new techniques/procedures?

Skepticism is what makes us discerning and critical endodontists. We need to question everything, consult with colleagues, and demand independent evidence-based research. However, every decade or so a new technology arrives that really is a game changer — rotary, microscopes, EAL, CBCT, and now GentleWave. Even if you don’t want to be the first to adopt a new technology, at least don’t be the last! Talk to colleagues. I constantly share my experiences with colleagues and routinely have people from the industry watch me work. I post cases (the good, the bad, and the ugly) on social media in hopes that even one other practitioner can learn from my experiences. It’s ok to be reluctant to try new things; we’re really good at embracing routine. I challenge you this year to step out of your comfort zone. You won’t regret it, and your patients will reap the benefits!

Dr. Eric Herbranson also has a philosophy on adding beneficial technologies like Sonendo to this practice. Read “The times they are a changin’” here: https://endopracticeus.com/the-times-they-are-a-changin/

Karen Potter, DDS, was born and raised in San Clemente, California. She attended the University of Southern California, where she graduated magna cum laude. She then attended the UCLA School of Dentistry and graduated summa cum laude. At UCLA, she spent time in leadership and endodontic research, which allowed her to publish multiple articles. After UCLA, she attended her Endodontic residency program at the University of Iowa. She practices in San Clemente and has been a Diplomate with the American Board of Endodontists for over 10 years. Dr. Potter is a busy working mother of three who loves to share her passion for Endodontics through teaching and social media. You can follow her @karenpotterdds.   Disclosure: Dr. Potter is a consultant for Sonendo®

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