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clinical articles • management advice • practice profiles • technology reviews Winter 2017 – Vol 10 No 4



New resources to mitigate failure in root canal treatment and retreatment


ENDODONTICS Corporate profile BrainTap

Dr. Alexandre Capelli, et al.

Company spotlight American Dental Partners, Inc.

Surgical treatment of an extensive periradicular lesion: outcome after 5 years of follow-up Drs. Maurício Paradella de Camargo, et al.



KEEP IT REAL. WHAT DO YOUR PATIENTS REALLY WANT? Patients Want to Keep Their Real Tooth. In a 2016 study published in JOE,1 patients named tooth retention as a top priority, second only to trust and communication about treatment options.

Patients Want to Avoid a Root Canal. Consumers have feared the idea of standard RCT for decades. The result? Patients and providers alike are opting for implantsupported crown replacement instead of RCT.

Patients Want an RCT Alternative. Enter the GentleWave® Procedure—a minimally invasive2, single-appointment procedure3 that delivers a higher standard of clean throughout the root canal system2—and a lower chance of failure3 that can result in tooth extraction.

Talk to Sonendo® about the GentleWave® System today. Make the real difference for your patients and the economy of your practice. Visit

Debris left behind after standard RCT*

A higher standard of clean with the GentleWave Procedure*

* 1000x magnification 1 Azarpazhooh A et al. (2016) J Endod. 42:365-370 2 Molina B et al. (2015) J Endod. 41:1701-5 3 Sigurdsson A et al. (2016) J Endod. 42:1040-48 © 2017 Sonendo, Inc. All rights reserved. SONENDO, the SONENDO logo, GENTLEWAVE, the GENTLEWAVE logo, and SOUND SCIENCE are trademarks of Sonendo, Inc. Patented: MM-0308 Rev 03

ASSOCIATE EDITORS Julian Webber, BDS, MS, DGDP, FICD Pierre Machtou, DDS, FICD Richard Mounce, DDS Clifford J Ruddle, DDS John West, DDS, MSD EDITORIAL ADVISORS Paul Abbott, BDSc, MDS, FRACDS, FPFA, FADI, FIVCD Professor Michael A. Baumann Dennis G. Brave, DDS David C. Brown, BDS, MDS, MSD L. Stephen Buchanan, DDS, FICD, FACD Gary B. Carr, DDS Arnaldo Castellucci, MD, DDS Gordon J. Christensen, DDS, MSD, PhD B. David Cohen, PhD, MSc, BDS, DGDP, LDS RCS Stephen Cohen, MS, DDS, FACD, FICD Simon Cunnington, BDS, LDS RCS, MS Samuel O. Dorn, DDS Josef Dovgan, DDS, MS Tony Druttman, MSc, BSc, BChD Chris Emery, BDS, MSc. MRD, MDGDS Luiz R. Fava, DDS Robert Fleisher, DMD Stephen Frais, BDS, MSc Marcela Fridland, DDS Gerald N. Glickman, DDS, MS Kishor Gulabivala, BDS, MSc, FDS, PhD Anthony E. Hoskinson BDS, MSc Jeffrey W Hutter, DMD, MEd Syngcuk Kim, DDS, PhD Kenneth A. Koch, DMD Peter F. Kurer, LDS, MGDS, RCS Gregori M. Kurtzman, DDS, MAGD, FPFA, FACD, DICOI Howard Lloyd, BDS, MSc, FDS RCS, MRD RCS Stephen Manning, BDS, MDSc, FRACDS Joshua Moshonov, DMD Carlos Murgel, CD Yosef Nahmias, DDS, MS Garry Nervo, BDSc, LDS, MDSc, FRACDS, FICD, FPFA Wilhelm Pertot, DCSD, DEA, PhD David L. Pitts, DDS, MDSD Alison Qualtrough, BChD, MSc, PhD, FDS, MRD RCS John Regan, BDentSc, MSC, DGDP Jeremy Rees, BDS, MScD, FDS RCS, PhD Louis E. Rossman, DMD Stephen F. Schwartz, DDS, MS Ken Serota, DDS, MMSc E Steve Senia, DDS, MS, BS Michael Tagger, DMD, MS Martin Trope, BDS, DMD Peter Velvart, DMD Rick Walton, DMD, MS John Whitworth, BchD, PhD, FDS RCS CE QUALITY ASSURANCE ADVISORY BOARD Dr. Alexandra Day, BDS, VT Julian English, BA (Hons), editorial director FMC Dr. Paul Langmaid, CBE, BDS, ex chief dental officer to the Government for Wales Dr. Ellis Paul, BDS, LDS, FFGDP (UK), FICD, editor-inchief Private Dentistry Dr. Chris Potts, BDS, DGDP (UK), business advisor and ex-head of Boots Dental, BUPA Dentalcover, Virgin Dr. Harry Shiers, BDS, MSc (implant surgery), MGDS, MFDS, Harley St referral implant surgeon © FMC 2017. All rights reserved. The publisher’s written consent must be obtained before any part of this publication may be reproduced in any form whatsoever, including photocopies and information retrieval systems. While every care has been taken in the preparation of this magazine, the publisher cannot be held responsible for the accuracy of the information printed herein, or in any consequence arising from it. The views expressed herein are those of the author(s) and not necessarily the opinion of either Endodontic Practice US or the publisher.

2018 — your best year ever!


s we complete 2017 and begin 2018, it’s hard not to reflect on what went well this past year and how can we improve in the coming year. A new year is always a great opportunity to start with a clean slate and resolve to make real improvements with your practice and life. Webster’s definition of resolve is to reach a firm, deliberate decision about something. In my own life and with clients I’ve worked with, there is a measurable difference in results when a person resolves to make clearly defined improvements versus just going with the flow and hoping things get better. As we begin 2018, let me offer three “Be’s” that can make this year Garth Hatch, DDS your best year ever. Be Proactive — Rather than reacting to problems as they come (and they always do), resolve to anticipate challenges your practice will encounter and find solutions to handle them. Tony Robbins talks about how the quality of our life is related to the quality of the questions we ask ourselves. Some questions you may consider asking include: • How frequently do I encounter a given problem? • Is there new technology or services available to help solve the issue? • How can I integrate these advancements into my practice? Be Focused — Pareto’s 80/20 rule states that roughly 80% of our results come from 20% of our efforts, yet we often treat every task that needs to be done as equal in importance. Focus on the two to three activities that produce 80% of your desired results and delegate, delay, or dismiss everything else. As an endodontist, I’ve found that at least 80% of my results are related to the quality and efficiency of my endodontic treatment and the relationships I have with our referring offices and patients. Most of my efforts are focused on continually improving these areas and finding leverage to deal with everything else. In our consulting services, we discuss the four pillars of practice success: Team, Environment, Referrals, and Marketing. This T.E.R.M. reminds our clients of what to focus on and how to use your team, space, and equipment for maximum leverage. Be Learning — Make this new year an opportunity to expand your knowledge in areas that will provide more value to those you serve. What areas of your practice would you like to improve, and what continuing education courses or training programs are available to make improvements in these areas? When do you plan on signing up for this training, and how will you get the time off to attend? As we learn new skills and improve our current abilities, we become more valuable to our referring offices, patients, and community. Remember, when we stop learning, we stop earning. As we become more proactive, focused, and continue learning, the pathway forward for our practice and life becomes clearer. Commit today to implementing these three “Be’s,” and make 2018 your best year ever! Dr. Garth Hatch

Garth Hatch, DDS, is President and Founder of Dental Specialist Institute, a dental consulting firm committed to helping specialists receive more referrals, profits, and freedom. He coaches endodontists and their teams to better leverage their time, space, and efforts to help minimize stress and maximize results. He is a native of Riverside, California, earned a BS in Exercise Physiology from Brigham Young University, and his DDS from Indiana University School of Dentistry. Dr. Hatch entered the U.S. Army Dental Corps and completed a 1-year AEGD residency at Fort Jackson, South Carolina, and later completed an endodontic residency program at Fort Gordon, Georgia. Dr. Hatch currently owns and practices in his endodontic practice in Kennewick, Washington. Dr. Hatch has authored several articles relating to endodontics and has lectured both nationally and internationally. He is dedicated to helping specialists create the practice of their dreams and achieve more abundance and freedom. Dr. Hatch can be reached at

ISSN number 2372-6245

Volume 10 Number 4

Endodontic practice 1


Winter 2017 - Volume 10 Number 4


Company spotlight American Dental Partners, Inc.

Corporate profile BrainTap


Sandra Marlowe discusses how a digital health firm is taking on the stress pandemic

A partnership model that invests in the programs, people, and processes that help dentists grow ..........................14

Case study Extreme endodontic interventions: a case report Drs. Karl Woodmansey and Yogesh Patel illustrate their interventions to retain a mandibular first molar..........16

Clinical/Case report Identification and resolution of edema of the head/neck in a 7-year-old child Drs. Denise Ferracioli Oda, Roberto Barreto Osaki, Paulo Henrique Weckwerth, Guilherme Ferreira da Silva, Murilo Priori Alcalde, Marco Antonio Hungaro Duarte, and Rodrigo Ricci Vivan discuss a challenging and dangerous condition........................20

Endodontic retrospective


Endodontic insight

Premixed nanoparticulate bioceramics in endodontics: the first decade

The importance of reliability and predictability in endodontic burs

Dr. Allen Ali Nasseh offers a review of an integral part of endodontic therapy

Dr. Garth Hatch discusses Tri Hawk’s Talon series of burs..........................24

ON THE COVER Inset image courtesy of Dr. Alexandre Capelli. See article on page 28.

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Volume 10 Number 4


Genius Files Cross Section Genius Files have double cutting edges with right positive action for asymmetric reciprocation and rotary action

With the Genius system, you don’t have to choose between safety and efficiency. Get reciprocation and rotary with the touch of a button. 800.552.5512 | Š 2017 Ultradent Products, Inc. All Rights Reserved.


Continuing education New resources to mitigate failure in root canal treatment and retreatment

Continuing education Surgical treatment of an extensive periradicular lesion: clinical, radiographic, and tomographic outcome after 5 years of follow-up Drs. Maurício Paradella de Camargo, Tiago Braga, Murilo Priori Alcalde, Marco Antonio H Duarte, Rafael de Camargo, and Rodrigo Ricci Vivan look back on a microsurgery with associated modified tissue guide regeneration techniques after 5 years .......................................................34

Dr. Alexandre Capelli with co-authors Drs. M.A.H. Duarte, R. Vivan, M. Camargo, and F. Quintela discuss the advantages of the combined use of mechanical instrumentation, ultrasonics, and magnification in root canal treatments and retreatments

Product profile The importance of MTA in endodontics...............................44

Industry news...............45

Practice management Endospective The Ace Process — more time, more money, and more freedom Dr. Albert (Ace) Goerig discusses the major goals of the Ace Process ......................................................40

Practice development SEO: Scam or critical marketing service? Part 1 Ian McNickle, MBA, defines SEO and discusses its importance................ 42 4 Endodontic practice


Continuing the journey Dr. Rich Mounce offers parting thoughts as he concentrates on private practice................................46

Small talk Five powerful leadership and culture-building statements Dr. Joel C. Small discusses how to cultivate shared values and a common purpose...........................................48

PUBLISHER | Lisa Moler Email: MANAGING EDITOR | Mali Schantz-Feld, MA Email: | Tel: (727) 515-5118 ASSISTANT EDITOR | Elizabeth Romanek Email: NATIONAL SALES DIRECTOR | Kristin Sammarco Email: CLIENT SERVICES/SALES SUPPORT | Adrienne Good Email: CREATIVE DIRECTOR/PROD. MGR. | Amanda Culver Email: OFFICE MANAGER/EXECUTIVE ASST. | Mystey Helm Email: MedMark, LLC 15720 N. Greenway-Hayden Loop #9 Scottsdale, AZ 85260 Tel: (480) 621-8955 Fax: (480) 629-4002 Toll-free: (866) 579-9496 |

SUBSCRIPTION RATES 1 year (4 issues) $129 | 3 years (12 issues) $349

Volume 10 Number 4

Seeing in true light. ZEISS EXTARO 300


The EXTARO® 300 from ZEISS offers optimized color balance and is the first device to combine polarized illumination with magnification. The TrueLight Mode facilitates identification of relevant dental tissues in a natural, white-light setting, while the NoGlare Mode allows you to visualize fine detail and precisely analyze the color shades of a tooth. • Analyze and restore teeth without distracting reflections • Work in natural light without causing premature composite curing • Distinguish between the slightest of color variations

SUR.9640 ©2017 Carl Zeiss Meditec, Inc. All copyrights reserved.


BrainTap Sandra Marlowe discusses how a digital health firm is taking on the stress pandemic


rowing up the son of an alcoholic was the greatest blessing of my life,” says Dr. Patrick Porter, founder of BrainTap Technologies, a company with a mission no less audacious than Empowering Humanity. His goal started in the 1970s, long before stress was the devastating malady it is today, when Porter’s father, in one of many desperate attempts to conquer his alcohol addiction, attended an AA-sponsored relaxation seminar and learned how to calm his racing mind. It worked so well, he decided to teach it to his nine children. “At age 12, I was a struggling student and storied troublemaker,” says Porter, “but I dreamed of being a great football player.

Patient wearing BrainTap headset

Dr. Patrick Porter, founder of BrainTap

Sports is how my dad got me hooked on his method. That year, I recorded my first visualization on a cassette recorder and used it for myself daily. I went on to become a three-sport captain in track, wrestling, and football, as well as an honor roll student.” Patrick K. Porter, PhD, has since been on the leading edge of personal

Sandra Marlowe has authored, co-written, or ghostwritten eight self-improvement books, including an award-winning bestseller. She has earned a Pushcart Prize nomination in literature. Marlowe regularly writes and speaks on topics related to brain health and self-development.

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performance technology and is an expert at teaching people to lead a stress-free lifestyle. He is the author of six books, including his popular Thrive in Overdrive and How to Navigate Your Overloaded Lifestyle. Porter and his technology have been featured in The Wall Street Journal, People, Entrepreneur, and Inc. magazines and on ABC, NBC, CBS and the Discovery® Channel. He is head of mind-based studies at the International Quantum University of Integrative Medicine and is a licensed master trainer of Neuro-Linguistic Programming.

The solution to 21st-century stress “In today’s society, people are faced with new kinds of stress,” says Porter. “With technology taking up every free moment, the human brain is no longer given a chance to relax and reboot.” A well-known way to achieve stress reduction is through meditation. That method became a $1 billion business in 2015 and was expected to reach $2 billion in 2017.

However, while millions of people want the benefits of meditation, it requires discipline. Thus, few people ever master it. “To put it simply,” Porter says, “BrainTap is an allnatural, drug-free solution for guiding the brain into deep meditative states naturally, which alleviates the effects of super-stress and resets the brain for optimal performance.” BrainTap can be accessed in many ways to fit a variety of lifestyles. • Anyone can easily get started with the BrainTap Pro app that features the company’s proprietary neuroencoding™ in its programs for stress, worry and anxiety, sleep, weight, and many others. • Braintappers can enhance their experience with the BrainTap headset, taking meditation to the next level with synchronized light pulses that create the deep, meditative brain states that even longtime disciplined meditators fail to achieve. The BrainTap Pro app can offer multiple solutions in every home. One family member may be using it to achieve physical fitness, Volume 10 Number 4


BrainTap headset with synchronized light pulses

while another uses it to advance a career or improve a golf game. The kids could be using BrainTap to accelerate learning or master a sport. All will benefit from peak brain performance, more restorative sleep, a positive mental attitude, and the energy to enjoy a productive fulfilling day, every day.

The science of brain wave entrainment Back in the 1970s, when Dr. Porter’s father initially learned how to relax and overcome his alcoholism, he used audio tones that match the brain wave state between 7 and 13 hertz called alpha. This is the state nearly all meditation programs try to achieve, and recordings featuring these sounds have recently become quite popular; but there are limits. “When the brain is at peak performance, all brain waves are engaged to some extent, something like a symphony, so it doesn’t make sense to put all our attention on a singular frequency,” Porter says, “My thought was, Let’s get that symphony perfectly tuned.” In 1986, Porter was introduced to the concept of brain wave synchronization through both light and sound. It’s also when a major breakthrough in electronics occurred with the invention of the Erasable Programmable Read-Only Memory chip (EPROM), which retains data even when there is no power supply. The EPROM chip allowed Porter’s team to synchronize light with sound and to store the algorithms on a device for repeated use. This first device was the MC2 (M-CSquare), and it was the world’s first personal light-and-sound device for brain wave entrainment. “This discovery allowed us to introduce to the world a new technology that takes the brain to the optimum state for restoring that symphony while the person simply relaxes.” Volume 10 Number 4

BrainTap Pro app program for sleep

“In 1989, we introduced the MC2 at the Consumer Electronics Show in Chicago, and the reception we received was phenomenal, culminating in our earning the ‘Best New Gadget of Year’ award.” As it turned out, the company was about 3 decades ahead of its time, and the technology proved difficult to sell in retail settings. Still, between the franchise company Porter founded and more than 1,500 clinics worldwide, he sold over a quarter of a million of these devices. Porter also came to realize that what people thought about while in the super brain states he was creating greatly affected

the outcome. “If your best thinking brought you to where you are, and it’s not working, then what needs to change is your thinking,” Porter says. He calls this “the Einstein factor” because, as Einstein said, you can’t solve the problem with the same thinking that created it. You must shift to solution thinking, then return to the problem with the solution in mind, which is a necessary step in creating new brain circuits. The addition of guided visualization, using Porter’s background in psychology and as a master trainer of Neuro-Linguistic Programming (NLP), brought it all together. “When we added guided visualization to the Endodontic practice 7


While stress has reached epidemic proportions, Dr. Porter’s message is clear — no one has to succumb to this silent killer. There are quick and easy solutions that can free us from its grasp.

light and sound mix, people started making profound changes in short periods of time — sometimes after a single session.” Dr. Porter uses a method of visualization he calls transformational thinking. “The first brain circuit that needs to change is the belief that you are a behavior,” he says. Even though the first law of psychology states you cannot be a behavior, many people use this kind of language all the time. As an example, people refer to themselves as “a smoker” all the time, and because of this belief, under stress, the first choice will be a cigarette. For others, it might be something different like food, alcohol, or whatever they believe is relief. “We’ve known for decades that beliefs are ruled by emotion, and what science now knows is that brain circuits are triggered by emotion. In fact, many brain circuits are only available in a specific emotional state,” Porter adds. Most people try to change beliefs with conscious effort or force of will. The problem is the conscious mind only controls 2% of the brain. The change needs to take place in the other 98% that’s really running the show.

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Attempting to access those brain circuits in the reactionary state of mind known as beta, 14 to 40 hertz, will likely only trigger an emotional response that can set off the very behavior we’re attempting to change. This is where meditation and relaxation techniques really accelerate in transforming a person’s thinking.

The future of BrainTap Dr. Porter has been the established leader in brain wave entrainment using light, sound, and vibration for 3 decades, making enhancements as new technologies came available. Today, the BrainTap Pro mobile app and the BrainTap headset enhance brain function in two ways — balancing brain wave activity and activating the brain’s neuroplasticity. He is confident that, with this combination, we can all achieve a stress-free state of mind and reach our full potential. For example, with this new science of digitallyenhanced meditation, you can awaken each day with a 10-minute meditation that Porter calls a digital cup of coffee. And, anytime day or night, you can tap into your nervous system’s natural rest-digest-recover mode to relax and reboot your body and brain. “We can all start our day feeling rested, refreshed, and ready for whatever the day may offer,” says Porter. With stress-related health and lifestyle issues at an all-time high, BrainTap is emerging as the world leader in digital health and wellness. “In 2018, we’re focusing on bringing the most engaging content to our mobile subscription service,” Porter says. By all indications, the company is seriously upping its game. For example, in the first quarter of 2018, BrainTap will be launching programs

with national celebrities such as Dr. Mehmet Oz of “The Dr. Oz Show®” for his growing nonprofit organization, Healthcorps, which sends mentors into schools to teach “a wellness lifestyle” to at-risk youth. Also in early 2018, BrainTap will release “Think Like a Shark” with Kevin Harrington, the original shark on Shark Tank®. While stress has reached epidemic proportions, Dr. Porter’s message is clear — no one has to succumb to this silent killer. There are quick and easy solutions that can free us from its grasp. With over 700 programs, BrainTap is quickly becoming an amazing component to people’s daily wellness routine, and over 1,500 health clinics worldwide recommend BrainTap to address the stress component of health and wellness. You can become an integral part of bringing transformational thinking and this digital health technology to your patients. BrainTap’s target market is head-ofhousehold wellness consumers — those who are struggling to manage an overloaded lifestyle and seeking a wellness solution for themselves and their families — one that fits into their busy lives and delivers genuine results. Dental professionals are uniquely positioned to reach this audience, and BrainTap is a perfect fit for the dental practice that’s already addressing sleep issues. Now you have a chance to experience transformational thinking by contacting BrainTap at 602-687-2147, or visiting www. EP This information was provided by BrainTap.

Volume 10 Number 4


Premixed nanoparticulate bioceramics in endodontics: the first decade Dr. Allen Ali Nasseh offers a review of an integral part of endodontic therapy


xactly 10 years ago, the first, and still the only premixed nano-particulate bioceramic cement was FDA approved for use as a universal root canal cement. The first two formulations were the Endosequence® BC Sealer™ and Endosequence® RRM™ (Brasseler USA, Savannah, Georgia) and were soon followed by a thicker, faster setting putty-like formulation called BC Putty FS (Brasseler USA, Savannah, Georgia). The very first bioceramic material in endodontics dates back to 1993; it was mineral trioxide aggregate (MTA) which was introduced for surgical root repair. MTA’s exceptional histological response was the impetus behind the development of the nanoparticulate premixed bioceramics for nonsurgical use. These newer bioceramics were designed from the ground up with the intent of taking full advantage of MTA’s biocompatibility, bonding capability, dimensional stability, non-resorbability, and hydrophilic qualities without some of its unnecessary components such as calcium aluminate and bismuth oxide impurities, which caused potential toxicity and dentin staining during endodontic clinical use.1-3 Therefore, a smaller particle size formulation was designed de novo, using a patented premix delivery method to allow improved delivery of bioceramics and expand its use from surgical repair materials into the realm of

Allen Ali Nasseh, DDS, MMSc, received his dental degree from Northwestern University Dental School in Chicago, Illinois, in 1994 and completed his postdoctoral endodontic training at Harvard School of Dental Medicine in 1997, where he also received a Masters in Medical Sciences (MMSc) degree in the area of bone physiology. He has been a clinical instructor and lecturer in the postdoctoral endodontic program at Harvard School of Dental Medicine since 1997 and the Alumni Editor of Harvard Dental Bulletin. Dr. Nasseh is the endodontic advisor to several educational groups and study clubs and is endodontic editor to several peer-reviewed journals and periodicals. He has published numerous articles and lectures extensively nationally and internationally in surgical and nonsurgical endodontic topics. Dr. Nasseh is in solo private practice ( in downtown Boston, Massachusetts. Disclosure: Dr. Nasseh is the President and Chief Executive Officer for the endodontic education company Real World Endo® (

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July 2008

Nov. 2008

July 2008

Nov. 2008

July 2016

Figure 1: A premolar and molar teeth in the maxillary left quadrant (teeth Nos. 12 and 14) were treated nonsurgically with hydraulic condensation in 2008 and subsequently recalled for evaluation in 2016. The patient was nonsymptomatic, and both teeth had healed lesions. Most importantly, the original sealer puffs were present, and the sealer showed perpetual integrity over the 8-year period

Figure 2: Hydraulic Condensation consists of placing the bioceramic cement in the canal and then seating a pre-fitted bioceramic coated GP cone all the way to full length. The cone is then seared off at the orifice and condensed apically. Since the cone is a slightly higher melting point, it acts as a plugger pushing the BC filler in the canal. This is similar to the concept of post cementation except that the cone reaches the apex and provides a path for retreatment if necessary

nonsurgical root canal therapy as an obturation cement and a filler. Real World Endo® (Boston, Massachusetts) developed techniques for the use of

these materials prior to their FDA approval and designed nonsurgical and surgical techniques called the Hydraulic Condensation Technique and the Lid Technique to harness Volume 10 Number 4





Underprepared Canal Anatomically Prepared Canal


Visit our website at To order call 800.841.4522 or fax 888.610.1937. In Canada call 800.363.3838 Patents Pending


Featuring Brasseler’s exclusive MaxWire® Technology, the XP-3D adapts to the canal’s natural anatomy by expanding once exposed to body temperature.


Overprepared Canal


ENDODONTIC RETROSPECTIVE the power of bioceramic technology to improve efficiency of nonsurgical and surgical obturation while still allowing this material to be retreatable if needed.4-6 The dimensional stability, bonding, and non-resorbability of these materials allowed these techniques to be developed. Figure 1 shows a nonsurgical root canal therapy in a maxillary premolar and molar under a bridge performed in 2008 and recalled in 2016. The radiographs show the stability of the cement over the 8-year period (Figure 1). The non-solubility and dimensional stability of the cement allows cementation of a bioceramic-coated master cone that is matched with the Master File to be seated to full length using the bioceramic cement as the interface to fill in any gaps. The guttapercha cone in this technique acts as both a cement delivery tool and filler while providing a predictable path for retreatment if needed. The actual seal is provided by the chemically bonding bioceramic cement, and the technique resembles the cementation of a passive post (Figure 2). Real World Endo® later designed the BC Putty specifically for surgical use, which allowed efficient repair with this bioceramic formulation without the handling limitations and staining side effects related to the bismuth oxide present in conventional MTA. The surgical use of the putty ranges from surgical apicoectomy and retrofilling (Figure 2), external root resorption or perforation repair (Figure 3), and many other uses such as pulpotomy, pulp capping, and regenerative procedures (Figure 5). Since the composition and material properties of the bioceramic line are the same as MTA, the same surgical and nonsurgical applications of MTA apply to these materials plus the ability to use them as a root canal cement due to the much smaller particle size. The improved clinical handling properties due to their premix nature and no dentin staining due to the absence of bismuth oxide are the main advantages of these products over MTA. BC Sealer, RRM, and Putty are three different viscosities of the same base premixed calcium silicate, calcium phosphate bioceramic that have been used for a decade and after being on the market for 10 years, and after millions of surgical and nonsurgical clinical cases, they’re time tested and growing rapidly in popularity (Figure 5). In conclusion, bioceramic materials are now an integral part of endodontic therapy, and the three premixed nano particulate bioceramic formulations discussed provide excellent clinical handling that can be used for the same clinical applications as MTA 12 Endodontic practice

Figure 3: A retrofilling technique called the “Lid Technique” was developed by RWE to make the most of combining the light body effects of RRM syringeable material (injection into the retropreparation) followed by placing a lid of the BC Putty to protect this material during the setting period. This technique helps make the retrofilling process very efficient

Bioceramic materials are now an integral part of endodontic therapy, and the three premixed nano particulate bioceramic formulations discussed provide excellent clinical handling that can be used for the same clinical applications as MTA with the addition of nonsurgical root canal obturation.

2008 PreOp

2009 Healing

2008 NS PostOp

2009 Healing

2008 Surgical Repair

2015 Recall

Figure 4: A large external resorptive defect in tooth No. 8 is treated nonsurgically with RRM Sealer and then flapped back for direct surgical repair using RRM Putty. One year and 7-year followups show great healing of the tissue and bone Volume 10 Number 4





Pulp Capping

Resorption Repair


Perf. Repair



Perf. Repair

Figure 5: Nonsurgical and surgical application of bioceramic cements

with the addition of nonsurgical root canal obturation. After 10 years of clinical experience and availability, the use of these materials is well accepted by the endodontic community, and these materials are now ready for prime time. EP

Volume 10 Number 4

Figure 6: The three main formulations of the nanoparticulate bioceramics (The Sealer, RRM, and Putty FS) can be used together or alone in many different applications of endodontic care both nonsurgically as well as surgically

REFERENCES 1. Zhang W, Li Z, Peng B. Ex vivo cytotoxicity of a new calcium silicate-based canal filling material. Int Endod J. 2010;43(9):769-774. 2. Ma J, Shen Y, Stojicic S, Haapasalo M. Biocompatibility of two novel root repair materials. J Endod. 2011;37(6): 793-798. 3. Keskin C, Demiryurek EO, Ozyurek T. Color stabilities of calcium silicate-based materials in contact with different

irrigation solutions. J Endod. 2015;41(3):409-411. 4. Nasseh AA. The rise of bioceramics. Endodontic Practice US. 2009;2:17-22. 5. Koch K, Brave GD, Nasseh AA. Bioceramic technology: closing the endo-restorative circle, part 1. Dent Today. 2010;29(2):100-105 6. Koch K, Brave GD, Nasseh AA. Bioceramic technology: closing the endo-restorative circle, part 2. Dent Today. 2010;29(3):98, 100, 102-105.

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Bioceramic Application


American Dental Partners, Inc. A partnership model that invests in the programs, people, and processes that help dentists grow


he dental industry, much like any other industry, is continuously growing and evolving. From technology and medical advancements to trends in practice management — this is an exciting time to be part of the field. Doctors have access to a variety of ways to practice, tools to use, and environments in which to establish their careers. For those who are interested in having added resources and administrative support — but value the traditional patient relationships associated with private practice — American Dental Partners presents a unique option where they can achieve both.

A new kind of partnership American Dental Partners, Inc., (ADPI) was established in 1995 with a mission to elevate the practice, profession, and delivery of oral healthcare. ADPI does this through a unique partnership model that gives local, community-based group practices the ability to thrive while keeping up with today’s patient demands and business best practices. Today, ADPI is partnered with 22 affiliated group practices in more than 280 locations across the United States. When it comes to branding and patient marketing, American Dental Partners invests in the local practice brand and the doctors themselves rather than the American Dental Partners brand. This allows the group to maintain its connection to the local community, while doctors can tap into a national network of colleagues within the ADPI family. Most affiliates have more than 20 years of history in their community before they partner with ADPI. Under this model, there are clear lines that define what the P.C. Group/Doctor Owner governs (patient care, treatment planning, patient records, doctor contracts, etc.) and what ADPI manages (facilities, employee benefits, patient marketing, continuing education, etc.). This partnership path is advantageous to both parties involved. It enables doctors to truly focus on meeting the needs and preferences of their patients, while gaining greater access to profit sharing, ownership, and a true business partner to help their practices grow. 14 Endodontic practice

Affliliate partners map

“When I was considering opportunities as an endodontist, I was searching for a group that provided exceptional care to patients while providing opportunities for professional growth. Premier Dental was a great fit, and now I am proud to be in the role of doctor-owner!” — Vanessa Reuter, Endodontist and Owner, Premier Dental Partners

Doctors collaborate to develop treatment plans that are in the best interest of their patient Volume 10 Number 4

Proprietary software and shared EMR being used at Metro Dentalcare

Helping specialists thrive Belonging to an American Dental Partners supported practice is particularly beneficial to specialists. Endodontists, oral surgeons, periodontists, and orthodontists can enjoy a steady patient demand that is mainly generated through internal doctor referrals. Tools such as shared electronic medical records (EMR), proprietary practice management software, and consistency in provider enrollment create an environment where collaboration between doctors is as effortless as possible. Specialists also benefit from having a home operatory with no required travel. Endodontists have a designated operatory that includes all necessary materials, including a microscope, so they can work as comfortably as possible. Taking away the need for excessive travel or the burden of lugging your own equipment helps to reduce burnout and stress and makes it easier for doctors to maintain a healthy work-life balance. Patients benefit from this model as well. They can easily receive the care they need from a team of professionals who are well aligned and aware of each patient’s unique needs, preferences, and goals. Doctors who maintain this healthy balance and are provided with opportunities to develop their skills will be empowered to deliver better care to patients and form rewarding relationships with their community.

Committed to quality In an effort to help its affiliates go above and beyond the typical protocols on safety and quality, American Dental Partners has Volume 10 Number 4

provided more than 60% of its practices with the needed resources to successfully achieve Accreditation Association for Ambulatory Health Care (AAAHC) Accreditation. This prestigious recognition means that the AAAHC and its independent team of health care professionals have found that these practices meet their rigorous, nationally recognized standards for health care services in areas such as infection prevention and control, quality management and improvement, risk management, and environmental safety.

Continuous growth Efforts designed to promote collaboration and improve the patient experience aren’t limited to taking place within the practice walls. ADPI has established several leadership and professional development programs that help participants work together to provide excellent service to patients while learning valuable personal and professional skillsets. The program is open to anyone who comes in regular contact with patients including doctors, practice managers, dental assistants, and scheduling managers. Topics covered include emotional intelligence, customer service, communication, and team leadership. With American Dental Partners, growth can be found around every corner. Whether it’s a dental hygienist who worked her way up to becoming a Director of Operations, or the group practice that started with just three locations and grew to more than 30 — each practice, each doctor owner, and each person has his/her own journey and story.

“My participation in the Service Academy has provided me with an opportunity to develop skills and knowledge that will serve me throughout my life. It always seems as though each session hits at just the right time in my professional and personal life.” — Christine Litak, Practice Team Lead, ForwardDental

Preserving these stories, and partnering with their people are what the team at American Dental Partners focuses on above all else.

Grow with us Whether it’s a new practice location or an increase in patient demand — opportunities across the country are being added and updated on a daily basis. We’re continuously investing in the programs, people, and processes that will empower team members, and ultimately deliver better care to the patients and communities we are privileged to serve. If you think it’s time someone invested in you, give us a call at 781-224-0880 or email Our Talent Acquisition team is ready to find the opportunity and practice environment that will help you achieve the lasting career you’ve been striving for. EP This information was provided by American Dental Partners, Inc.

Endodontic practice 15


Modern, inviting practice spaces at Metro Dentalcare


Extreme endodontic interventions: a case report Drs. Karl Woodmansey and Yogesh Patel illustrate their interventions to retain a mandibular first molar


his case report illustrates extreme endodontic interventions to retain a mandibular first molar. At many decision points during the treatment of this tooth, dental implants could have been considered as an appropriate treatment plan. Although dental implants can provide functional replacements for lost teeth, this patient desired to retain her natural tooth at all costs — and to date, she has. This tooth was treated by two endodontic residents (KW and YP) at the Texas A&M University/Baylor College of Dentistry in Dallas, Texas. All treatment was performed prior to widespread availability of cone beam CT imaging.

Case report A 40-year-old black female in good general health with no medications and no allergies initially presented to the Baylor College of Dentistry Graduate Endodontics Department in January 2004 with a chief complaint of pain on biting with tooth No. 30 (Figure 1). The patient reported that the previous root canal treatment was “many years old.” A periapical radiolucency was noted at the distal root apex. The mesial canals appeared obturated with silver points (Figure 2). Tooth No. 30 was diagnosed as previously treated with subacute periradicular periodontitis. Nonsurgical endodontic retreatment was completed in February 2004 (final radiograph not available). In February 2004, a dental student placed a Brasseler post (Brasseler USA®, Savannah, Georgia) and a resin buildup (final radiograph not available). In December 2004, the patient returned to graduate endodontics and reported spontaneous aching and pain on biting with tooth No. 30. The radiograph documents a large parallel-post cemented in the distal canal. Karl Woodmansey, DDS, MA, is Adjunct Associate Professor of Endodontics at Saint Louis University in St. Louis, Missouri. Yogesh Patel, DDS, is the owner and a practicing endodontist with North Dallas Endodontics in Dallas, Texas.

16 Endodontic practice

Figure 2

Figure 1

The post appears to “strip-perforate” the furcation wall of the distal root with cement extrusion and an associated furcal radiolucency. The distal root periapex demonstrates some radiographic healing (Figure 3). In January 2005, the post was removed, and a furcal perforation of the distal root was confirmed. The apical segment was retreated with gutta percha; the perforation was internally repaired with mineral trioxide aggregate (MTA) (ProRoot® MTA, Dentsply Sirona, York, Pennsylvania); and the coronal portion of the canal was obturated with MTA. The mesial canals were not retreated. A new buildup/ access-repair restoration was placed. In the posttreatment radiographs, the perforation repair is evident as is the residual thinness of the root walls (Figure 4). This August 2005 radiograph illustrates partial healing of the distal root’s apical and furcal areas (Figure 5). In September 2005, a new PFM crown was cemented (radiograph not available). In November 2007, the patient returned reporting vague pain in the tooth No. 30 area for the past 2 months, with pain on chewing and occasionally requiring Tylenol® for pain relief. Her chief complaint was, “This tooth is hurting again.” A photograph documented the quadrant dentition and restorations (Figure 6).

Figure 3

Figure 4

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CASE STUDY A bitewing radiograph demonstrated complete healing of the furcation perforation (Figure 7). A periapical radiograph (November 2007) demonstrated complete healing of the distal

periapex, but now a periapical radiolucency was present at the apex of the mesial root (Figure 8). Although nonsurgical endodontic retreatment was considered as a possible treatment

Figure 7

option, the patient was offered extraction/ implant or endodontic surgery as treatment options. She elected endodontic surgery, desiring to retain her natural tooth. Surgical root canal treatment, root-end resection, and root-end filling (apicoectomy) of the mesial root were performed in December 2007. This photo shows the osteotomy and resection of the apex of the mesial root. The PDL space and inter-canal isthmus are stained with methylene blue. This isthmus illustrates the difficulty of debriding, disinfecting, and obturating complex canal anatomy with nonsurgical endodontic treatment. Here, with surgical access, the treating endodontist can directly address the bacterial biofilm residing within the isthmus space (Figure 9). Table: Treatment Summary Tooth No. 30

Figure 6

Figure 9

Figure 12 18 Endodontic practice

Figure 8

Figure 10

Figure 13

Initial root canal treatment


PFM crown


Nonsurgical retreatment




Repair of furcal perforation


New buildup and PFM crown


Surgical retreatment


Figure 11

Figure 14 Volume 10 Number 4


Figure 15

Figure 17 Figure 16

This is the histopathologic specimen removed from the apex, diagnosed by the Baylor College of Dentistry Oral Pathology Service as a dental granuloma. The specimen includes infiltrates of plasma cells and lymphocytes. The brown material is extruded sealer (Figure 10). This photo shows the root-end MTA filling (White ProRootÂŽ MTA, Dentsply Sirona, York, Pennsylvania) condensed into the preparation, including the isthmus (Figure 11). These periapical radiographs show the root-end filling immediately post-surgery (December 2007) (Figures 12 and 13). This radiograph from July 2009 documents good healing of the apical defect with re-formation of the PDL space and lamina dura. Some altered trabeculation remains. The patient is asymptomatic and has retained her natural dentition (Figures 14 and 15). The patient was asymptomatic at her August 2010 re-evaluation visit. This clinical photo documents the condition of tooth No. 30 at that time (Figure 16). Radiographs from the August 2010 reevaluation demonstrate continued/complete healing of the apical defect with re-formation of the PDL space and lamina dura. Some altered trabeculation remains (Figure 17).

Acknowledgments Drs. Woodmansey and Patel wish to acknowledge the skilled faculty who guided their treatment of this patient. EP

Volume 10 Number 4

Endodontic practice 19


Identification and resolution of edema of the head/ neck in a 7-year-old child Drs. Denise Ferracioli Oda, Roberto Barreto Osaki, Paulo Henrique Weckwerth, Guilherme Ferreira da Silva, Murilo Priori Alcalde, Marco Antonio Hungaro Duarte, and Rodrigo Ricci Vivan discuss a challenging and dangerous condition Introduction Infections in the head/neck region present a high level of severity because they are capable of easily dissipating through the fascial spaces and planes of the region.1 When this occurs, the patient could develop Ludwig’s Angina, an extremely fatal clinical condition characterized by a large edema in the neck region that compromises the vital performance of the airways.2 Problems arising from the oral cavity are responsible for 90% of cases of Ludwig’s Angina,3 because the roots of the mandibular teeth are located below the hyoid line of the mandible, which facilitates the dissipation of edema into the submandibular space. However, several other factors can trigger edema in the head and neck area, such as suppurative lymphadenitis, parotiditis, sialolithiasis, and trauma, among others.4 All of these conditions, when unidentified or identified late, may result in dissipation of the edema and its evolution to pneumonia, Denise Ferracioli Oda, DDS, MSc, is a graduate student (PhD program) at the Department of Operative Dentistry, Endodontics and Dental Materials, Bauru School of Dentistry, University of São Paulo, Bauru, SP, Brazil. Roberto Barreto Osaki, DDS, is in Private practice in Marília, SP, Brazil. Paulo Henrique Weckwerth, DDS, MSc, PhD, is a Professor at the Sagrado Coração University, School of Dentistry, Bauru, SP, Brazil. Guilherme Ferreira da Silva, DDS, MSc, PhD, is a Professor at the Sagrado Coração University, School of Dentistry, Bauru, SP, Brazil. Murilo Priori Alcalde, DDS, MSc, is a graduate student (PhD program) at the Department of Operative Dentistry, Endodontics and Dental Materials, Bauru School of Dentistry, University of São Paulo, Bauru, SP, Brazil. Marco Antonio Hungaro Duarte, DDS, MSc, PhD, is a Full Professor at the Department of Operative Dentistry, Endodontics and Dental Materials, Bauru School of Dentistry, University of São Paulo, Bauru, SP, Brazil. Rodrigo Ricci Vivan, DDS, MSc, PhD, is a Professor at the Department of Operative Dentistry, Endodontics and Dental Materials, Bauru School of Dentistry, University of São Paulo, Bauru, SP, Brazil.

20 Endodontic practice

Figures 1A-1F: 1A. Injection of liquid contrast into the extra oral fistula. 1B. Radiographic image of the tooth filled with calcium hydroxide paste added to CMPC, iodoform, and propylene glycol. 1C and 1D. Root canal filling finished. 1E and 1F. control after 6 months

emphysema, arterial erosion, pericarditis, cardiac arrest, sepsis, and potentially death of the patient.5,6 In these cases, complementary exams help in obtaining more precise information about the disease, increasing the chances of an accurate diagnosis. When the intra- or

extraoral fistula is present, this may facilitate the investigation because it allows rapid tracking of the cause by injection of contrasts. However, in view of the seriousness of the condition and the rush of emergency procedures, complementary examinations are sometimes omitted, and Volume 10 Number 4

Case study The patient, a 7-year-old child, was brought to the dental clinic by his mother, complaining of pain, edema, and an extraoral fistula that had been present for 10 months. Because the fistula was inactive, and the large edema was in the head and neck region, the patient was immediately referred to the hospital for emergency oral drainage. With the suspicion that this infection was of glandular origin, the doctors had scheduled immediate removal of the salivary glands, but the injection of liquid contrast identified the cause as being of dental origin (Figure 1). Therefore, the gland removal surgery was canceled, and after reducing the chances of risk of death, the patient was referred to the dentist. In the radiographic evaluation, the dentist verified that the origin of the focus of infection was tooth No. 46, which presented pulp necrosis, periapical lesion, and incomplete rhizogenesis at Nolla stage 8. The root canal preparations were performed in the Reciproc® technique with the R25 and R50 instruments (VDW® GmbH, Munich, Germany). During the entire procedure, the canals were irrigated with 2% chlorhexidine solution (Biodinâmica, Ibiporã, PR, Brazil), alternately using saline solution, and the final irrigation was performed with 17% EDTA (Biodinâmica, Ibiporã, PR, Brazil). The formocresol (Biodinâmica, Ibiporã, PR, Brazil) was used as the first intracanal dressing, and the cavity was sealed with glass ionomer cement (GIC) (Vidrion R, SS White, Rio de Janeiro, RJ, Brazil; Lakewood, New Jersey). After 7 days, the canals were again accessed and irrigated with 2% chlorhexidine and 17% EDTA solutions. They were then completely filled with the second medication, a paste composed of calcium hydroxide powder, camphorated Volume 10 Number 4

Infections in the head/neck region present a high level of severity because they are capable of easily dissipating through the fascial spaces and planes of the region. paramonochlorophenol (CPMC) and iodoform (Biodinâmica, Ibiporã, PR, Brazil), all manipulated in propylene glycol (Figure 1). The cavity was again sealed. After waiting 15 days, upon the patient’s return, there was a significant regression of the abscess and fistula, and the patient reported complete cessation of pain and drainage. Thus, the dentist decided to continue with the intracanal medication for another 15 days.

At the end of 30 days with the calcium hydroxide paste medication, complete regression of the abscess was observed, leaving only the scar resulting from extra oral drainage (Figure 2). Before filling the root canals, a hydroxide powder PA (Biodinâmica, Ibiporã, PR, Brazil) plug was inserted in the apical region, and then the root canal filling was performed by the controlled biological technique (Figure 1). After the tooth had been restored, the patient was guided and referred to a plastic surgeon to soften the scar. The patient did not report pain or any discomfort in final appointment of the treatment. There was total regression of the head/neck edema. In the clinical and radiographic control after 6 months, a regression of the periapical lesion, and biological sealing of the region were observed (Figure 1). During this period, there was continued absence of signs of pain, fistula, and edema (Figure 2).

Endodontic practice 21


treatments are performed based on clinical signs only. This underestimation of the disease is serious because it generates long and erroneous treatments, especially if the patient is a child for whom the prognosis becomes more somber. Thus, it is indispensable for doctors and dental surgeons to collect as much information as possible to prevent fatal complications, enabling them to perform the correct treatment successfully. The present case report described a significant edema in the head and neck region in a 7-year-old child, and provided a description of identifying the cause and performing the treatment of choice.

CLINICAL/CASE REPORT Discussion Abscesses in the head and neck region are a medical emergency, and the patient should immediately be referred for hospitallevel care.4 In the present clinical case report, when the abscess was identified in a critical area, the dental surgeon adopted the correct behavior when requesting immediate medical support to perform the surgical drainage, a protocol indicated in cases of abscess in submandibular space,7 thereby reducing the chances of the patient developing fatal complications. Complementary exams combined with clinical examination are decisive in identifying the causative agent. However, negligence in the investigation of the disease may result in unnecessary invasive procedures being performed, such as removal of the salivary gland mentioned in the present case. In view of the incorrect diagnosis of sialolithiasis, implementation of the planned procedure would not have favored resolution of the abscess, but would have contributed to the evolution of the infection, and allowed the occurrence of fatal complications, because the true cause would have been identified and treated too late. Only after the injection of contrast was it possible to identify that the cause was of dental origin, tooth No. 46, and the patient was immediately referred to the dental surgeon to begin treatment. The tooth that caused the infection had incomplete formation of the root apex, a situation that favored the occurrence of injuries to the adjacent periradicular tissues and persistence of the focus of inflammation. In this case, a 2% chlorhexidine solution was used as an irrigating solution during the root canal preparation because it had a low caustic action on the tissues, different from sodium hypochlorite.8 In addition, it exhibited satisfactory antimicrobial action during and after its use. White RR, et al., verified that it continued to exert antimicrobial action up to 72 hours after its use in already instrumented root canals. This effect of chlorhexidine substantivity favored the maintenance of antisepsis and non-recontamination of the root canal.9 The presence of incomplete rhizogenesis made it difficult to clean the root canal by the mechanical action of the instrumentation and irrigation, so it was essential to use medications in order to overcome this deficiency. The first medication used in this case was formocresol, a substance that has demonstrated absence of genotoxicity by not inducing DNA damage in fibroblasts10 22 Endodontic practice

Figures 2A-2C: 2A. Initial aspect of the fistula in the neck area. 2B. After 30 days. 2C. Final aspect after 6 months

and was capable of promoting high bacterial disinfection in a short period of time,11 helping with stabilization and regression of the infectious focus. Calcium hydroxide was used as the second intracanal medication to complement disinfection of the root canal. Studies have shown that the addition of camphorated paramonochlorophenol (CMPC) to calcium hydroxide has been able to potentiate its antimicrobial action, and this combination was indicated for procedures of inoculation in infected teeth.12 Studies have shown that the use of this combination in a viscous vehicle further increased the effectiveness and speed of the bactericidal action, in which the paste made with viscous vehicle presented greater antimicrobial efficacy when compared with calcium hydroxide paste only in saline solution.13,14 In addition to the ability to inactivate bacteria and their toxins, calcium hydroxide presented anti-exudative action and ability to induce the formation of mineralized tissue, fundamental properties for the success of the present clinical case.15-17 To prevent periapical tissue injury in teeth with incomplete rhizogenesis, it is necessary to create a physical barrier that allows adequate accommodation of the filling material, without its overflow into the periapical tissues.18 In this case, an apical plug was made with calcium hydroxide powder PA, which not only acted as a physical barrier, but also was biologically tolerated by the organism and had the capacity to induce mineralized tissue formation, characteristics that favored appropriate biological sealing of the apical region.17

— fundamental conditions for obtaining posttreatment success.


14. Siqueira JF Jr, Lopes HP, de Uzeda M. Recontamination of coronally unsealed root canals medicated with camphorated paramonochlorophenol or calcium hydroxide pastes after saliva challenge. J Endod. 1998;24(1):11-14.

The prior and correct identification of the causative agent allowed the adequate treatment in time to avoid the evolution of the disease, preventing the occurrence of fatal complications. The use of different substances and techniques, suitable for the present case, promoted the regression of the focus of infection, in addition to preserving the integrity of the periradicular tissues

Acknowledgments The authors deny any conflicts of interest. The patient’s legal guardian authorized disclosure of the images and information about the case, by means of signing a form of free and informed consent. EP

REFERENCES 1. Levitt GW. Cervical fascia and deep neck infections. Laryngoscope. 1970;80(3):409-35. 2. Britt JC, Josephson GD, Gross CW. Ludwig’s angina in the pediatric population: report of a case and review of the literature. Int J Pediatr Otorhinolaryngol. 2000;52(1):79-87. 3. Tschiassny K. Ludwig’s angina: an anatomic study of the lower molar teeth in its pathogenesis. Arch Otolaryngol. 1943;38(5):485-496. 4. Larawin V, Naipao J, Dubey SP. Head and neck space infections. Otolaryngol Head Neck Surg. 2006;135(6):889-893. 5. Fritsch DE, Klein DG. Ludwig’s angina. Heart Lung. 1992;21(1):39-46. 6. Colmenero Ruiz C, Labajo AD , Yañez Vilas, Paniagua J. Thoracic complications of deeply situated serious neck infections. J Craniomaxillofac Surg. 1993;21(2):76-81. 7. Ardehali MM, Jafari M, Hagh AB. Submandibular space abscess: a clinical trial for testing a new technique. Otolaryngol Head Neck Surg. 2012;146(5):716-718. 8. Jeansonne MJ, White RR. A comparison of 2.0% chlorhexidine gluconate and 5.25% sodium hypochlorite as antimicrobial endodontic irrigants. J Endod. 1994;20(6):276-278. 9. White RR, Hays GL, Janer LR. Residual antimicrobial activity after canal irrigation with chlorhexidine. J Endod. 1997;23(4):229-31. 10. Ribeiro DA, Marques ME, Salvadori DM. Lack of genotoxicity of formocresol, paramonochlorophenol, and calcium hydroxide on mammalian cells by comet assay. J Endod. 2004;30(8):593-596. 11. Siqueira JF Jr, Rôcas IN, Lopes HP, Magalhães FA, Uzeda M. Elimination of Candida albicans infection of the radicular dentin by intracanal medications. J Endod. 2003;29(8):501–504. 12. Frank AL. Therapy for the divergent pulpless tooth by continued apical formation. J Am Dent Assoc. 1966;72(1):87-93. 13. Siqueira JF Jr, de Uzeda M. Disinfection by calcium hydroxide pastes of dentinal tubules infected with two obligate and one facultative anaerobic bacteria. J Endod. 1996;22(12):674-676.

15. Chong BS, Pitt Ford TR. The role of intracanal medication in root canal treatment. Int Endod J. 1992;25(2):97-106. 16. Heithersay GS. Calcium hydroxide in the treatment of pulpless teeth with associated pathology. J Br Endod Soc. 1975;8(2):74-93. 17. Soares J, Santos S, César C, et al. Calcium hydroxide induced apexification with apical root development: a clinical case report. Int Endod J. 2008;41(8):710-719. 18. Holland GR. Periapical response to apical plugs of dentin and calcium hydroxide in ferret canines. J Endod. 1984;10(2):71-74.

Volume 10 Number 4

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The importance of reliability and predictability in endodontic burs Dr. Garth Hatch discusses Tri Hawk’s Talon series of burs


s an endodontist and practice management consultant, I’m always looking for technological breakthroughs that lead to greater efficiency, safety, and predictability. In the modern world, we often think of big advances in technology coming in the shape of electronics and fancy machines, but often the things that make the biggest difference come in the smallest and least thought of aspects of our jobs. In this case, we are looking at the dental burs that all dentists use and are incredibly important to endodontics. Most endodontists have experienced the stress that occurs when a bur breaks during an apicoectomy or the difficulty of accessing through crowns efficiently yet still preserving the porcelain to avoid costly crown replacement. Selecting the right bur for the right job can truly elevate the level of predictability possible during surgical procedures, endo-access, and more. Tri Hawk’s Talon series of burs is just such a technological breakthrough that can truly enhance your practice.

occurs with the use of dental burs. When burs break, it almost always occurs at the union between the cutting bur and shank as this is typically the weakest junction in the bur. My own personal frustration with having burs break during treatment, especially during surgeries, is what led me to try the Talon burs. Although any bur on the market today can break under enough torque or load, the Tri Hawk Talon burs are extremely fracture resistant due to their unique steel blend and a proprietary welding technique. When I tried the Talon burs for the first time, I was extremely impressed with their strength and cutting efficiency and immediately became a big fan. I highly recommend single-use burs with any surgical procedure, including the Tri Hawk Talon burs. This ensures the bur is sharp, clean, strong, and will function at its best every time it comes out of the package. The Tri Hawk line of burs can be utilized for many different dental applications and procedures. Here are some of the most common.

Equipment efficiency — a pillar of professional dentistry


Within my operatory, I expect to have reliable results based on my selection of equipment, technique, and staff to mitigate risk. One of the immediate points of contact with the patient in most endodontic procedures

Dr. Garth Hatch, DDS, is President and Founder of Dental Specialist Institute, a dental consulting firm committed to helping specialists receive more referrals, profits, and freedom. He coaches endodontists and their teams to better leverage their time, space, and efforts to help minimize stress and maximize results. He is a native of Riverside, California, earned a BS in Exercise Physiology from Brigham Young University, and his DDS from Indiana University School of Dentistry. Dr. Hatch entered the U.S. Army Dental Corps and completed a 1-year AEGD residency at Fort Jackson, South Carolina, and later completed an endodontic residency program at Fort Gordon, Georgia. Dr. Hatch currently owns and practices in his endodontic practice in Kennewick, Washington. Dr. Hatch has authored several articles relating to endodontics and has lectured both nationally and internationally. He is dedicated to helping specialists create the practice of their dreams and achieve more abundance and freedom.

24 Endodontic practice

If you perform apicoectomies on a regular basis, you’ve likely experienced the gut-wrenching feeling of having a surgical bur break while accessing through bone or retroprepping the apex. This bur breakage isn’t just an inconvenience, but potentially can cause major complications if the broken bur ends up in the sinus, is aspirated, or lodged underneath the surgical flap where locating and retrieval would be difficult. Costly and challenging surgical procedures may be required to remove the bur tip depending on the situation. Any of these scenarios could harm the patient and lead to lawsuits or ill-will between the patient and health care provider. Another major advantage of the Tri Hawk Talon surgical burs is their length and extreme cutting efficiency. The Talon 12 Surgical brings a 25-mm length to the hyperbolic shape, exacting all the strength and speed that you would expect from a standard length. The shape also offers easy evacuation of bio-material, so that cutting ability and visibility remain true throughout

the procedure. The Talon cutting efficiency also reduces chatter while cutting through root apices and bone to help reduce microfractures.

Endo-access hole through PFM Preserving a crown means avoiding expensive replacement cost. The Talon 10 has no crosscut teeth, which reduces microfactures in porcelain-fused-to-metal crowns and possible fracturing of a porcelain cusp. This reduction in microfractures also helps to preserve the porcelain margin around the hole. Once the access hole is made vertically, access can be expanded using the Volume 10 Number 4

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horizontal blades. There’s no changing of burs or the need to remove the bur from the access hole, which improves speed and treatment efficiency.

Endo-access hole through zirconia Zirconium crowns can be particularly difficult to access through due to the hardness of the material. For these crowns, it is necessary to switch to a diamond bur. I recommend using Tri Hawk Diamond round burs in a coarse grit. There are other burs on the market that are comparable in cutting efficiency to the coarse round burs, but I’ve found that one or two coarse burs are a better value than some of the more costly burs designed for cutting zirconium.

Crown and bridge removal This is a common procedure that can take an excessive amount of chair time. Removing a hardened crown typically means leading with a diamond and switching mid-procedure to a carbide. The Talon 12 reduces the steps down to one. See the video at There is no need for more than one bur. Clean and consistent cutting, sections both porcelain and metal with one clean sweep.

Implants The growing demand for implants from both patients and dentists alike have ushered the need for the Talon 14 Surgical. The efficiency of the larger bur head is prized by dentists in our clinic for quick and efficient cutting ability. It cuts as fast during the last 10 seconds as the first 10 seconds. It has proven to be a great tool for sectioning and removing teeth due to the 26 Endodontic practice

ability to penetrate down and sideways at the same time. In addition to these features, the Talon series of burs will trim any type of post or abutment including titanium with little effort.

Important notes on using this incredible technology that Tri Hawk offers Tri Hawk states that “The Tri Hawk Talon Line of burs offers versatile solutions to modern dentistry. Its unique hyperbolic design offers an aggressive rake angle that carves through any hardened material with ease. With both horizontal and vertical blades, the Talon can easily cut through any resistant material such as metal alloys, semiprecious metal, amalgam, porcelain-fusedto-metal or bone.“ This is all well and good, but to get these kinds of results, you do need to use the product properly. There are two secrets that I have found are effective and Tri Hawk recommends in order to cut most efficiently through all of the materials that Tri Hawk lists: Give the bur a little bit of a tilt, and use a very light touch. In the use of this product, the best results have been achieved by giving the bur a little tilt. By cutting at an angle of 30 to 40 degrees, you are taking advantage of both end-cut and side-cut capability at the same time and engaging the most aggressive cutting edges. The Talon cuts through its target like a hot knife through butter. There is a great video on line at that demonstrates this technique extremely well. When using an aggressive cutting carbide bur like Tri Hawk’s Talon line, it is also very important to use a feather light touch; just let the bur do the work. Be firm

in your grip so that you have good control over where you are cutting, but don’t apply any more pressure than what you need to start the cutting. This will give you both the best control and the fastest cutting speeds. Not only does Tri-Hawk focus on performance, they also ship the burs in functional, convenient, easy-to-use hospital-style packaging. They want the Talon to offer its best performance every time you take it out of its package. They promote “single-use” because it promotes patient comfort, speed, safety, and the dentist’s bottom line. A new and sharp bur means a faster more comfortable procedure, and prevents any patient-topatient transmission of pathogens. This also means more patients seen on time, more referrals, and fewer potential complications.

Who Is Tri Hawk? The strength of Tri Hawk burs is unparalleled. They are virtually unbreakable due to their special steel blend and a proprietary welding process that facilitates a stronger design — the burs are made stronger! Industry wide, most burs are tested 2 to 3 times throughout production. Tri Hawk burs must pass eight stringent quality control tests throughout the production process before being deemed high enough quality for their customers. Tri Hawk has been selling burs since 1969 and manufacturing dental burs since 1986. Gustel Fischer, Tri Hawk’s owner and president, talks about the company as having been “on a never-ending quest for the perfect bur.” This quest for perfection shows in their product, which include regular carbide burs, surgical carbide burs, Diamond burs, and the Talon line of crown-cutting carbide burs. EP This information was provided by Tri Hawk.

Volume 10 Number 4


New resources to mitigate failure in root canal treatment and retreatment Dr. Alexandre Capelli with co-authors Drs. M.A.H. Duarte, R. Vivan, M. Camargo, and F. Quintela discuss the advantages of the combined use of mechanical instrumentation, ultrasonics, and magnification in root canal treatments and retreatments


onventional endodontics advocates that treatments should be done performing cleaning and shaping procedural steps in the root canal. Currently, with the widespread use of nickel-titanium instruments, the shaping process has become faster and safer; however, studies have shown that up to 35% of the canal walls remain untouched during the biomechanical shaping stage.1-3 The use of ultrasonic tips improves efficiency of treatment and should be considered as an adjunct to how treatment is rendered to improve quality of care, especially on surfaces and regions where conventional instruments do not reach, considering that many teeth have isthmuses and flattened areas.1-4 The use of ultrasonic tips under optical magnification (either using glasses or microscope) and proper lighting is a safe and effective way to address a great number of endodontic clinical situations. It can be applied to the following: 1. Removing calcified nodules inside the pulp chamber 2. Refining access and searching for calcified and/or hidden canals (Figure 1) 3. Removing separated instruments and other obstructions inside the root canal 4. Removing intraradicular posts 5. Preparing isthmus and flattened areas

Alexandre Capelli, DDS, MSc, DSc Bio, is a specialist in endodontics and founder of Helse Ultrasonic. After many years working as a reputed endodontist and professor, Dr. Capelli decided to dedicate his career to design and manufacture ultrasonic tips for endodontics.

Educational aims and objectives

This clinical article aims to explain the advantages of the combined use of mechanical instrumentation, ultrasonics, and magnification in root canal treatments and retreatments.

Expected outcomes

Endodontic Practice US subscribers can answer the CE questions on page 38 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: •

Identify the main reason of failures in root canal treatments.

Recognize the main applications of ultrasonics in endodontics.

Recognize the importance of preparing and cleaning isthmuses, flattened areas, and secondary root canals.

Identify the clinical protocols to perform a thorough cleaning of the whole root canal system.

Realize the obturation removal in retreatments without the use of solvents and complying with a minimally invasive approach.

6. Agitating root canal irrigants and disinfectants 7. Activating calcium hydroxide and root canal sealer 8. Root canal obturation removal within the canal system 9. Cutting and condensing gutta percha 10. During periapical surgery, for osteotomy, apicoectomy, and retropreparation procedures The piezoelectric ultrasonic unit is a remarkable tool, indispensable for its precision and effectiveness, with potential to be incorporated as the main tool in most steps of the root canal treatment and retreatment.

The ultrasonic tip The ultrasonic tip is a metal insert that will actuate directly on the terminal end of the

tip where it contacts tooth structure. A tip is selected for a specific application, according to the geometry and utilization of the tip. An ultrasonic tip can be of many different shapes and angles, and made for different piezo units, but one main characteristic that must be considered is whether or not it is diamond coated.

Diamond-coated tips Diamond-coated tips are used to cut dentin quickly and effectively, requiring less time than regular stainless steel or zirconium nitride inserts in similar preparations (Figure 2). The diamond-coated tips have an abrasive effect on dentin and are useful to remove pulp stones and calcifications, to locate canals, to remove secondary dentin, and to clean isthmus areas.

José Mauricio Paradella de Camargo: MSc and PhD in Endodontics at UNESP College of Dentistry in Araraquara/SP. Marco Antonio Hungaro Duarte: MSc, PhD and Tenured Professor at São Paulo University in Bauru/SP. Rodrigo Ricci Vivan: MSc in Endodontics at São Paulo University in Bauru/SP and PhD in Endodontics at UNESP College of Dentistry in Araraquara/SP.

28 Endodontic practice

Figure 1: Locating calcified canals using a pear-shaped diamond-coated ultrasonic tip (E6D diamond-coated ultrasonic tip, Helse Ultrasonic, Santa Rosa de Viterbo, Brazil; GEFD-1 ultrasonic tip, Vista Dental, Racine, Wisconsin; or Pear Diamond ultrasonic tip, Excellence in Endodontics, San Diego, California.) Volume 10 Number 4

Figure 3: MEV image from a non-diamond-coated ultrasonic tip

Standard tips Standard tips are mostly used when it is necessary to preserve as much tooth structure as possible, as these cut less aggressively than diamond-coated tips. They are most useful to remove posts, separated instruments, gutta percha, cement, foreign bodies, debris, and smear layer through activation of irrigants in the canal system.

Main causes of failure in endodontic treatments One of the main causes of failed endodontic treatments is the presence of bacterial biofilm in the root canal system, especially inside areas of complex anatomy and lateral canals.5 As a file — whether it is a hand file or NiTi rotary — is only able to reach the main canal and is unable to instrument any lateral anatomy, irrigation is key to endodontic success to clean bacteria and pupal tissue that the file cannot contact. A root canal left undiscovered or contaminated is likely to be the reason for the treatment failure. The persistent endodontic infection may be due to the difficulty in reducing the microbial load below a certain threshold. These microorganisms (isolated or within a biofilm) may be located in the ramifications of the root canal, including isthmus areas.6 According to one micro-CT study, 85% of all molars have isthmus areas.7 Therefore, the presence of difficult access anatomic areas is not an exception, but a rule. The current micro-CT studies require an anatomic pairing before the research itself. It is remarkable that many times the isthmus area is larger than the root canal area. With that in mind, in order to reduce the microbial load below the necessary threshold, it is imperative to thoroughly clean these areas using Volume 10 Number 4

Figure 4: Presence of debris in the buccal and lingual areas of a distal mandibular molar after the use of NiTi rotary files

irrigation combined with some type of agitation process (mechanic, sonic, ultrasonic, or laser agitation). Besides the clinical diagnosis and the case planning, knowing the root canal morphology and its many potential variations is fundamental to achieving success in endodontic treatment.8 When dealing with C-shaped canals, rotary and reciprocating instruments can easily shape the canals, which can then be cleaned and disinfected with the appropriate irrigating solutions. But many research papers have shown that mechanical preparation does not contact the entire canal system.1-3,9-11 On top of that, during preparation the debris produced when cutting the dentin walls of the canal

are pushed inside lateral canals and isthmus areas (Figure 3). The problem is quite clear: The vast majority of root canals do not have a simple anatomy. There is a high occurrence of flattened and oval-shaped canals, especially in mandibular molars; and the available rotary/ reciprocating systems cut dentin in a conical shape, leaving a considerable percentage of untouched areas.1-3

Presence of isthmus With the exception of upper anterior teeth, the isthmus is a common anatomic structure in human teeth. The isthmus can be described as a small horizontal groove that unites two root canals and can run all the way to the root Endodontic practice 29


Figure 2: MEV image from a diamond-coated ultrasonic tip

CONTINUING EDUCATION or be limited to the coronal or mid portion of the canal, or even be present only at the apical portion. The isthmus is an area difficult clean and decontaminate with mechanical preparation due to its perpendicular position to the file, and it can have a major impact in the success of a root canal treatment.5,8 In a clinical study,12 1,400 teeth from 618 patients were evaluated using cone beam computed tomography. The study demonstrated that 87.9% of mandibular molars have isthmus present (Figure 4). A high prevalence of isthmus areas means the practitioner must pay special attention during the preparation of mandibular molars. The use of ultrasonics and optical magnification is a fundamental tool to locate, identify, and clean this intricate anatomy. Besides the high percentage of isthmus areas in mandibular molars, another clinical difficulty is the presence of a third canal in the mesial root, the middle mesial canal. This canal is located between the mesiobuccal and mesiolingual canals. The entrance point for the middle mesial canal is very hard to find without the use of magnification; however, in studies using the operative microscope, the canal was found in 46% of the investigated molars.13 The instrumentation, either manual or mechanized, is restricted by the main canal diameter, having little or no effect on flattened areas and twists/curvature of the root canal. Specially designed ultrasonic instruments allied to ultrasonic cavitation can favor the treatment inside flattened regions — raising the percentage of touched wall areas by the activated irrigants and performing a thorough cleaning without promoting excessive loss of tooth structure.

2. Once the isthmus is visible through magnification, initiate its cleaning using a thin tip such as the E18D diamond-coated ultrasonic tip (Helse Ultrasonic, Santa Rosa de Viterbo, Brazil) or the UCT-1 diamond-coated ultrasonic tip (Vista Dental, Racine, Wisconsin) or the BUC-1A (Kerr Dental, Orange, California). 3. In addition to cleaning this area, we must look for the middle mesial

canal, which is generally located closest to the mesiolingual than to the mesiobuccal canal. 4. Once the entrance is found, prepare the canal with carbon steel hand files, since they have a proper stiffness for this situation. A No. 6 carbon steel file is ideal for initial exploration of the canal due to its greater stiffness compared to a stainless steel file of the same size.

Protocol to prepare the mesial root canals in mandibular molars (Figure 5) 1. After preparing the mesiobuccal and mesiolingual canals, remove the dentin over the isthmus using a diamondcoated ultrasonic tip. This procedure is best accomplished with a thick cone, pear, or sphere-shaped tip.

Figure 5: Micro-CT showing high prevalence of flattened canals and isthmus areas 30 Endodontic practice

Figure 6: A. Diagnostic X-Ray kindly provided by Dr. Tiago Braga; B. Image taken after access surgery showing the mesiobuccal, mesiolingual, and distal canals already prepared; C. Middle mesial canal entrance located using an pear-shaped diamondcoated ultrasonic tip; D. Middle mesial canal after bio-mechanical preparation; E. Final X-ray showing preparation for a post in the distal root; F. Inverted X-ray image. Volume 10 Number 4

After having prepared the distal root using rotary or reciprocating files, use an ultrasonic tip to clean the buccal and lingual walls, touching every area that hasn’t been cleaned by the files. This procedure is better accomplished with a thin diamond-coated tip (examples: E2D diamond-coated ultrasonic tip, Helse Ultrasonic, Santa Rosa de Viterbo, Brazil; CKT2 Diamond, diamond-coated ultrasonic tip, Excellence in Endodontics, San Diego, California; or CPR-2D ultrasonic tip Kerr Dental, Orange, California). The basic idea is using the ultrasonic tips to remove debris and dissociate biofilm in the areas left untouched by conventional instruments, allowing a greater penetration of the irrigating solutions (Figure 6).

Apical region According to van der Sluis, Versluis, and Wesselink,14 using ultrasonic activated irrigation to clean the root canal system, including the apical region, is as effective as a K-file when dealing with curved canals, provided that a properly designed ultrasonic tip is used, one that is flexible enough to go 2 mm short of the working length. That way, the irrigation solution can be pushed into the isthmus areas, thus removing dentin debris, tissue remains, and biofilm. The application of ultrasonic energy to agitate the irrigating solution has shown great effectiveness to clean isthmus and other difficult access areas.15,16 The E1 Irrisonic™ ultrasonic tip (Helse Ultrasonic, Santa Rosa de Viterbo, Brazil, Figure 8) and the IrriSafe™ ultrasonic tip (Satelec Acteon, Figure 9) were especially developed to activate the irrigation solution in the whole root canal system, including the apical region. The agitation of the irrigation solution must be done with the ultrasonic hand piece placed by the buccal side of the tooth. That will help to enhance the cleaning process, since it will follow the isthmus anatomy.17 Recommended ultrasonic activation protocol: 1. Fill the canals and the chamber with 17% EDTA solution and activate with the ultrasonic tip for 15 seconds. 2. Rinse the canal with water, apply suction, and then refill the canals and the chamber again with sodium hypochlorite, and activate the solution with the ultrasonic tip for 15 seconds. 3. Repeat steps 1 and 2 until the solution in the chamber remains clear Volume 10 Number 4

Figure 7: A. Flattened distal canal of a mandibular molar; B. Same tooth after preparation using rotary instruments; C. Note the red line over the area left untouched by the rotary files; D. Same canal after using an E18D diamond-coated ultrasonic tip (Helse Ultrasonic, Santa Rosa de Viterbo, Brazil.) (Alternative tips: CPR-4D ultrasonic tip, Kerr Dental, Orange, California or UCT-1 ultrasonic tip, Vista Dental, Racine, Wisconsin)

Figure 8: E1 Irrisonic ultrasonic tip

Figure 9: IrriSafe ultrasonic tip

(absence of cloudiness related to debris). The ultrasonic agitation can also be applied to calcium hydroxide (CaOH2) paste in order to potentiate its penetration into the dentinal tubules and accessory canal anatomy, raising the alkalinity and resulting in better asepsis.18,19 The same ultrasonic tip is recommended to disperse the CaOH2 paste. Calcium hydroxide paste activation protocol: 1. Fill the root canal with the calcium hydroxide paste and agitate it with the ultrasonic tip for 30 seconds in the buccal-lingual direction. 2. Fill the root canal with additional paste and agitate it for another 30 seconds, this time in the mesial-distal direction.

3. If necessary, repeat steps 1 and 2. The ultrasonic unit can also be used to agitate the obturation sealer, to do lateral condensation, and to cut the gutta percha cone. The agitation of the sealer results in a greater penetration into dentinal tubules and accessory anatomy and promotes a higher adhesion of epoxy and MTA-based sealer.20,21 To perform lateral condensation using ultrasonics, it is necessary to choose an ultrasonic tip with the ability to thermoplasticize gutta percha. These tips also create room for accessory cones, enhancing the obturation homogeneity. Finally, a cylinder-shaped ultrasonic tip like the E10 ultrasonic tip (Helse Ultrasonic, Santa Rosa de Viterbo, Brazil) or the CT4 ultrasonic tip (Vista Dental, Racine, Endodontic practice 31


Protocol to prepare the distal root in mandibular molars

CONTINUING EDUCATION Wisconsin) is recommended for cutting the obturation cones at the canal entrance level.

Protocol to activate the obturation sealer 1. Fill the root canal with obturation sealer using a file or a Lentulo spiral, and agitate it with the ultrasonic tip for 30 seconds in the buccal-lingual direction. 2. Fill the root canal with obturation sealer again, and agitate for another 30 seconds, this time in the mesialdistal direction, and insert the main cone coated in sealer to working length. The ultrasonic tip is activated and inserted into the canal alongside the cone that has been placed to condense the obturation material and create space for accessory cones. 3. When space allows, accessory cones are coated with additional sealer and inserted, then condensed with the ultrasonic tip until the canals are fully obturated. 4. An E10 or equivalent tip is utilized to cut off any cones protruding above the canal orifice.

Figure 10: Root canals where the obturation sealer was activated using an ultrasonic tip and the gutta-percha cones were thermoplasticized also with the aid of ultrasonics

Retreatment Different retreatment techniques have been proposed for endodontic retreatment, including hand files with or without the use of chemical solvents22-24, rotary nickel-titanium systems, reciprocating systems, and adaptive motion systems. However, none of the existing techniques and file systems were able to completely remove the filling material from the canals.22-27 This has been shown to occur mainly in cases with anatomical complexities like oval-shaped and flattened canals27 or presence of an isthmus.28 In this way, several supplementary techniques have been suggested as additional approaches to improve root filling removal during endodontic retreatment, such as the use of ultrasonic tips26,29 and the XP-Endo Finisher (Martensite-Austenite ElectropolishFleX, FKG Dentaire).30 At first, a R1 Clearsonic ultrasonic tip (Helse Ultrasonic; no similar tips found from other manufacturers) can be used to remove gutta percha from the coronal and middle portions of the root canal. The heat produced by the ultrasonic energy is enough to remove the gutta percha during retreatments without the need for solvents. The cone-shaped tip end allows the practitioner to “fish” the already softened gutta-percha mass out of the canal. This method is cleaner and faster than using manual files. Another advantage is related to the canal anatomy, 32 Endodontic practice

Figure 11: A. Pulp chamber after access — regular canal with gutta percha; B. Ultrasonic tip removing the gutta percha from the canal; C. Remaining gutta percha in the apical portion after using the ultrasonic approach

which is kept intact by the ultrasonic tip — it removes filling material without removing dentin (Figure 10). After removing the gutta percha from the coronal and middle portions of the root canal, the remaining obturation inside the apical portion must be removed with an XP-Shaper .04/30 instrument (MartensiteAustenite ElectropolishFleX, FKG Dentaire). The XP-Shaper should be used at 1000

RPMs after having used #10 and #15 manual files, through wide forward and backward rotary movements, in order to remove the gutta percha that is still attached to the canal walls. The instrument tip must go all the way from the coronal to the apical portion. After using the XP-Shaper, perform an abundant irrigation followed by suction. To finalize the gutta percha and cement removal, it is necessary to perform the Volume 10 Number 4

ultrasonic activation of the irrigation solution in order to detach the remaining obturation material that is still holding to the root canal walls. The combination of ultrasonic tips and XP-Shaper instruments allow a much more complete removal of gutta percha and sealer from the main canals and also from the secondary anatomy. Recommended ultrasonic activation protocol: 1. Fill the chamber with EDTA and activate the solution with the ultrasonic tip for 15 seconds. 2. Rinse the canal, apply suction, and then flood it again — this time with sodium hypochlorite — and activate

the solution with the ultrasonic tip for 15 seconds. 3. Repeat steps 1 and 2 until all of the existing gutta percha and sealer has been removed. 4. Check for any gutta-percha remains. 5. If there are gutta-percha remains, they can be removed using a thin tip like the E18D diamond coated ultrasonic tip (Helse Ultrasonic, Santa Rosa de Viterbo, Brazil) or the BUC-1A ultrasonic tip (SybronEndo, Orange, USA). These tips or their equivalents, because of the reduced diameter, are more likely to penetrate difficult access regions.

REFERENCES 1. Paqué F, Balmer M, Attin T, Peters OA. Preparation of oval-shaped root canals in mandibular molars using nickel-titanium rotary instruments: a micro-computed tomography study. J Endod. 2010;36(4):703-707. 2. Siqueira JF Jr, Alves FR, Almeida BM, de Oliveira JC, Rôças IN. Ability of chemomechanical preparation with either rotary instruments or self-adjusting file to disinfect oval-shaped root canals. J Endod. 2010;36(11):1860-1865. 3. Peters OA, Boessler C, Paqué F. Root canal preparation with a novel nickel-titanium instrument evaluated with micro-computed tomography: canal surface preparation over time. J Endod. 2010;36(2):1068-1072. 4. Villas-Bôas MH, Bernardineli N, Cavenago BC, et al. Micro-computed tomography study of the internal anatomy of mesial root canals of mandibular molars. J Endod. 2011;37(12):1682-1686. 5. Ricucci D, Siqueira JF Jr, Bate AL, Pitt Ford TR. Histologic investigation on root canal treated teeth with apical periodontitis: a retrospective study from twenty-four patients. J Endod. 2009;35(4):493-502. 6. Nair PN. On the causes of persistent apical periodontitis: a review. Int Endod J. 2006;39(4):249-281.

Conclusion An endodontic treatment that fails to remove biofilm in the root canal system is highly likely to become a failed endodontic treatment. Identifying and cleaning difficult access areas and accessory canals is very important to prevent failure and the need for future retreatment. Among all available options, the combination of mechanical files, ultrasonic tips, and magnification is an inexpensive and highly effective way to boost the success rate of one’s root canal treatments. And, when a retreatment is needed, the same combination can be used to remove obturation materials without having the negative side of using solvents. EP

of an ultrasonic file on the cleaning efficacy of passive ultrasonic irrigation. J Endod. 2010;36(8):1372-1376. 18. Duarte MA, Balan NV, Zeferino MA, et al. Effect of ultrasonic activation on pH and calcium released by calcium hydroxide pastes in simulated external root resorption. J Endod. 2012;38(6):834-837. 19. Arias MP, Maliza AG, Midena RZ, Graeff MS Duarte MA, Aandrade FB. Effect of ultrasonic streaming on intra-dentinal disinfection and penetration of calcium hydroxide paste in endodontic treatment. J Appl Oral Sci. 2016;24(6):575-581. 20. Guimarães BM, Amoroso-Silva PA, Alcalde MP, Marciano MA, de Andrade FB, Duarte MA. Influence of ultrasonic activation of 4 root canal sealers on the filling quality. J Endod. 2014;40(7):964-968. 21. Wiesse PEB, Silva-Sousa YT, Pereira RD, et al. Effect of ultrasonic and sonic activation of root canal sealers on the push-out bond strength and interfacial adaptation to root canal dentine. Int Endod J. 2017. 22. Horvath SD, Altenburger MJ, Naumann M, Wolkewitz M, Schirrmeister JF. Cleanliness of dentinal tubules following gutta-percha removal with and without solvents: a scanning electron microscopic study. Int Endod J. 2009;42(11):1032-1038.

7. Fan B, Pan Y, Gao Y, Fang F, Wu Q, Gutmann JL. Three-dimensional morphologic analysis of isthmuses in the mesial roots of mandibular molars. J Endod. 2010;36(11):1866-1869.

23. Roggendorf MJ, Legner M, Ebert J, Fillery E, Frankenberger R, Friedman S. Micro-CT evaluation of residual material in canals filled with Activ GP or Gutta Flow following removal with NiTi instruments. Int Endod J. 2010;43(3):200-209.

8. Carr GB, Schwartz RS, Schaudinn C, Gorur A, Costerton JW. Ultrastructural examination of failed molar retreatment with secondary apical periodontitis: an examination of endodontic biofilms in an endodontic retreatment failure. J Endod. 2009;35(9):1303-1309.

24. Barreto MS, da Rosa RA, Santini MF, et al. Efficacy of ultrasonic activation of NaOCl and orange oil in removing filling. J Appl Oral Sci. 2016;24(1):37-44.

9. Peters OA, Paqué F. Root canal preparation of maxillary molars with the self-adjusting file: a micro-computed tomography study. J Endod. 2011;37(1):53-57.

25. Barletta FB, Rahde Nde M, Limongi O, Moura AA, Zanesco C, Mazocatto G. In vitro comparative analysis of 2 mechanical techniques for removing Gutta-Percha during retreatment. J Can Dent Assoc. 2007;73(1):65.

10. Zhao D, Shen Y, Peng B, Haapasalo M. Root canal preparation of mandibular molars with 3 nickel-titanium rotary instruments: a micro-computed tomographic study. J Endod. 2014;40(11):1860-1864.

26. Bernardes RA, Duarte MA, Vivan RR, Alcalde MP, Vasconcelos BC, Bramante CM. Comparison of three retreatment techniques with ultrasonic activation in flattened canals using microcomputed tomography and scanning electron microscopy. Int Endod J. 2016;49:890-897.

11. Duque JA, Vivan RR, Cavenago BC, et al. Influence of NiTi alloy on the root canal shaping capabilities of the ProTaper Universal and ProTaper Gold rotary instrument systems. J Appl Oral Sci. 2017;25(1):27-33.

27. Crozeta BM, Silva-Sousa YT, Leoni GB, et al. Micro-computed tomography study of filling material removal from oval-shaped canals by using rotary, reciprocating, and adaptive motion systems. J Endod. 2016;42(5):793-797.

12. Estrela C, Rabelo LE, de Souza JB, et al. Frequency of root canal isthmi in human permanent teeth determined by cone-beam computed tomography. J Endod. 2015;41(9):1535-1539.

28. Cavenago BC, Ordinola-Zapata R, Duarte MA, et al. Efficacy of xylene and passive ultrasonic irrigation on remaining root filling material during retreatment of anatomically complex teeth. Int Endod J. 2014;47(11):1078-1083.

13. Azim AA, Deutsch AS, Solomon CS. Prevalence of middle mesial canals in mandibular molars after guided troughing under high magnification: an in vivo investigation. J Endod. 2015;41(2):164-168. 14. van der Sluis LW, Versluis M, Wu MK, Wesselink PR, et al. Passive ultrasonic irrigation of the root canal: a review of the literature. Int Endod J. 2007;40(6):415-426. 15. Burleson A, Nusstein J, Reader A, Beck M. The in vivo evaluation of hand/rotatory/ultrasound instrumentation in necrotic, human mandibular molars. J Endod. 2007; 33(7):782-787. 16. Gutarts R, Nusstein J, Reader A, Beck M. In vivo debridement efficacy of ultrasonic irrigation following hand-rotary instrumentation in human mandibular molars. J Endod. 2005;31(3):166-170. 17. Jiang LM, Verhaagen B, Versluis M, van der Sluis LW. Influence of the oscillation direction

Volume 10 Number 4

29. Fruchi LC, Ordinola-Zapata R, Cavenago BC, Hungaro Duarte MA, Bueno CE, De Martin AS. Efficacy of reciprocating instruments for removing filling material in curved canals obturated with a single-cone technique: a micro-computed tomographic analysis. J Endod. 2014;40(7):1000-1004. 30. Alves FR, Marceliano-Alves MF, Sousa JC, Silveira SB, Provenzano JC, Siqueira JF Jr Removal of root canal fillings in curved canals using either reciprocating single- or rotary multi-instrument systems and a supplementary step with the XP-Endo Finisher. J Endod. 2016;(42) (7)1114-1119. 31. Ma J, Al-Ashaw AJ, Shen Y, et al. Efficacy of ProTaper Universal Rotary Retreatment system for gutta-percha removal from oval root canals: a micro-computed tomography study. J Endod. 2012;38(11):1516-1520.

Endodontic practice 33


The most effective retreatment technique available today combines mechanical instrumentation, magnification, and ultrasonics.

A complete cleaning of the root canal walls can be achieved through the use of ultrasonic tips combined with magnification and after the mechanical removal of gutta percha using NiTi rotary or reciprocating instruments.26,31 Hence, the most effective retreatment technique available today combines mechanical instrumentation, magnification, and ultrasonics.


Surgical treatment of an extensive periradicular lesion: clinical, radiographic, and tomographic outcome after 5 years of follow-up Drs. Maurício Paradella de Camargo, Tiago Braga, Murilo Priori Alcalde, Marco Antonio H Duarte, Rafael de Camargo, and Rodrigo Ricci Vivan look back on a microsurgery with associated modified tissue guide regeneration techniques after 5 years Introduction The aim of endodontic treatment is to treat apical periodontitis caused by infection of the root canal system.1 However, persistent infection can occur after primary or even secondary root canal treatment and could demand apical surgery to remove the infected site, favoring the apical healing.2 Bone defects are mainly caused by trauma, infections, congenital malformations, and post-surgical procedures.3,4 Although the human body has significant repair capacity, in cases of extensive bone lesions, the bone deposition cannot occur completely, forming a scar of fibrosis.2,3 This inadequate tissue growth is caused by the invagination of connective and/or epithelium tissue into the bone-defect area.2,4,5 Guided tissue regeneration (GTR) — using barrier membranes, bone grafts, and/or biomaterials on the bone defect created by infection and/or surgical techniques — has been widely used to avoid the epithelium invagination area and improve the healing of the surgical area.6,7 Currently, the most common materials used for GTR in the surgical procedures are bone replacement

Educational aims and objectives

This clinical article aims to discuss clinical aspects of a microsurgery with associated modified tissue guide regeneration.

Expected outcomes

Endodontic Practice US subscribers can answer the CE questions on page 38 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: •

Identify some causes and possible treatment for bone defects.

Identify some commonly used materials for guided bone regeneration.

Recognize CBCT as a suitable and important tool for diagnosis, treatment planning, pre- and postoperative evaluation, and management of complex periradicular surgery.

Identify some aspects of surgical treatment of a radicular cyst.

Realize that persistent infection can occur after primary or even secondary root canal treatment, necessitating an apical surgery.

grafts, barrier membranes, and host modulating agents such as platelet-rich plasma (GRP).8-11 Platelet-rich plasma is the result of laboratory processing of autologous blood collected in the preoperative period. It consists of a group of polypeptides in which the growth factors released by platelets form a group of biological mediators that regulate important cellular events in tissue repair and/or

Tiago Braga, DDS, MSc, PhD, is a Professor in General Dental Practice, Simulation Laboratory and Clinical Supervisor in the School of Dentistry and Oral Health Griffith University, Australia.

cell proliferation. These include differentiation, chemo taxis, and matrix formation.10-12 CBCT is a suitable and important tool for diagnosis, treatment planning, pre- and postoperative evaluation, and management of complex periradicular surgery.13,14 In addition, CBCT provides a three-dimensional analysis of a periradicular lesion and prevents damage of anatomical structures, which cannot be viewed on two-dimensional images of conventional radiography.13-15 The purpose of this clinical case report is to describe a microsurgery with associated modified tissue guide regeneraton techniques performed to treat an extensive periradicular lesion with a successful clinical, radiographic, and tomographic outcome after 5 years of follow-up.

Murilo Priori Alcalde, DDS, MSc, is a PhD candidate at the of Department of Operative Dentistry, Endodontics, and Dental Materials at Bauru School of Dentistry, University of São Paulo, Bauru, São Paulo, Brazil.

Materials and methods

Maurcío Paradella de Camargo, DDS, graduated from São Franscico University, Bragança Paulista, Brazil. He attended the Araraquara School of Dentistry (FOAR), State University of São Paulo (UNESP) (Araraquara, Brazil) for his specialty, Master and PhD formation in Endodontics. He is Professor of Endodontics and Operating Microscope in ACDC - Campinas, APCD - São Carlos, Grisi Institute - Ribeirão Preto, São Paulo, Brazil.

Marco Antonio H. Duarte, DDS, MSc, PhD, is Head Professor of the Department of Operative Dentistry, Endodontics, and Dental Materials at Bauru School of Dentistry. Rafael de Camargo, DDS, is a Master candidate at the Department of Operative Dentistry, Endodontics and Dental Materials, Ribeirão Preto Dental School of Dentistry, University of São Paulo, Bauru, Ribeirão Preto, Brazil. Rodrigo Ricci Vivan, DDS, MSc, PhD, is Professor of the Department of Operative Dentistry, Endodontics, and Dental Materials at Bauru School of Dentistry. Disclosure: The authors certify that they not have any commercial or associated interests that represent a conflict of interest in connection with the submitted manuscript.

34 Endodontic practice

Case report A 45-year-old male patient came to the dental office reporting a mild pain during palpation on the maxillary right lateral incisor (No. 7) and maxillary right central incisor (No. 8). During clinical exams, there was no swelling or any visual alteration in the region of the maxillary right lateral incisor (tooth No. 7) and maxillary right central incisor (tooth Volume 10 Number 4

Volume 10 Number 4

Figure 1: Periapical radiograph of the persistent periapical lesion after 1 year of root canal treatment 1A. 3D reconstruction of CBCT images. Note the size of the periapical lesion in axial. 1B. and 1C. Sagittal CBCT images. 1D. and 1E. The red lines show the extension of the lesion

Figure 2: The case after the enucleation of the periapical lesion, apicectomy, and retropreparation. 1A. Retrofilling material being performed on the teeth Nos. 7 and 8. 2B. Surgical cavity placement with HA nanoparticle + PLGA+ PRP. 2C. PPP barrier placed on the surgical cavity. 2D. Clinical view after suture procedure with Vycril® 6.0

anesthesia with 3% mepivacaine with epinephrine 1:100,000 (Mepiadre DFL). The incision procedure was performed with a micro blade No. 67, and a full-thickness mucoperiosteal triangular flap was reflected at the base of the papillae, extending from the maxillary right central incisor to the left maxillary right canine. The vertical incision was placed on the distal side of the right maxillary canine. There was no cortical bone loss; thus, the osteotomy was performed with a slow-speed

spherical bur under copious saline solution irrigation. The periapical lesion was completely enucleated, and the granulation tissue was sent to histopathology. The apicectomy was performed on the maxillary right lateral incisor (tooth No. 7) and the maxillary right central incisor (tooth No. 8) with drill 699 under saline irrigation. A retrograde cavity preparation of the teeth was done with 5 mm of extension using a Berutti ultrasonic tip (EMS [Electro Medical System], Switzerland). The surgical cavity and the root canals were placed with Endodontic practice 35


No. 8 ) (Figure 1A). After the clinical examination, the periapical radiographic exams detected the presence of a periapical lesion involving the previously reported teeth. The cold-thermal pulp test (Roeko Endo Frost, Langenau, Germany; Coltène/Whaledent Inc., Cuyahoga Falls, Ohio, USA) gave a nonvital result for both teeth, and periapical percussion and palpation tests indicated sensitivity. Root canal treatment was performed with a crown-down technique using rotary system files, and irrigation was performed with 2.5% of sodium hypochlorite (NaOCl) through a 30 gauge needle (NaviTip®) (Ultradent, South Jordan, Utah) coupled to a 5 ml disposable syringe (NaviTip). After the root canal preparation, ultrasonic activation with 17% EDTA and 2.5% NaOCL solutions was performed 3 times for 20 seconds in each tooth. Afterward, the root canals were dried, and an intracanal dressing with calcium hydroxide paste (Biodinâmica, Ibiporã, PR, Brazil) was used, and the teeth were coronally sealed with Coltosol® (Coltène/Whaledent Inc., Cuyahoga Falls, Ohio, USA) and composite. After 21 days, the intracanal dressing was removed by copious irrigation with saline solution, the root canals were dried, and the obturation was performed using gutta-percha points and AH Plus® (Dentsply Maillefer, Tulsa, Oklahoma, USA) with lateral compaction technique, and the coronal sealing was performed with composite resin. After 12 months of follow-up, the symptoms disappeared; however, the periapical lesion was not healed (Figure 1B). Thus, the patient was then recommended for endodontic microsurgery. A CBCT (i-CAT™ [voxel dimension 0.2 mm]; Imaging Sciences International, Hatfield, Pennsylvania) was requested due to the dimension of the periapical lesion. The CBCT images showed an extensive periapical lesion involving the mesial portion of the maxillary central right incisor (tooth No. 8) until the mesial portion of the maxillary right canine (tooth No. 6) (Figures 1C and 1D). In addition, substantial bone loss was observed in the buccal-palatal direction without cortical bone loss. In the clinical examination, there was no buccal or palatal swelling. The decision was made to proceed with endodontic surgery. Fifteen minutes before the surgery, the biochemist specialist collected 35 ml of the patient’s blood to process the PRP. For extraoral antisepsis, 2% chlorhexidine was used and local

CONTINUING EDUCATION methylene blue 0.005% (DMC Brazil; DMC USA, Plantation, Florida), and photodynamic therapy was applied. The methylene blue was removed with copious saline solution irrigation, and the canals were dried with sterile paper points and retrofilled with Sealapex™ sealer (Kerr Dental, Orange County, California) mixed with MTA (ProRoot® MTA, Dentsply Maillefer, Tulsa, Oklahoma, USA) (Figure 2A). To prevent an undesirable fibrous repair, the PRP was mixed with hydroxyapatite nanoparticle + Lactic acid-co-glycolic acid (PLGA) (DMC Brazil; DMC USA, Plantation, Florida), and the surgical cavity was completely filled (Figure 2B). In order to protect the filling material, a membrane of platelet-poor plasma (PPP) was used on top of it (Figure 2C). The flap was repositioned after incising the periosteum at the base of the flap to obtain tension-free closure, and a suture was performed with VICRYL® 6.0 (Ethicon) (Figure 2D). For all procedures, a range of 3x to 25x magnification was used. The histopathology results confirmed the presence of a radicular cyst. The clinical and radiographic assessment 5 years postoperatively confirmed a stable outcome (Figures 3A and 3B). CBCT showed the presence of the bone graft filling the surgical cavity (Figures 3B and 3C). The tissue appeared well integrated, and a similar radiopaque and granular is compared with the adjacent bone.

Results and discussion Nonsurgical endodontic treatment should be the first choice of a persistent apical periodontitis.16 However, the treatment can fail because of intra- and/or extraradicular infections.1,2 The persistence of an infection concurs to the development of a radicular cyst.2,3,17 Although, in most cases, small cystic lesions repair after endodontic treatment, in the large lesions, an apical surgery may be needed.18,19 The histopathological examination confirmed the presence of radicular cyst, which explains the non-resolution after 1-year post-endodontic treatment and supports the surgical intervention. The surgical treatment of a radicular cyst involves the debridement of granulation tissue, apical root resection, and retro filling of root apex.18-20 The retro filling was performed using the Sealapex mixed with MTA ProRoot. The Sealapex, a calcium hydroxide-based root canal sealer, can also be used as root-end filling material. However, it is recommended to incorporate 36 Endodontic practice

Figure 3: 3A. Clinical image of the patient after 5 years of follow-up. 3B. Periapical radiograph of the patient after 5 years of follow-up, showing absence of periapical lesion. 3C. and 3D. Axial and sagittal CBCT images. Both show the suitable healing of the periapical tissues

zinc oxide to provide better consistency and facilitate the clinical use.21,22 In this case, we used the Sealapex mixed with MTA to promote slight periapical inflammation, presence of fibrous capsule, and formation of new cementum in many cases.22,23 CBCT showed a satisfactory periapical healing, and the radiographic examination showed periodontal space formation. The bone repair after apical surgery depends on the blood clot, angiogenesis of vessels, source of undifferentiated cells, space maintenance, and stability of the wound.24 Currently, GTR with the use of barrier membranes, bone grafts, and/ or biomaterials to fill the bone defects has been widely used to improve the healing of surgical area.6-8 Synthetic calcium phosphate ceramics, HA, and tricalcium-phosphate are biocompatible and have a composition and structure similar to the mineral part of bone tissue. These materials have been used to fill bone defects due to their osteoconductive action.7-9 Regular ceramics have low tensile strength; thus, the association of HA dispersed on support substrate is indispensable.25 In this case, we combined PLGA with HA to fill the bone surgical defect. Previous studies reported that the association of the PLGA with HA increases mechanical properties, reduces degradation of the copolymers, helps maintain pH, increases the

absorption of proteins, and improves the adhesion and growth of osteoblasts inside these hybrid frameworks.26,27 The PRP favors fibrin formation, improving the osteoconduction of the bone graft.11,28,29 Marx, et al.,20 showed that association of bone grafts with PRP increases 50% in the consolidation and mineralization and with an improvement of 15% to 30% in the density of the trabecular bone as a result of its osteoprogenitor properties. In this case, the surgical bone defect was filled with PRP + HA + PLGA to support the overlying membrane and also potentially as a scaffold to favor the osteoconductive properties for new bone formation. Resorbable membranes have been used as a barrier to provide a wound stabilization after apical surgery, which can provide a wound stabilization during 6 to 8 weeks.9,31 In this case, the PPP gel was used as an alternative to conventional membranes. Previous studies showed that PPP is rich in fibronectin, which is known to increase cell proliferation and healing.32,33

Conclusion The apical surgery in combination with GTR and PRP membrane led to a successful clinical, radiographic, and tomographic outcome after 5 years of follow-up, resulting in no gingival resection, the absence of bone defects, and hard tissue formation on the apical tissues. EP Volume 10 Number 4

1. Siqueira JF Jr. Aetiology of root canal treatment failure: why well-treated teeth can fail. Int Endod J. 2001;34(10):1-10. 2. Nair PN, Sjögren U, Figdor D, Sundqvist G. Persistent periapical radiolucencies of root-filled human teeth, failed endodontic treatments, and periapical scars. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1999;87(5):617-627. 3. Nair P. On the causes of persistent apical periodontitis: a review. Int Endod J. 2006;39(4):249-281. 4. Lin LM, Rosenberg PA. Repair and regeneration in endodontics. Int Endod J. 2011;44(10):889-906. 5. Ducheyne P, Mauck RL, Smith DH. Biomaterials in the repair of sports injuries. Nat Mater. 2012;11(8):652-654. 6. Corbella S, Taschieri S, Elkabbany A, Del Fabbro M, von Arx T. Guided tissue regeneration using a barrier membrane in endodontic surgery. Swiss Dent J. 2016:126(1):13-25. 7. Amini AR, Laurencin CT, Nukavarapu SP. Bone tissue engineering: recent advances and challenges. Crit Rev Biomed Eng. 2012;40(5):363-408. 8. Taschieri S, Corbella S, Tsesis I, Bortolin M, Del Fabbro M. Effect of guided tissue regeneration on the outcome of surgical endodontic treatment of through-and-through lesions: a retrospective study at 4-year follow-up. Oral Maxillofac Surg. 2011;15(3):153-159.

periapical surgery: a systematic review. Med Oral Patol Oral Cir Bucal. 2014;19(4):e419-e425. 13. Patel S, Durack C, Abella F, Shemesh H, Roig M, Lemberg K. Cone beam computed tomography in endodontics — a review. Int Endod J. 2015;48(1):3-15. 14. Bornstein MM, Lauber R, Sendi P, von Arx T. Comparison of periapical radiography and limited cone-beam computed tomography in mandibular molars for analysis of anatomical landmarks before apical surgery. J Endod. 2011;37(2):151-157. 15. Huumonen S, Ørstavik D. Radiological aspects of apical periodontitis. Endodontic Topics. 2002;1(1):3-25. 16. Barone C, Dao TT, Basrani BB, Wang N, Friedman S. Treatment outcome in endodontics: the Toronto study — phases 3, 4, and 5: apical surgery. J Endod. 2010; 36(1):28-35. 17. Sagit M, Guler S, Tasdemir A, Akf Somdas M. Large radicular cyst in the maxillary sinus. J Craniofac Surg. 2011;22(6):e64-e65. 18. Martin SA. Conventional endodontic therapy of upper central incisor combined with cyst decompression: a case report. J Endod. 2007;33(6):753-757. 19. Kourkouta S, Bailey GC. Periradicular regenerative surgery in a maxillary central incisor: 7-year results including cone-beam computed tomography. J Endod. 2014;40(7):1013-1019.

9. von Arx T, Al Saeed M. The use of regenerative techniques in apical surgery: a literature review. Saudi Dent J. 2011;23(3):113-127.

20. Bashutski JD, Wang HL. Periodontal and endodontic regeneration. J Endod. 2009;35(3):321-328.

10. Meschi N, Castro AB, Vandamme K, Quirynen M, Lambrechts P. The impact of autologous platelet concentrates on endodontic healing: a systematic review. Platelets. 2016;27(7):613-633.

21. Cunha SA, Rached FJ Jr, Alfredo E, León JE, Perez DE. Biocompatibility of sealers used in apical surgery: a histological study in rat subcutaneous tissue. Braz Dent J. 2011;22(4):299-305.

11. Qiu G, Shi Z, Xu HHK, et al. Bone regeneration in minipigs via calcium phosphate cement scaffold delivering autologous bone marrow mesenchymal stem cells and plateletrich plasma. J Tissue Eng Regen Med. 2017; In press. doi: 10.1002/term.2416.

22. Tanomaru-Filho M, Luis MR, Leonardo MR, Tanomaru JM, Silva LA. Evaluation of periapical repair following retrograde filling with different root-end filling materials in dog teeth with periapical lesions. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006;102(1):127-132.

12. Sánchez-Torres A, Sánchez-Garcés MÁ, Gay-Escoda C. Materials and prognostic factors of bone regeneration in

23. Bernabé PF, Holland R, Morandi, et al. Comparative study of MTA and other materials in retrofilling of pulpless dogs’

teeth. Braz Dent J. 2005;16(2):149-155. 24. Torabinejad M, Watson TF, Pitt Ford TR. Sealing ability of a mineral trioxide aggregate when used as a root end filling material. J Endod. 1993;19(12):591-595. 25. Boyapati L, Wang HL. The role of stress in periodontal disease and wound healing. Periodontol 2000. 2007:44:195-210. 26. Sui G, Yang X, Mei F, et al. Poly-L-lactic acid/hydroxyapatite hybrid membrane for bone tissue regeneration. J Biomed Mater Res A. 2007;82(2):445-454. 27. Tsuruga E, Takita H, Itoh H, Wakisaka Y, Kuboki Y. Pore size of porous hydroxyapatite as the cell-substratum controls BMPinduced osteogenesis. J Biochem. 1997;121(2):317-324. 28. Motta AC, Duek EAR. Synthesis, characterization, and “in vitro” degradation of poly (L-lactic acid-co-glycolic acid), PLGA. Matéria (Rio J). 2006;11(3);340-350. 29. Lozada JL, Caplanis N, Proussaefs P, Willardsen J, Kammeyer G. Platelet-rich plasma application in sinus graft surgery: Part I — Background and processing techniques. J Oral Implantol. 2001;27(1):38-42. 30. Liu Y, Kalén A, Risto O, Wahlström O. Fibroblast proliferation due to exposure to a platelet concentrate in vitro is pH dependent. Wound Repair Regen. 2002;10(5):336-340. 31. Marx RE. Platelet-rich plasma: evidence to support its use. J Oral Maxillofac Surg. 2004;62(4):489-496. 32. Douthitt C, Gutmann JL, Witherspoon DE. Histologic assessment of healing after the use of a bioresorbable membrane in the management of buccal bone loss concomitant with periradicular surgery. J Endod. 2001;27(6):404-410. 33. Simonpieri A, Del Corso M, Vervelle A, et al. Current knowledge and perspectives for the use of platelet-rich plasma (PRP) and platelet-rich fibrin (PRF) in oral and maxillofacial surgery part 2: Bone graft, implant and reconstructive surgery. Curr Pharm Biotechnol. 2012;13(7):1231-1256. 34. Gubina B, Rožman P, Bišcević M, Domanović D, Smrke D. The influence of allogeneic platelet gel on the morphology of human long bones. Coll Antropol. 2008;38(3):865-870.

844.880.ENDO (3636)

Volume 10 Number 4

Endodontic practice 37





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New resources to mitigate failure in root canal treatment and retreatment CAPELLI, ET AL.


Currently, with the widespread use of nickel-titanium instruments, the shaping process has become faster and safer; however, studies have shown that up to _____ of the canal walls remain untouched during the biomechanical shaping stage. a. 5% b. 10% c. 25% d. 35%



Surgical treatment of an extensive periradicular lesion: clinical, radiographic, and tomographic outcome after 5 years of follow-up CAMARGO, ET AL.

According to one micro-CT study, ______ of all molars have isthmus areas. a. 66% b. 78% c. 85% d. 92%


The entrance point for the middle mesial canal (in mandibular molars) is very hard to find without the use of magnification; however, in studies using the operative microscope, the canal was found in ____ of the investigated molars. a. 15% b. 27% c. 35% d. 46%


Bone defects are mainly caused by _______ and post-surgical procedures. a. trauma b. infections c. congenital malformations d. all of the above Guided tissue regeneration (GTR) — using _______ on the bone defect created by infection and/or surgical techniques — has been widely used to avoid the epithelium invagination area and improve the healing of the surgical area. a. barrier membranes b. bone grafts c. biomaterials d. all of the above


A (ultrasonic) tip is selected for a specific application, according to the ________. a. geometry of the tip b. utilization of the tip c. cost of the tip d. both a and b


The diamond-coated tips have an abrasive effect on dentin and are useful to ________ and to clean isthmus areas. a. remove pulp stones and calcifications b. locate canals c. remove secondary dentin d. all of the above


The agitation of the irrigation solution must be done with the ultrasonic hand piece placed by the ______ of the tooth. a. mesial surface b. buccal side c. labial side d. lingual surface


________ is the result of laboratory processing of autologous blood collected in the preoperative period. a. Platelet-rich plasma b. Humate P c. Fibrin-infused coagulant d. none of the above


Standard tips are mostly used when it is necessary to preserve as much tooth structure as possible, as these cut _______ than diamond-coated tips. a. less aggressively b. more aggressively c. more precisely d. more efficiently


The ultrasonic agitation can also be applied to _______ in order to potentiate its penetration into the dentinal tubules and accessory canal anatomy, raising the alkalinity and resulting in better asepsis. a. EDTA solution b. sodium hypochlorite c. calcium hydroxide (CaOH2) paste d. NiTi instruments



One of the main causes of failed endodontic treatments is the _______, especially inside areas of complex anatomy and lateral canals. a. presence of bacterial biofilm in the root canal system b. use of nickel-titanium instruments c. isthmus and flattened areas d. decalcified nodules

In addition, ______ provides a three-dimensional analysis of a periradicular lesion and prevents damage of anatomical structures, which cannot be viewed on two-dimensional images of conventional radiography. a. panoramic X-rays b. digital X-rays c. CBCT d. transillumination


The agitation of the sealer results in a ________. a. gentler penetration in to the dentinal tubules b. greater penetration into dentinal tubules and accessory anatomy c. promotion of a higher adhesion of epoxy and MTA-based sealer d. both b and c


________ should be the first choice of a persistent apical periodontitis. a. Surgical endodontic treatment b. Nonsurgical endodontic treatment c. Monitoring the situation with no clinical intervention

38 Endodontic practice


Putting the patient on an antibiotic regimen for 6 weeks


The surgical treatment of a radicular cyst involves the _______. a. debridement of granulation tissue b. apical root resection c. retro filling of root apex d. all of the above


These materials (synthetic calcium phosphate ceramics, HA, and tricalcium-phosphate) have been used to fill bone defects due to their _______. a. osteoconductive action b. anti-inflammatory properties c. flexible nature d. color/shade matching capabilities


The PRP favors fibrin formation, ______ the osteoconduction of the bone graft. a. reducing b. delaying c. improving d. impeding


Marx, et al., showed that association of bone grafts with PRP increases _____ in the consolidation and mineralization and with an improvement of 15% to 30% in the density of the trabecular bone as a result of its osteoprogenitor properties. a. 25% b. 30% c. 40% d. 50%


Previous studies showed that PPP is rich in fibronectin, which is known to ______ cell proliferation and healing. a. increase b. decrease c. have no effect on d. inhibit

Volume 10 Number 4




The ULTIMATE Mastery Course for Today’s Endodontic Team Scottsdale, AZ | January 26 & 27, 2018 San Jose, CA June 22 & 23, 2018 Scottsdale, AZ – Maggiano’s Little Italy San Jose, CA – Maggiano’s Little Italy

How does your practice compare?

Want to find out if you are in the top 5%? Fill out a “Practice Analysis” at: To Register or for more information:

Call us at 800-482-7563 or email These seminars sell out fast. Reserve your spot now!

Let me share with you the secrets that I have learned over the past 20 years to help those who have taken this course to increase their net profit by over 100%. I look forward to seeing you,

Dr. Ace Goerig


The Ace Process — more time, more money, and more freedom Dr. Albert (Ace) Goerig discusses the major goals of the Ace Process


ver the past 20 years, there have been many changes in our endodontic technology and the way we treat patients. During the same 20-year period, even with all these changes, profitability has decreased, practices have declined, and endodontists are more stressed than ever. They are still working 4 or 5 days a week with very few real vacations. As an endodontic coach, I have reviewed over 20% of all the endodontists’ numbers in the country during that same time. I have found that in the single-doctor practice, about 80% have an average production between $700,000 and $900,000 with the average net ranging between $300,000 and $450,000 — basically, an overhead of 50%. These endodontists are completing, on an average, three to four cases per day. If they consistently complete seven cases per day, they are in the top 10% of all the endodontists in the country. (To determine your daily case average, divide the number of completed cases done this year by the number of days worked.) When I asked these endodontists to time themselves to see how long it takes to treat a four-canal molar, most of them would say it would take about an hour. Then I asked, If you are working a 9-hour day, why are you not completing nine cases? Some have no answer, but others will say they had too many

cancellations or no-shows; patients who did not need treatment were in treatment slots or too many side bookings and difficult cases. We can deduce from this that efficiency and profitability are less related to clinical technique and more related to office process. By evaluating and changing a few of their office systems, most endodontists could complete an additional two cases per day and take home another $500,000 a year. The Ace Process has been designed specifically for endodontists and their teams to learn how to do more cases per day with less stress. Most of the endodontists I have worked with over the years find it easy to change their systems through this process, resulting in increased office profitability and personal peace for both the doctor and the team while having more time to enjoy life. During this process, many of the doctors reduce the days they work by 20 to 50 days a year. Additional benefits are the doctor and team are less stressed, do better clinical cases, and have fun in the office again.

Looking at the results of our coaching clients in 2016, our doctors earned an average increase in net profitability of $467,893 with the lowest increase of an additional $164,184 to the bottom line. One doctor increased his net profit by almost $1.07 million, resulting in a total net profit of $1,372,624. (See the chart.) It is surprising that these increases did not come from any change in their clinical technique. The average increase above is just two more cases per day. With the right systems and coaching, these doctors found it easier to complete six, seven, or even eight cases a day with less stress than when they were doing only three or four cases per day.

Albert (Ace) Goerig, DDS, MS, is a nationally known speaker who has lectured extensively in his field of endodontics and dental practice management to dentists throughout the United States, Canada, and abroad. He has authored over 60 articles and is a contributing author to the following textbooks: Pathways of the Pulp, Ingle’s Endodontics, and Practical Endodontics. Dr. Goerig is a Diplomate of the American Board of Endodontics and a Fellow of both the American and International College of Dentists. He has been involved in teaching both endodontics and general dentistry residents for many years. He is in private dental practice in Olympia, Washington, specializing in endodontics. In 1996, he co-founded Endodontic Practice Mastery to teach endodontists the business of dentistry while helping them to love their practice. Since then he has personally coached over 22% of all endodontists and their teams in the U.S. and Canada. He is also the co-author of Time and Money: Your Guide to Financial Freedom. He and his wife, Nancy, were married in 1969 and have five children. He has many hobbies, including fishing, scuba diving, skiing, and travel.

40 Endodontic practice

Volume 10 Number 4

䨀唀匀吀 吀䠀䔀 吀圀伀 伀䘀 唀匀⸀⸀⸀ ㈀ⴀ䘀䤀䰀䔀 䔀一䐀伀 䬀䤀吀匀

⠀㄀ⴀ䜀䰀䤀䐀䔀 倀䄀吀䠀 ⬀ ㄀ⴀ匀䠀䄀倀䔀刀⤀ 䜀攀琀 琀栀攀 樀漀戀 搀漀渀攀 猀愀昀攀爀Ⰰ 洀漀爀攀  攀昀ǻ挀椀攀渀琀氀礀Ⰰ 愀渀搀 攀挀漀渀漀洀椀挀愀氀氀礀 眀椀琀栀 樀甀猀琀 琀眀漀 倀爀漀䐀攀猀椀最渀  䰀漀最椀挀 ǻ氀攀猀⸀ 嘀椀猀椀琀 眀眀眀⸀䔀愀猀礀䔀渀搀漀唀匀䄀⸀挀漀洀 昀漀爀 洀漀爀攀 椀渀昀漀爀洀愀琀椀漀渀 愀渀搀  琀漀 瀀甀爀挀栀愀猀攀⸀

Volume 10 Number 4

• Hiring, motivating, and keeping a great team • Designating, creating, and empowering team leaders • Strong internal and external referral marketing • Creating an incredible patient experience • Painless and efficient, quality endodontics • Simplified monitors to track and understand the numbers • Business systems • When and how to bring in the “right” associates. Retiring in practice is the foundation of the Ace Process. This begins with increasing office efficiency to complete two more cases a day ($500k/year), paying off all debt, and bringing in the associate once collections by the owner-doctor reaches $1.4 million per year. At this point, the owner works only 3 days a week, taking 10 to 12 weeks’ vacation each year. With an associate, the practice is always open 5 days

a week, having emergency appointments available every day. This is what the referring dentists want, making the practice highly competitive in today’s endodontic market. The greatest mistake endodontists make is bringing in an associate before collections are $1.4 million per year. If they do, there will not be enough work for the associate, and the associate will leave for better pay. If the owner provides enough patients to the associate when there are not enough patients to fill the owner’s schedule, the owner will see a big drop in his/her personal net income. One of the major goals of the Ace Process is to get a single owner-doctor collecting $1.4 million per year, so he/she can bring in an associate. For some practices this can be done in a year; others may take 2 to 4 years. When this happens, the owner-doctors can have the practice of their dreams, working 130 days a year and securing true personal freedom! EP This information was provided by Endo Mastery.

伀一䔀 䘀䤀䰀䔀 吀伀 刀唀䰀䔀 吀䠀䔀䴀 䄀䰀䰀℀

匀愀瘀攀 琀椀洀攀Ⰰ 挀漀猀琀Ⰰ 愀渀搀 琀漀漀琀栀 猀琀爀甀挀琀甀爀攀 眀椀琀栀 樀甀猀琀 愀 猀椀渀最氀攀 倀爀漀䐀攀猀椀最渀 䰀漀最椀挀 猀栀愀瀀攀爀 ǻ氀攀⸀

嘀椀猀椀琀 眀眀眀⸀䔀愀猀礀䔀渀搀漀唀匀䄀⸀挀漀洀 昀漀爀 洀漀爀攀 椀渀昀漀爀洀愀琀椀漀渀 愀渀搀 琀漀 瀀甀爀挀栀愀猀攀⸀

Endodontic practice 41


Just two additional cases per day provided them with an extra $500,000 per year. These doctors now had the ability to pay off ALL debt within 3 to 5 years, provide higher incomes for their teams, put more toward retirement, donate more to charity, and enjoy more time with their families. If looking at the power of compounding, $500,000 invested every year at 7% over 30 years yields a return of $50,831,000. Not bad for just two more root canals per day. The answer is in the fine-tuning and redesigning the many systems of the practice. Every practice is unique, and each has different problems. The most effective way to determine what systems need to be modified, fixed, or eliminated is through office observation. The following are many of the systems that need to be evaluated and adjusted: • Scheduling and patient flow • Scripting to prevent cancellations, no-shows, and non-treatment • Office communication • How to present and collect fees


SEO: Scam or critical marketing service? Part 1 Ian McNickle, MBA, defines SEO and discusses its importance


he world of online marketing can be quite confusing, if not downright aggravating. It can be challenging to know what to do, how to do it, and who should do it for you. One of the most popular services discussed these days is “Search Engine Optimization” (SEO). Most people understand that SEO is a sort of mysterious service that somehow gets you ranked highly on Google and the other search engines.

“What exactly is SEO?” SEO can be defined as a set of ongoing monthly activities that must be performed in order for your website to rank highly on Google and the other search engines. SEO includes both “on-page” optimization and “off-page” optimization. On-page optimization includes items done on the website itself (code, content, images, videos, sitemap, blogs, etc). Off-page optimization includes items that are on the Internet, but not the website (online reviews, social media, directories, backlinks, etc). So in a nutshell, SEO is some combination of all these things performed each month. Determining which items should be done and how much of each item should be done depends on your goals and local competition.

“I’ve tried SEO and got ripped off!” I frequently lecture all over North America about SEO and many other online marketing topics. If I had a dollar for every time I’ve heard a doctor complain about getting ripped off, I could probably retire. I feel their pain and frustration. It’s real. Hiring an SEO company is kind of like taking your car to the mechanic. You hope they are honest and

Ian McNickle, MBA, is a national speaker, writer, and marketer. He is a Co-Founder and Partner at WEO Media, winner of the 2016 Cellerant Best of Class Award for Online Marketing and Websites. If you have questions about any marketing related topic, please contact Ian McNickle directly at, or by calling 888-246-6906. For more information, you can visit online at

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Receive your free marketing consultation today: 888-246-6906 or good at what they do so you’ll get value for your money, but it is difficult for you to assess that ahead of time (or even afterwards). In my estimation, SEO is indeed one of the most misunderstood services, and therefore, a lot of doctors get taken advantage of when hiring an SEO company. My goal with this article series is to educate doctors and staff to prevent you from getting ripped off, or at least from making bad decisions.

“How does it work?” In order to understand why SEO needs to be done a certain way, it is important to first understand a little bit about how search engines operate. For most average websites, the search engines review your website about every 30 days. When a search engine reviews your website, it actually indexes (reads and stores on its servers) every line of content and code on your website. Each time it does this, it compares all of your code and content to what it indexed 30 days prior and looks for improvements, new content, etc. Search engines also take into account your online reviews (Google, Yelp, Healthgrades, Facebook, etc), as well as social media activity and engagement (Facebook, Instagram, Pinterest, Twitter, You Tube, etc). A well-designed SEO program will involve some combination of many of these activities every month so that each time the search engines index your website and online activity, your practice will be rewarded with

higher rankings (or at least by not dropping in the rankings). SEO takeaway No. 1 — SEO activities must be done every month in order to be rewarded by search engines. If not, your search rankings will plateau or decline.

“How can I tell if I’m getting real SEO?” Google has over 200 variables it evaluates when assigning search rankings to websites. I normally group the most important variables into five major categories: 1) website code, 2) website content, 3) incoming links to the website, 4) online reviews, and 5) social media. In part 2 of our SEO series, we will explore these five major categories, so practices will be able to understand what they need to do (or what their SEO company should be doing) in order to rank highly on Google and other search engines. In part 3 of our series, we will discuss questions to ask when interviewing SEO companies and how to spot scams (and low-end SEO services).

Marketing consultation If you have questions about your website, SEO, social media, or online marketing, you may contact WEO Media for a consultation to learn more about the latest industry trends and strategies. The consultation is free if you identify yourself as a reader of this publication. EP Volume 10 Number 4

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The importance of MTA in endodontics


ndodontics has had important achievements in recent decades. Equipment for this specialty is increasingly sophisticated, providing every day safer, more accurate, and predictable procedures. However, the technology focused on this area does not apply only to equipment and instruments. One of the great findings of dentistry was MTA — aggregated mineral trioxide, a silicate-based sealant. Known as the “Miracle of Endodontics,” MTA emerged in the 1990s, and from 2002, Angelus, a Brazilian company focused on innovation for the dental market, developed and began to manufacture MTA Angelus. Since then, the product has been acknowledged by the market. There are many scientific studies that prove the effectiveness of this material highly compatible with the human body. MTA’s ability to form mineralized tissue can be attributed to its sealing capacity, alkalinity, biocompatibility, or other properties associated with it. It can be successfully applied in several clinical situations such as perforations, root resorptions, and paraendodontic surgeries. Professor Leandro Pereira, Master and Doctor in Pharmacology, Anesthesiology, and Drug Therapy at FOP-UNICAMP, mentions that he had his first contact with MTA in the 1990s and subsequently, due to its geographic location, Campinas/SP-Brazil, started working with MTA Angelus.

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Pereira says, “In every follow-up of cases treated with this material, it was possible to see the clinical and radiographic response with the desired tissue repair even in complex cases.” However, even with so many advantages, an issue bothered the endodontists: manipulating the material. “Its sandy consistency hampers the clinical activity,” reports Pereira, “but just as the evolution of endodontics as a whole, these sealants have also evolved.” To improve this feature, Angelus has developed a new formulation called MTA Repair HP — “High Plasticity.” MTA Repair HP is an endodontic bioceramic reparative sealant of high plasticity, composed of mineral oxides in the form of thin particles. This new formula keeps all chemical and biological properties of the original MTA, ensuring the success of the treatment. The main change is in its physical

manipulation properties as an organic plasticizer was added to the liquid that forms the material. The result is a product with greater plasticity — facilitating manipulation, and insertion in the dental cavity. Moreover, another innovation has been well received by those who already work with MTA Repair HP. Calcium tungstate (CaWO4) replaced bismuth oxide as a radiopacifier in the formula, ensuring high opacity without changing the color or causing any stains on the patient’s tooth. Pereira is very well-known in endodontics and was one of the first professionals to have access to the new MTA. “After the first use of MTA-HP, I’ve made it as my newest material of choice for cases of root perforations and retro-fillings. Its radiopacity is excellent, and it is possible to observe it very clearly radiographically. This material is now an integral part of the endodontics I’ve been practicing.” EP This information was provided by Angelus.

Volume 10 Number 4


Carestream Dental joins with Mercy Ships to deliver dental care to Cameroon Carestream Dental has donated RVG intraoral sensor technology to Mercy Ships for use onboard the Africa Mercy during its next field service to the western African nation of Cameroon. The Africa Mercy is the world’s largest private hospital ship, a 152-meter long former rail ferry, completely refitted, including a 1,200-square meter hospital complete with five state-of-the-art operating rooms. The ship arrived off the coast of Cameroon for its 10-month mission in early September. While thousands of free, life-changing medical procedures will be performed onboard, the dental team will work ashore at a specially prepared clinic to provide cleanings, extractions, restorations, and oral hygiene education to the local population. Since the inception of Mercy Ships in 1978, the dental team volunteers have treated over 147,000 dental patients and have provided over 390,000 dental procedures. The five donated RVG intraoral sensors from Carestream Dental have an excellent image resolution, which provides clear digital images for faster, more accurate diagnoses. The sensors are also equipped with the latest version of Logicon Caries Detector v5.2 software, the only commercially available FDAapproved computer-aided radiographic caries diagnosis software. For more information about Mercy Ships, visit For more information about Carestream Dental’s RVG intraoral imaging systems, call 800-944-6365, or visit

Share your good (endo) news! Submit your press release for consideration to managing editor Mali Schantz-Feld via email at

Volume 10 Number 4

Endodontic practice 45


Continuing the journey Dr. Rich Mounce offers parting thoughts as he concentrates on private practice


his is my final Endospective column. Moving forward, I will be focused entirely on private practice. It’s been a privilege to work with Lisa Moler (the owner of MedMark Media and publisher of Endodontic Practice US) and Mali Schantz-Feld (the managing editor). Endodontic Practice US is clinically relevant, timely, and accessible to GPs and specialists alike. Each issue is loaded with useful information written by passionate clinicians. Count me as a big fan of all the MedMark publications including Implant Practice US. As endodontic clinicians, we live professionally in a very small space, literally a canal sometimes measured in hundredths of a mm. As such, it’s easy to lose track of the larger trends happening outside of our operatories. In no particular order, these are the future opportunities, headwinds, and undercurrents, which in my view currently present themselves. It is hoped that sharing these will spur thought and action by the reader. • Minimally invasive and single file philosophy will ultimately predominate endodontics. How could it not? It simply makes sense. • Heat-treated nickel titanium (NiTi) has become a commodity. This trend will accelerate. We will soon see a day where imported high quality heattreated NiTi costs $10 a box. The days of paying a premium for new and innovative file designs is ending. • Amazon will enter the dental and medical supply market; expect massive disruption and price collapses in current sales channels. • Endodontic education will become more widely available on a global scale via the Internet, but for better or worse, corporations with a vested Dr. Mounce has lectured and written globally in the specialty. He can be reached at Richard, Dr. Mounce has no commercial interest in any companies or products.

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Dr. Rich Mounce with his wife, Laura, and dog, Zinho

commercial interest will disseminate much of this education. The rise of corporate dentistry in the United States will continue unabated; it is dismissed at one’s peril. Private practice, as we know it, will become an ever smaller segment of available dental service. Competition for endodontic referrals will become keener as corporations hold more “in-house.” If Sonendo® develops an efficient obturation technology matching its potential to clean canals, all bets are off as to the future of the specialty. Personally, I’d rather watch paint dry than read the biases, pontificating, and bickering on display on many endodontic message boards. In my travels, I’ve met a lot of young and very confident endodontic residents and a lot of older endodontists who are quite humble and much more risk-averse. Graduating from a residency is a first step, not a destination. Beware the guru; no one has a lock on endodontic technique or wisdom. Follow the money. It is disconcerting to hear and read comments by gurus

speaking on issues and products with which they are entirely unfamiliar. Using ProDesign Logic (Easy Endo USA) as an example, if you haven’t used it clinically, how can one comment pro or con for its utility in single file endo? I use it and love it; it’s magic. • Every developed country in the world has clinicians of the highest caliber. Among many, Drs. Alex Chan (Hong Kong), Gary Glassman (Canada); Charlie Boveda (Venezuela), and Marga Ree (Holland), are all worldclass and not necessarily household names. Consider attending meetings in other countries to catch these and similar top clinicians. • The only thing that ultimately matters is the patient in the chair. Are they comfortable, informed, and cared for as we would our family? Take care of the patient in the chair right now. The rest will take care of itself. • Nurture your health. Preserve your money. Family first. In the end there are no medals for the guy or gal who made the most money or filled the most canals. Enjoy the journey. See you at the Apex. EP Volume 10 Number 4

JUST THE TWO OF US... Get the job done safer, more efficiently, and economically with just two ProDesign Logic les. For Free Samples go to


Five powerful leadership and culture-building statements Dr. Joel C. Small discusses how to cultivate shared values and a common purpose


dgar Schein, a noted authority on the subject of organizational culture, has stated that the primary job of a leader is to establish an organization’s culture. An organizational culture is considered to be the guiding principles that dictate how people work together to achieve a common goal. It has its foundation in shared values and a common purpose as well as other less tangible beliefs and assumptions shared by members of the organization. Schein is not alone in his opinion as other distinguished authorities refer to the undeniable link between leadership and an organization’s culture. The leader is both the architect and the guardian of an organizational culture. Unfortunately, many of us fail to realize that we serve in this capacity and that like it or not, we cannot delegate this vital role that is so essential to organizational health. We have only to observe well-functioning, highly productive clinical practices to substantiate this statement. If we could pull back the curtain, we would find that every successful, highly productive, and well-functioning clinical practice has two essential ingredients — an engaged leader and a strong culture. Having studied and witnessed both effective and ineffective leadership practices in healthcare organizations, I have come to the conclusion that there are certain types of statements that serve to define a strong leader and help build an optimal culture. It is not necessary to use these phrases in their exact form. Please change them to suit your specific comfort zone. My purpose is to present a different style of communication that has been shown to be highly effective in

promoting strong leadership and developing optimal cultures.

“Tell me what you think.” I know of no better way to empower staff and provide them with a sense of relevance than to ask their opinion on important practice-related issues. They not only will feel more a part of the team, but also will be more willing to offer helpful suggestions in the future. We will be more prone to ask for their feedback as well because we will likely find that they have valuable insights. Like my coach often says, “No one is as smart as all of us!”

“I’m sorry. I made a mistake.” I am a firm believer that unless we are willing to be vulnerable, we will never fully realize our leadership potential. We often worry too much about being “right” and fail to acknowledge the importance of being “real.” Our team appreciates that we are knowledgeable, but they also want us to be approachable. A healthy mixture of both is the proper prescription for sound leadership and a healthy culture.

“How can I best support you?” Checking in with team members is an important way to let them know that we care about them and what they are doing. This is also helpful in ensuring that team members feel as though they have received adequate resources and training to complete tasks. Ultimately, we will no longer need to ask. As our team realizes that we are interested in their success, they will willingly let us know what they need to be successful.

Joel C. Small, DDS, MBA, ACC, FICD, is a practicing endodontist and the author of Face to Face: A Leadership Guide for Healthcare Professionals and Entrepreneurs. He received his MBA, with an emphasis in healthcare management, from Texas Tech University. He is a graduate of the University of Texas at Dallas postgraduate program in executive coaching and limits his coaching practice to motivated healthcare professionals. He is a nationally recognized speaker on the subjects of leadership and professional development. Dr. Small is available for speaking engagements and for coaching healthcare professionals who wish to experience personal and professional growth while taking their practices to a higher level of productivity.

“How does this action align with our practice values?” When actions and decisions are aligned with our shared values, our culture is operating at peak performance. Post the practice’s values throughout the office for everyone to see and refer to. (You do have shared values for your practice, right?) Whenever we need to evaluate our actions or decisions, we should ask this question of ourselves and others. There is no greater form of accountability than living our values.

“No one is perfect, including you and me.” Mistakes will happen. What is important is to determine the intent. If someone has the right intention but makes a mistake, we have an incredible opportunity to show what leadership and culture is all about. This is a time to soothe the pain rather than demean the person. By accepting a well-intended misstep, we are then able to create a powerful teachable moment by asking a critical question: “What did you learn from this?” I can almost guarantee that you will notice significant positive change in your staff’s attitude and performance if you become comfortable using these phrases. How do I know that communicating in this manner is effective? I know this because this form of communication is the foundation of executive coaching and has a long and proven track record for achieving results. Currently, I am working on a program designed to bring a coaching culture to clinical healthcare practices. The concept is to train healthcare professionals in basic coaching concepts, so they can improve their leadership skills and create a strong vibrant culture in their practice. Expect to hear more about this in the near future. *If you have not already defined your practice values, please contact me and I will send you a step-by-step practice value exercise. EP

*To receive a free copy of my “Core Values Exercise,” please contact me at I am also available for a complimentary coaching session to discuss your practice-related issues.

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Volume 10 Number 4

The Power is On January 2018

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Endodontic Practice US Winter 2017 Vol 10 No 4  
Endodontic Practice US Winter 2017 Vol 10 No 4