Endodontic Practice US Summer 2022 Vol 15 No 2 by MedMark, LLC

Summer 2022 Vol 15 No 2

USEndoPartners.com/podcasts

4 CE Credits Available in This Issue*

endopracticeus.com

Blueprint for the future

Northern Colorado Endodontics

CBCT — recognizing anatomic structures before implant surgery Dr. John Pasicznyk

Reduce stress by monitoring reviews Dr. Mehmood Asghar

Managing controlled substances in dental practice

Tyler Dougherty, PharmD, et al.

the

PODCAST

Deep dives and unexpected conversations with the top names in Endo.

New Endo Files episodes streaming now.

Implants

PROMOTING EXCELLENCE IN ENDODONTICS The Spirit of US

Say Hello to ™ CleanFlow Simpler for you. Better for your patients.™

Introducing the GentleWave® Procedure with CleanFlow™ Technology CleanFlow™ facilitates single-handed cleaning and disinfection of the root canal system from outside the tooth.

To learn more, scan here or visit

sonendo.com/cleanflow

© 2022 Sonendo, Inc. All rights reserved. SONENDO, the SONENDO logo, SAVING TEETH. IMPROVING LIVES., GENTLEWAVE, the GENTLEWAVE logo, CLEANFLOW and SIMPLER FOR YOU. BETTER FOR YOUR PATIENTS. are trademarks of Sonendo, Inc. Patented: sonendo.com/intellectualproperty. 22SON117 MM-1622 Rev 01

INTRODUCTION

Summer 2022

Volume 15 Number 2

Editorial Advisors 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 Stephen Cohen, MS, DDS, FACD, FICD Samuel O. Dorn, DDS Josef Dovgan, DDS, MS Luiz R. Fava, DDS Robert Fleisher, DMD Marcela Fridland, DDS Gerald N. Glickman, DDS, MS Jeffrey W Hutter, DMD, MEd Syngcuk Kim, DDS, PhD Kenneth A. Koch, DMD Gregori M. Kurtzman, DDS, MAGD, FPFA, FACD, DICOI Joshua Moshonov, DMD Richard Mounce, DDS Yosef Nahmias, DDS, MS David L. Pitts, DDS, MDSD 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 West, DDS, MSD CE Quality Assurance Board Bradford N. Edgren, DDS, MS, FACD Fred Stewart Feld, DMD Gregori M. Kurtzman, DDS, MAGD, FPFA, FACD, FADI, DICOI, DADIA Justin D. Moody, DDS, DABOI, DICOI Lisa Moler (Publisher)

A moment deserving of tremendous gratitude

“R

eflect upon your present blessings.” — Charles Dickens As endodontists, we are living in an abundant era! Root canal treatment serves patients globally as the primary treatment to save millions of teeth annually. The research and results prove that endodontic treatment is safe and effective. Today we have so many modernizations in our specialty to help us provide the best possible care to our patients. Our predecessors, who paved the way for us, would be astounded by the advances we have at our disposal. Technology has absolutely expanded our capacity to save teeth with flexible and strong instruments, digital radiology, microscopes, 3D imaging with CBCT, guided navigation, biocompatible materials, long-lasting restorative materials, advanced irrigation solutions, innovative and disruptive irrigation delivery devices, and more. Couple our advanced skills and knowledge with technology, and our patients WIN. Social media has also advanced our abilities and knowledge. With so many endodontists communicating and sharing together via social media channels, online groups, and education platforms, we are learning together and growing as a global endodontic community. Our ability to develop, foster, and enjoy new connections and relationships with colleagues around the world enhances our practices and enriches our lives beyond what was previously possible. New graduates now have unprecedented access to experienced colleagues who are graciously sharing their cases, knowledge, and experience on how to approach a myriad of case scenarios. With these communication advances, our collective passion for practice and teaching grows, and the next generation of practitioners starts their careers with more resources, mentors, and motivation to pay the knowledge base forward over time. The pandemic also created an incredible moment in our specialty, which called us into duty to serve and support healthcare systems around the world. Who could have imagined that endodontists would be primed to serve as front-line defenders to support a massive surge and strain on hospitals in the early months of the pandemic? As a specialty, we strapped on our PPE and went to work serving patients with dental emergencies to prevent them from going to overburdened emergency rooms. Personally, I was terrified at what we did not yet know about the virus. However, along with my global endodontic colleagues, we did not close our offices and went in each day to serve our communities. When duty called, endodontists answered! Finally, new partnership opportunities to align our private practices have blossomed into reality. The chance to partner our practices with other practices has created a unity and strength for endodontists to own their futures both personally and professionally. By joining forces, we can share best practices, gain valuable business support, and provide new grads with outstanding mentorship opportunities. We, as a collective team of endodontists, can shape and protect the future of our specialty. Replace the vulnerability of owning a small business with the strength and security of joining a team. We are an integral part of a moment deserving of tremendous gratitude.

Mali Schantz-Feld, MA, CDE (Managing Editor) Lou Shuman, DMD, CAGS

© MedMark, LLC 2022. 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.

ISSN number 2372-6245

Brett E. Gilbert, DDS, graduated from the University of Maryland Dental School in 2001 and completed his postgraduate training in endodontics from the University of Maryland Dental School in 2003. He is currently a clinical assistant professor in the Department of Endodontics at the University of Illinois Chicago, College of Dentistry and on staff at Presence Resurrection Medical Center in Chicago. He is a past president of the Illinois Association of Endodontists. Dr. Gilbert is Board-certified, a Diplomate of the American Board of Endodontics. He was named a top ten young dental educator in America by the Seattle Study Club in 2017. In 2019, he was named to Academic Keys Who’s Who in Dentistry Higher Education (WWDHE). Dr. Gilbert lectures nationally and internationally on clinical endodontics. He has a full-time private practice limited to Endodontics in Niles, Illinois. Dr. Gilbert is a partner in US Endo Partners. He can be contacted online at www.drbrettgilbert.com.

endopracticeus.com

Volume 15 Number 2

TABLE OF CONTENTS

PUBLISHER’S PERSPECTIVE

A little bit of summer Lisa Moler, Founder/CEO, MedMark Media............................... 6

COVER STORY

Blueprint for the future Northern Colorado Endodontics

Cover image of Drs. Bergo, Dimond, Geraets, and LeValley courtesy of US Endo Partners.

CLINICAL

Use of bioceramics in conventional endodontic treatment associated with endodontic surgery of teeth with extensive periapical lesions

Stefanya Dias de Oliveira, Artur Henrique Cabral, Danielly Davi Correia Lima, Alexia da Mata Galvão, Dr. Gabriella Lopes de Rezende Barbosa, Larissa Rodrigues Santiago, and Dr. Maria Antonieta Veloso Carvalho de Oliveira show how bioceramics help the healing process Endodontic Practice US

Volume 15 Number 2

CONTINUING EDUCATION

CBCT — recognizing anatomic structures before implant surgery Dr. John Pasicznyk discusses implants and how CBCT can help endodontists with treatment planning............................................ 18

CONTINUING EDUCATION

Remember when you had time to transform patients’ lives? HighFive clears those monotonous business and administrative tasks from your plate, so you can get back to what matters.

Team Approach We operate as a family! Our goal is for every patient to have the best experience in all of our practices. Our open, fun and collaborative culture creates an innovative approach to operations, quality and buying power.

Practice Management

With cloud-based solutions at our fingertips, we convert systems, communications, best practices and corporate backend procedures into metrics that track gaps and opportunities within your business.

The Digital Experience From online appointment scheduling to check out, we leverage tech innovation to make the patient experience easy, streamlined and secure.

Our formula for success starts by not thinking of people as part of a formula. Contact us for a preliminary chat: www.high5health.com

TABLE OF CONTENTS

ENDOSPECTIVE

The business of healthcare Dr. Robert M. Fleisher discusses advertising, ethics, and professionalism................................. 32

SERVICE PROFILE

It takes a team to be your best PRACTICE MANAGEMENT

An interview with William B. Looney, DMD, a HighFive Partner.................. 34

PRODUCT PROFILE

MANI JIZAI NiTi File System JIZAI can be translated from

Reduce management stress by monitoring reviews Dr. Mehmood Asghar suggests ways to manage your practice’s reputation

Japanese to mean “being at will” .............................................................. 36

PRODUCT SPOTLIGHT

Using bioactive bioceramics to heal dens evanginatus

SMALL TALK

Dr. Rico D. Short discusses dens

Drs. Joel C. Small and Edwin

evaginatus treatment with a

McDonald describe a powerful

combination of two bioactive

motivator that drives positive

bioceramic products.....................38

change................................................. 39

What is creative tension? Why does it matter?

SERVICE PROFILE

US Endo Partners Building culture delivers financial returns............................................. 40

*Paid subscribers can earn 4 continuing education credits per issue by passing the 2 CE article quizzes online at https://endopracticeus.com/category/continuing-education/

www.endopracticeus.com READ the latest industry news and business WATCH DocTalk Dental video interviews with KOLs LEARN through live and archived webinars RECEIVE news and event updates in your

inbox by registering for our eNewsletter

CONNECT with us on social media Connect. Be Seen. Grow. Succeed. | www.medmarkmedia.com

Endodontic Practice US

Volume 15 Number 2

BY YOUR SIDE

NEW!

ALL-IN-ONE IRRIGATION SOLUTION Unlike traditional irrigants or other advanced 2:1 solutions, Triton works differently by avoiding using EDTA and CHX altogether. ✓ Multi-functional single irrigation solution reduces chair time, procedural steps, and overall irrigation costs ✓ Simultaneous organic and inorganic debris removal ✓ Patent-pending composition allows for a lower concentration of NaOCl to be used while also delivering improved efficacy ✓ More effective at smear layer removal vs. NaOCl with EDTA† ✓ Dissolves organic tissue up to 1.7x faster than traditional NaOCl‡

It’s time to simplify your irrigation protocol. Learn more at BrasselerUSA.com/Triton.

† https://bit.ly/TritonResearchSummary ‡ https://bit.ly/TritonDHF

B-5557-EP-06.22

PUBLISHER’S PERSPECTIVE

A little bit of summer Published by

hile writing my message for this summer issue, John Mayer’s song “Wildfire” started playing on the radio. It started me thinking about what summer means. The song says, “… a little bit of summer is what the whole year’s all about.” After the past 2 years of rethinking, regrouping, and reopening, we’ve all worked so hard to get back to business. Working hard is what dentists do best — outfitting the office with the best equipment, taking continuing education courses, and learning new management techniques to keep the offices running smoothly. All the while keeping patients happy and offering the best Lisa Moler dental care. Throwing your practice into high gear takes lots Founder/Publisher, MedMark Media of energy and diligence. But we also must remember to take a step back and at least for a little while, enjoy some of the joys of summer. An article in Forbes titled, “The Evolving Definition of Work-Life Balance,” says that “maintaining work-life balance helps reduce stress and helps prevent burnout in the workplace.” The article continues, saying that stress is one of the most common health issues in the workplace, leading to high blood pressure, stomach issues, aches, pains, and heart problems. Emotionally, stress can lead to depression, anxiety, insomnia, irritability, and low work performance.1 Balance means different things to different people. To alleviate stress, some people just like to spend some quality time with family or friends; some want to hop back on that cruise ship; and others like to hit the hiking trails and commune with nature. Whatever brings a smile to your face will keep summer in your heart and mind for the rest of the year. Take us with you! Whether you are on vacation or on your backyard deck, you can still consider new concepts to bring back to your office. Whether you read our publications in print, on your laptop, iPad, or phone, our articles are meant to inform, intrigue, and inspire you to new techniques, products, and services that promote success. The Cover Story in our summer issue focuses on Northern Colorado Endodontics, its stance on growth and technology and joining forces with US Endo Partners, a Specialty Dental Service Organization. The CE by Dr. John Pasicznyk takes a look at CBCT scans and how this imaging modality can be utilized in making treatment decisions for implant therapy. Stefanya Dias de Oliveira and colleagues illustrate the use of bioceramics to help the bone-healing process during treatment of extensive periapical lesions. How do you know when to take a step back so that you can continue moving forward? Here are a few tips: • Be aware of your feelings. If you start to feel more sad or grouchy than energized and content, it’s time to figure out why. • Consider your priorities. What is most important to you in life? Do you need more time for yourself, friends, family, or just your pet? • Don’t be afraid to change. Once you decide on a plan — do it! Change or rearrange your office duties to help create a calmer or more effective workplace. We love our work. But we also have to remember to include a bit of play. At work, you are changing lives, and at play, you are making memories. We need to rest and rejuvenate to create. John Mayer’s lyrics sum it up so well — “a little bit of summer makes a lot of history.” To your best success!

Kohll A. The Evolving Definition of Work-Life Balance. Forbes. March 27, 2018. Accessed April 21, 2022. https:// www.forbes.com/sites/alankohll/2018/03/27/the-evolving-definition-of-work-life-balance/?sh=78c3e10d9ed3.

Endodontic Practice US

Volume 15 Number 2

Publisher Lisa Moler lmoler@medmarkmedia.com Managing Editor Mali Schantz-Feld, MA, CDE mali@medmarkmedia.com Tel: (727) 515-5118 Assistant Editor Elizabeth Romanek betty@medmarkmedia.com National Account Manager Adrienne Good agood@medmarkmedia.com Tel: (623) 340-4373 Sales Assistant & Client Services Melissa Minnick melissa@medmarkmedia.com Creative Director/Production Manager Amanda Culver amanda@medmarkmedia.com Marketing & Digital Strategy Amzi Koury amzi@medmarkmedia.com Digital Marketing Assistant Hana Kahn support@medmarkmedia.com Webmaster Mike Campbell webmaster@medmarkmedia.com eMedia Coordinator Michelle Britzius emedia@medmarkmedia.com Social Media Manager April Gutierrez socialmedia@medmarkmedia.com Operations Manager Teresa Heiler teresa@medmarkmedia.com MedMark, LLC 15720 N. Greenway-Hayden Loop #9 Scottsdale, AZ 85260 Tel: (480) 621-8955 Toll-free: (866) 579-9496 www.medmarkmedia.com www.endopracticeus.com Subscription Rate 1 year (4 issues) $149 https://endopracticeus.com/subscribe/

COVER STORY

Blueprint for the future Northern Colorado Endodontics

uilt on a rock-solid foundation of trust, respect, and philosophical alignment, and stemming from a friendship that began in dental school, the team at Northern Colorado Endodontics has been tapping into the power of partnership for almost 25 years. The four partners practice within three thriving locations in the diverse communities of Fort Collins, Longmont, and Greeley, Colorado, tucked against the foothills of the scenic Rocky Mountains, just north of Denver. But none of that was in the plan until a chance meeting occurred, seemingly out of a movie plot. Founding partners Drs. Shane Bergo and Bradley LeValley lost touch after completing dental school at the University of Iowa in the 1980s. LeValley went off to Marquette University to study endodontics, and Drs. LeValley (foreground), Bergo, Dimond, and Geraets (left to right) with Practice Bergo attended the University of Indiana for his resiManager Norea Schmollinger dency and then did a stint in the Army, including a tour in South Korea. They reconnected unexpectedly at the “It really was that easy,” Bergo said. “We’ve seen a lot of 1996 AAE Annual Meeting in Seattle. other partnerships, even in the dental community here; they try “I remember getting to the hotel and looking at the attendees for a year, and it falls apart. I don’t think we think about things list, and thinking, ‘Brad LeValley — oh, wow,’” Bergo reminisced. in exactly the same way, but just enough to complement each “I called him up, and about two hours later, we were partners.” other.” LeValley and Bergo cite similar upbringings in Iowa, “I think he was stalking me,” LeValley joked with a laugh. mutual personality traits, and a shared philosophy of patient“We met up, and I just happened to have the blueprints for my centered care as binding agents. office in my bag. I rolled them out and said, ‘It’s got four oper“We put the patients first and value being able to get people atories. These two can be yours, and these two can be mine.’” in who are in discomfort. Not everything we see is an emerBergo said he was considering opening a practice in Wiscongency, but I would say most are urgencies. I think we all put oursin but had always loved Colorado because of the opportunities selves in that patient’s shoes and have empathy; that’s probably for outdoor recreation and the family atmosphere; he knew our biggest commonality,” Bergo said. immediately a partnership with LeValley was the right choice Bergo and LeValley also share a common approach of nurfor his future. turing their team members and treating them like family. “We’ve always put a priority on taking really good care of our team because when you find the good ones, you want to hang on to them,” LeValley said. Practice Manager Norea Schmollinger knows that better than anyone, having served the tight-knit, flourishing team with her business savvy and keen attention to detail for more than 20 years. “This place is my first child,” Schmollinger said, gesturing to the lobby of the Fort Collins office. “Starting out with Brad and Shane, we were like brothers and sister. It makes me emotional to think about the growth, and how exciting it’s been, watching this mature into what it is. It’s truly phenomenal. And I love it; I love this place.” Schmollinger said she never believed she would work in one place for so long, and only planned on serving the duo as a receptionist for a couple of years before moving on to pursue Dr. Bradley LaValley and his assistant treat a patient in the group’s Fort Collins, Colorado office other things. Endodontic Practice US

Volume 15 Number 2

COVER STORY

“I was right out of school, having just graduated from the University of Northern Colorado in Greeley,” she said. “Three months in, the office manager suddenly quit, and Shane and Brad just turned to me and said, ‘Do you want it?’ I said, ‘I don’t know what I’m doing, but I’ll try it as long as you’re patient with me; I’ve never managed anything.’ I started, and then the growth — it just grew and grew.” “It was just so comfortable and so easy to be with the guys — I trust them because they are truly phenomenal people. They do everything wholeheartedly; it’s just who they are, and everyone they bring on has the same philosophy,” Schmollinger expounded. Even with a specific work ethic and care philosophy in mind, Bergo and LeValley’s luck of being in the right place at the right time held, and they didn’t have to look far to find the next member of their practice family. Dr. Galen Geraets, then a general dentist and top referrer to Northern Colorado Endodontics, had always the notion to go back to school to study endodontics in order to relieve people of acute pain. He approached Bergo and LeValley, trusted peers and study club cohorts, for a letter of recommendation. They offered not only the letter, but also the promise of partnership. Geraets accepted, and LeValley and Bergo spent the next two years anticipating his return and the opportunity for expansion. “Galen was an excellent dentist, and we knew he was going to be an excellent endodontist,” LeValley said. And as it turned out, the practice would soon need another clinician. Shortly after Geraets’ return to Colorado from Case Western Reserve University in Cleveland, Ohio, the opportunity to acquire the Longmont, Colorado location arose because a peer in the specialty decided to relocate. “The timing just worked out,” LeValley said. “We thought we’d hit the sweet spot and were done.”

With two busy locations and three doctors, Northern Colorado Endodontics had grown as much as it comfortably could. But that didn’t keep the phone from ringing. One short year later, another local colleague in Greeley, Colorado, reached out to LeValley to offer her practice for sale. He told her that he appreciated the offer, but that they had reached capacity for the time being. “But then I hung up the phone and started thinking about it,” LeValley said. “We were already seeing lots of patients from that area — we always had — and some of our referring dentists had been a little disappointed that we hadn’t expanded in that direction. So, I called her right back.” The move to expand access to care in the region was the right thing to do for patients. The offices are strategically placed so that the team can easily cover any location but are spread out by enough distance that patients — even those from neighboring states like Wyoming and Nebraska — can get treatment when needed. Geraets said that reach is particularly important because there aren’t many options for specialty dental services in the Plains. The location growth necessitated the addition of an associate to keep up with the demand. They landed one — an excellent fit — but lost him and his wife to another beautiful

The members of the Northern Colorado Endodontics team consider themselves a family, building relationships over potlucks and parties. Above right: The group from Northern Colorado Endodontics and Ronny Rowell, US Endo Chief Operations Officer (left) at US Endo Partners’ 2021 Vision Summit in Dallas endopracticeus.com

Volume 15 Number 2

COVER STORY

Drs. LeValley, Bergo, and Geraets (left to right) enjoyed sharing their experiences with fellow endodontist in the US Endo booth at AAE22 in Phoenix

mountain town just two years later. But then entered Dr. Colby Dimond, who rounded out the jovial, close-knit band of brothers and their Practice Manager sister. “Someone was looking out for us,” Bergo said. Dimond, a Utah-native, attended dental school at the University of Michigan and completed his residency at the University of Minnesota. “Seeing the camaraderie and the friendship, my wife and I knew immediately it was the right place,” Dimond said. He and his family, now bustling with four young children, were welcomed with open arms. The group has a running joke that they were just as interested in bringing on Dimond’s friendly, personable wife as they were the doctor. “We really do think of ourselves as a family — we probably spend more time together here with this family than we do with our families at home — so we try to keep that in mind,” Schmollinger said. “We have Friday afternoon clubs where we bring in a potluck and stay after to build some camaraderie. We have a big annual Christmas party, we celebrate in the summers, and have barbecues together trying to build team and family connections.” The Northern Colorado Endodontics family has grown to almost 25 team members, many of whom have been on board for years. Together their commitment to patients is evident, as is their stance on growth and staying on the cutting edge of technology. “It was invigorating getting these guys (Geraets and Dimond) in after being in practice for 10-plus years. You can get a little stagnant, even when you read the journals and keep up, so it’s good to get that rejuvenation with younger blood,” Bergo said. Recently, the group took stock of the state of the specialty and began to consider another sort of partnership for further rejuvenation and support, and to future-proof the practice. In 2021, Northern Colorado Endodontics made the leap and joined forces with US Endo Partners, a Specialty Dental Service Organization. US Endo is a national network of growth-minded clinicians, who collaborate to create better outcomes for their patients, partners, and teams, and to advance the endodontic specialty. They focus on sharing best practices and key learnings, challenging one another to push past comfort zones, and encouraging peers to think bigger and to achieve a higher level of success while Endodontic Practice US

Dr. Shane Bergo consults with a patient in the Fort Collins location

feeling invigorated, connected, and content in their careers and at home. “We were very successful, and our model was working well for us, but we saw what was happening with US Endo and the endodontists who were already involved — many of whom we already knew, who were very smart people with the same patient-first mentality,” LeValley said. “It’s a larger resource and a brain trust you can draw from.” Bergo said the value of having a wealth of business specialists looking out for the practice is the key to the next phase of the practice’s growth. “We’re good businesspeople — better endodontists, but good businesspeople. It’s great to get that outside perspective — even things like getting some help looking at the cost of our expendables or help reducing bottom line numbers,” Bergo said. “Eliminating some of those things from our plate allows us to treat more patients, which makes a difference.” Dimond said the business support is not only key for practice operations, but also for his personal life. “It’s been a great decision and might even be more so at the start of my career. Knowing that I can focus on my family, which is still in its early stages, is important,” Dimond said. “I have four kids, so being able to dedicate a lot of time to them is something that hadn’t really been a part of my life during residency, which was kind of chaotic at times. To have the backend business things being handled and knowing that I have a group of partners with me for support is crucial for this part of my career.” Dimond added that the community-centric culture US Endo offers also plays a role in personal and professional growth. “You get so focused on your little world — your office, your operatory,” Dimond said. “This kind of partnership sort of expands your vision and gives you a broader view of the people you work with in the industry. It opens your mind.” Ultimately, though, it all boils down to a steadfast commitment to each other and to patients — just as it did when the practice formed at the AAE in 1996, after a quick review of some blueprints casually pulled from a bag. “I don’t take any of it for granted,” LeValley said. “We all have the same goals in the end, and it’s all about patient care.” EP This information was provided by US Endo Partners.

Volume 15 Number 2

Experiencing the power of digital communication. ZEISS EXTARO 300 in y a t S h! c u o t

The integrated HD camera of the EXTARO® 300 from ZEISS records wirelessly to the ZEISS Connect App — empowering patient interaction and informed decisions with images and videos directly transferred to your local network. • Benefit from a digital workflow • Easily educate your patients • Demonstrate the value of your work CAP-en-US_30_030_0185II © 2022 Carl Zeiss Meditec, Inc. All rights reserved.

CLINICAL

Use of bioceramics in conventional endodontic treatment associated with endodontic surgery of teeth with extensive periapical lesions Stefanya Dias de Oliveira, Artur Henrique Cabral, Danielly Davi Correia Lima, Alexia da Mata Galvão, Dr. Gabriella Lopes de Rezende Barbosa, Larissa Rodrigues Santiago, and Dr. Maria Antonieta Veloso Carvalho de Oliveira show how bioceramics help the healing process Abstract

This study reports the clinical case of a 56-yearold male patient with extensive periapical lesions associated with teeth Nos. 7, 9, and 10, suggestive of chronic apical periodontitis on radiographic examination and disruption of the cortical bone on CBCT examination. Conventional endodontic treatment and retreatment were performed associated with endodontic surgery using bioceramic materials with 34 months of follow-up. At follow-up, there Figures 1A and 1B: Initial clinical aspect. 1A. Buccal surface and 1B. Palatal surface of teeth Nos. 7, 9, and 10 was bone formation around teeth Nos. 7 and 10, a significant decrease in the size of the lesion on the load of microorganisms, and model and seal the conduits to tooth No. 9, and no symptoms. In view of the histopathological minimize the risk of recontamination.1,2 diagnosis of cystic lesions of odontogenic origin, it was found Even though the success rates of root canal therapy are that endodontic surgery was necessary as a complement to conaround 97%, posttreatment problems can occur3 due to inacventional treatment. The use of bioceramics probably helped in cessibility to all apical ramifications for cleaning and sealing.4 the bone healing process, enabling tooth maintenance. When conventional endodontics fail, and it is no longer possible to perform orthograde retreatment, endodontic surgery is Introduction the method indicated for treatment.2,4,5,6 By removing diseased Endodontic treatment aims to promote the disinfection of the tissue, apical surgery also encompasses sealing the root canal root canal system in order to eliminate necrotic tissue, reduce system, preventing the colonization of any remaining bacteria in the periradicular tissues and the appearance of lesions.5,7,8 Stefanya Dias de Oliveira and Artur Henrique Cabral are graduate students Studies show that the surgical approach has great predictat School of Dentistry of Federal University of Uberlândia, Brazil. ability because of the final apical filling probably due to the Danielly Davi Correia Lima is a master´s degree student at School of essential characteristics present in the filling materials.4,9,10 BioDentistry of Federal University of Uberlândia, Brazil. ceramic cement was developed as a retrograde filling material because it has characteristics such as biocompatibility, encourAlexia da Mata Galvão is a PhD student at School of Dentistry of Federal University of Uberlândia, Brazil. aging the growth of natural tissues, and upon setting was insoluble preventing recurrent apical leakage. It has bioactive capacity Gabriella Lopes de Rezende Barbosa, DDS, MS, PhD, is a teacher at the and low toxicity, allows a hermetic seal with good dimensional Department of Oral Diagnosis, School of Dentistry, Federal University of Uberlândia, Brazil. stability with antibacterial and antifungal activity, in addition to being bio-inert.11,12,13,14,15,16 Larissa Rodrigues Santiago is a third year resident of surgery and The aim of this article was to report a clinical case of a patient traumatology, Federal University of Uberlândia, Brazil. with an extensive periapical lesion who underwent conventional Maria Antonieta Veloso Carvalho de Oliveira, PhD, is a teacher at the endodontic treatment and retreatment associated with surgery Department of Endodontics, School of Dentistry, Federal University of on teeth Nos. 7, 9, and 10 using bioceramic materials with 34 Uberlândia, Brazil. months of follow-up. Endodontic Practice US

Volume 15 Number 2

CLINICAL

All three teeth underwent weekly changes of bioceramic intracanal medication (Bio-C® Temp – Angelus Dental Products Industry S.A., Londrina, PR, Brazil) for 1 month. Tooth No. 9 showed the presence of exudate inside the root canal during the 30 days of treatment. After several factors — e.g, the size of the lesions, the continuous accumulation of purulent secretion on tooth No. 9, the difficulties in carrying out clinical care arising from the patient’s systemic problems, the dependence on the calendar of a multi-

Case report

The patient, a 56-year-old man, who attended the clinic of the Stomatological Diagnosis Unit of the School of Dentistry of the Federal University of Uberlândia (FOUFU), presented complaining of pain and dental fracture. In the health history review, the patient reported a previous history of dental caries. Clinical examination revealed the presence of a coronal fracture on teeth Nos. 7 and 9, coronal opening with provisional sealing on tooth 10 (Figure 1), and absence of symptoms in the vertical and horizontal percussion tests and in the cold thermal sensitivity test (Hygenic® Endo Ice® spray, Maquira Dental Products Industry S.A, Maringá, PR, Brazil). Radiographic examination revealed the presence of an extensive periapical lesion associated with teeth 7, 9, and 10, and prior endodontic treatment on teeth Nos. 7 and 10 (Figure 2). Cone beam computed tomography (CBCT) was also performed using a Gendex CB-500 scanner (Gendex Dental Systems, Hatfield, Pennsylvania). It showed the real dimension of bone loss with the presence of disruption of the buccal and palatal cortical bone (Figure 3) with an epicenter in the region of tooth No. 7 and measuring 11.15 mm x 16.98 mm, and measuring 12.45 mm x 19.24 mm in the region of teeth Nos. 9 and 10 with the epicenter close to the apex of tooth No. 9. The likely clinical/radiographic diagnosis was chronic apical periodontitis. Figures 2A and 2B: Periapical radiographs. 2A. Tooth No. 12. 2B. Teeth Nos. 9 After coronal opening, endodontic retreatment of teeth Nos. and 10 7 and 10 was performed using a Gates-Glidden drill (Dentsply Sirona, New York, New York), Hedströen files (Dentsply Sirona) and ProTaper® retreatment rotary files (Dentsply Sirona) to remove the filling material. In tooth No. 7, there was a deviation of the canal to the mesial side during the attempt to remove the filling in the apical third, preventing the total removal of the gutta percha from this region. The ProTaper Figures 3A-3D: Tomographic aspect of the sections. 3A. Axial. 3B. Coronal. 3C and 3D. Sagittal of Next™ system (Dentsply Sirona, New York) up the periapical lesions (yellow arrow) of teeth Nos. 7, 9, and 10 to the X3 file was used for the biomechanical preparation of the three teeth. The canals were irrigated throughout the treatment with 1% sodium hypochlorite (Biodinâmica, Ibiraporã, PR, Brazil) and saline solution (Biodinâmica, Ibiraporã, PR, Brazil), and the teeth were provisionally sealed with glass ionomer-based cement (FGM Dental Group, Stamford, Connecticut). Figures 4A-4C: Clinical aspect. 4A. Apex section. 4B. Retrofilling. 4C. Apical fragment

Figures 5A-5C: Clinical aspect: 5A. Removal of the lesion from the region of teeth Nos. 9 and 10. 5B. After apicoectomy. 5C. After retrofilling

endopracticeus.com

Volume 15 Number 2

CLINICAL

disciplinary team to perform the surgical process, and the end of the academic semester at FOUFU that would last 4 months — it was not possible to change the intracanal medication until the exudate ceased. Also, taking into consideration the failure of complete removal of gutta percha from tooth No. 7, endodontic surgery was chosen as the treatment approach (Figures 4 and 5). Thus, before surgery, only tooth No. 10 was filled using the lateral and vertical condensation technique with gutta percha (Dentsply Sirona, New York) and bioceramic cement (Bio-C Sealer – Angelus Dental Products Industry S.A., Londrina, PR, Brazil). Endodontic surgery was performed at the FOUFU surgery clinic by an oral and maxillofacial surgeon. Prior to the beginning of the procedure, antibiotic prophylaxis, antisepsis, oral cavity asepsis, and local anesthesia were performed. A horizontal incision was made with small curvatures in the gingiva inserted 3.0 mm from the gingival sulcus and complemented with two vertical incisions above the maxillary incisors with a scalpel handle and 15 blade providing a Luebke-Ochsenbein flap (submarginal incision flap) technique. Tissue dissection and flap detachment were

performed with a Molt periosteal elevator (S.S. White, Duflex, Lakewood, New Jersey), and the osteotomy to access the apices of teeth Nos. 7, 9, and 10 was performed with a carbide drill and a 702 blade in high rotation with abundant irrigation using saline solution (Biodinâmica, Ibiraporã, PR, Brazil). After the osteotomy, the lesions were removed with a Lucas curette (S.S. White/Duflex, Lakewood, New Jersey) (Figure 5A) and placed in a closed container containing 1% formaldehyde and sent for histopathological examination. This examination diagnosed the lesions as cystic of odontogenic origin (Figure 6). An apioectomy was performed by removing 3.0 mm of the apical portion of the root (Figure 4C) with a conical diamond bur (Kavo, Charlotte, North Carolina) in high rotation at an angle of 45º (Figure 4A). Retrofilling was performed with bioceramic cement (MTA Repair HP – Angelus Dental Products Industry S.A., Londrina, PR, Brazil), and (Figure 4B) with the aid of an MTA applicator (Angelus Dental Products Industry S.A., Londrina, PR, Brazil). The suture was performed using 5-0 absorbable sutures (Ethicon; Johnson & Johnson, New Brunswick, New Jersey). Fifteen days after surgery, teeth Nos. 7 and 9 were filled using a No. 50 McSpadden compactor (Dentsply Sirona, New York). At the first follow-up visit after 3 months (Figure 7), the patient had no painful symptoms and no purulent secretion. However, it was radiographically observed that the retrofilling material of tooth No. 7 was displaced (Figure 7A). Due to the patient’s health problems, only 9 months after the end of endodontic treatment, a new intervention was possible on tooth No. 7 to replace the retrofilling. All surgical procedures were performed in the same way as in the first surgery. The retrofilling was performed with bioceramic cement MTA Repair HP (Angelus Dental Products Industry S.A., Londrina, PR, Brazil). At the follow-up visit after 34 months (Figure 8), bone neoformation was observed around the three teeth. Comparing the initial CBCT examination with the 34-month examination, the evolution of bone neoformation can be seen (Figure 9).

Discussion

Figure 6: Low magnification photomicrograph of histological section stained with hematoxylin and eosin, showing evident cystic architecture: pathological cavity, partially lined by stratified epithelium with a thick capsule of dense connective tissue, permeated by inflammatory cells and hemosiderin pigmentation

The root canal retreatment performed on teeth Nos. 7 and 10 in the present case had the same objective as the primary treatment, completely eliminating pathogens and making the hermetic seal with bioceramic materials. Studies indicate that

Figures 7A and 7B: Follow-up periapical radiographs after 3 months. 7A. Tooth No. 7. 7B. Teeth Nos. 9 and 10

Figures 8A and 8B: Radiographic aspect after 34 months of follow-up. 8A. Teeth Nos. 7 and 10. 8B. Tooth No. 10

Endodontic Practice US

Volume 15 Number 2

CLINICAL

placed during root canal filling probably due to the pressure exerted in the thermoplastic process of gutta percha. After 34 months of follow-up, periapical bone formation around teeth Nos. 7 and 10 and a decrease in the size of the lesion on tooth No. 9 were observed, in addition to absence of mobility and of painful symptoms.

Conclusion In the present clinical case, in view of the histopathological diagnosis of cystic lesions of Figure 9A and 9B: Tomographic comparison of lesions in axial sections. 9A. Initial. 9B. After 34 odontogenic origin, it was found that endodontic months of follow-up surgery was really necessary as a way of complementing the treatment, aiming to eliminate microbial agents inaccessible to conventional endodontic therapy. The persistent lesions in the periapex are not rare, and the prevalence use of bioceramics helped in the bone-healing process, enabling is around 30%.1 tooth maintenance. EP The diagnosis of periapical lesions may require more than clinical and histological assessments and intraoral periapical radiographs. In this sense, more advanced methods such as CBCT can offer a higher quality of diagnostic evaluation, allowing an assertive treatment plan and prognosis.17 CBCT was used in the present case with the aim of performing a pre-surgical study, analyzing the teeth and their surrounding structures, helping to determine the actual size of the lesion, evidencing the damage caused such as the disruption of the buccal and palatal cortical bone, and helping in the choice of performing conventional treatment associated with surgery. The type of lesion is closely related to the success of the treatment. Periapical granuloma-type lesions can be more easily eliminated with conventional treatment, while periapical cysts and extraradicular infections usually do not regress, causing failures in the primary intervention.4 In the present clinical case, in view of the histopathological diagnosis of cystic lesions of odontogenic origin, it was found that endodontic surgery was necessary as a way of complementing the treatment, aiming to eliminate microbial agents inaccessible to conventional endodontic therapy.4,8,18 In the surgical intervention, the removal of the periapical lesion was planned through an osteotomy. The resection of the infected root end was performed with the apical portions apicectomized at 3 mm to reduce 98% of the apical ramifications and 93% of the lateral canals, avoiding the risk of reinfection and eventual failure.8 The filling of the apical system of the root canal was made with a bioceramic material, allowing the healing of the periapical tissue through neo-osteogenesis.3,5,12 The osteoconductivity and excellent biocompatibility of bioceramics by the formation of hydroxyapatite allow the interaction with the surrounding tissues, promoting their regeneration from the release of calcium and silicon as well.11,13,15 In the present clinical case, bioceramic materials were used as intracanal medication, sealer in endodontic treatment and retreatment, and as post-surgery retrofilling cement. Due to the filling of teeth Nos. 7 and 10 after surgery, another surgical procedure was necessary similar to the first to accommodate a new MTA apical plug in tooth No. 7, which was disEndodontic Practice US

REFERENCES 1.

Fabbro M, Taschieri S, Taschieri S, Francetti L, Weinstein RL. Surgical versus non-surgical endodontic re-treatment for periradicular lesions. Cochrane Database Syst Rev. 2007;18(3):1-17.

Alghamdi F, Alhaddad AJ, Abuzinadah S. Healing of Periapical Lesions After Surgical Endodontic Retreatment: A Systematic Review. Cureus 2020;12:1-9.

Fabbro MD, Corbella S, Sequeira-Byron P, et al. Endodontic procedures for retreatment of periapical lesions. Cochrane Database Syst Rev. 2016;10(10):1-105.

Pavelski M, Portinho D, Casagrande-Neto A, Griza GL, Ribeiro RG. Paraendodontic surgery: case report. Revista Gaúcha Odontológica. 2016;64: 460-466.

Christiansen R, Kirkevang LL, Hørsted-Bindslev P, Wenzel A. Randomized clinical trial of root-end resection followed by root-end filling with mineral trioxide aggregate or smoothing of the orthograde gutta-percha root filling – 1-year follow-up. Int Endod J. 2009;42(4):105-114.

Karabucak B, Setzer FC. Conventional and surgical retreatment of complex periradicular lesions with periodontal involvement. J Endod. 2009;35(9):1310-1315.

Pasha S, S Madhu K, Nagaraja S. Treatment outcome of surgical management in endodontic retreatment failure. Pakistan Oral & Dental Journal. 2013;33(3):554-557.

Kim S, Kratchman S. Modern endodontic surgery concepts and practice: a review. J Endod. 2006;32(7):601-623.

Kruse C, Spin-Neto R, Christiansen R, Wenzel A, Kirkevang LL. Periapical Bone Healing after Apicectomy with and without Retrograde Root Filling with Mineral Trioxide Aggregate: A 6-year Follow-up of a Randomized Controlled Trial. J Endod. 2016;42(4):533-537.

10. Safi C, Kohli MR, Kratchman SI, Setzer FC, Karabucak B. Outcome of Endodontic Microsurgery Using Mineral Trioxide Aggregate or Root Repair Material as Root-end Filling Material: A Randomized Controlled Trial with Cone-beam Computed Tomographic Evaluation. J Endod. 2019;45(7):831-839. 11. Utneja S, Nawal RR, Talwar S, Verma M. Current perspectives of bio-ceramic technology in endodontics: calcium enriched mixture cement — review of its composition, properties and applications. Restor Dent Endod. 2015;40(1):1-13. 12. AL-Haddad A, Che Ab Aziz ZA. Bioceramic-Based Root Canal Sealers: A Review. Int J Biomat. 2016;2016:1-10. 13. Jitaru S, Hodisan I, Timis L, Lucian A, Bud M. the use of bioceramics in endodontics — literature review. Clujul Med. 2016;89(4):470-473. 14. Raghavendra SS, Jadhav GR, Gathani KM, Kotadia P. bioceramics in endodontics — a review. J Istanb Univ Fac Dent. 2017;51(3 suppl 1):s128-s137. 15. Jiménez-Sánchez MC, Segura-Egea JJ, Díaz-Cuenca A. A Microstructure Insight of MTA Repair HP of Rapid Setting Capacity and Bioactive Response. Materials (Basel). 2020;13(7):1-11. 16. Zafar K, Jamal S, Ghafoor R. Bio-active cements-Mineral Trioxide Aggregate based calcium silicate materials: a narrative review. J Park Med Assoc. 2020;70(3):497-504. 17. Shekhar V, Shashikala K. Cone Beam Computed Tomography Evaluation of the Diagnosis, Treatment Planning, and Long-Term Followup of Large Periapical Lesions Treated by Endodontic Surgery: Two Case Reports. Case Rep Dent. 2013; 2013:1-12. 18. Ribeiro FC, Fabri B, Roldi A, Pereira RS, et al. Prevalence of periapical lesions in endodontic treatment teeth. Revista Saúde. 2013;9(4):244-52.

Volume 15 Number 2

YOU’LL BE SMILING...

KNOWING WE ARE THE ONLY Endodontic Partnership led by Endodontists. Imagine solely focusing on the “practice” part of your endodontic practice. We partner with endodontists nationwide to empower them to do just that, while helping you to achieve your goals. Endo1 Partners

305-206-7388

Endo1partners.com

supports our endodontic partners by implementing business best practices to reduce administrative burden, increase efficiency, and prioritize growth.

Our family of brands

CONTINUING EDUCATION

CBCT — recognizing anatomic structures before implant surgery Dr. John Pasicznyk discusses implants and how CBCT can help endodontists with treatment planning

mplant dentistry is a rapidly growing aspect of the profession as more clinicians start to provide implant therapy as a routine aspect of treatment. This creates an atmosphere where patients are aware of implants as a treatment option and may even question the recommendation to save a tooth rather than remove and replace it with an implant. What once was a specialist-only procedure in the OMFS or periodontal practice is now performed in many general practices, including a growing number of endodontic practices. Since many GPs utilize their endodontic colleagues as a “last resort” at saving a tooth, it is very reasonable for the endodontist to be equipped to help patients make treatment decisions regarding endodontic therapy versus implant therapy, and even to complete the necessary implant procedures if they so desire. Consider how many times a tooth has a severe periapical abscess, which can only be fully appreciated once treatment is initiated, or cracks in the root, which can only be visualized upon opening the tooth and viewing with a microscope. In these cases, proper planning ahead of time, appropriate informed consent, and an adequate armamentarium can allow the endodontic procedure to seamlessly shift to implant placement. This CE will provide vital information in how CBCT can be utilized in making treatment decisions by identifying anatomic structures visible on CBCT imaging and by understanding the importance of CBCT in implant therapy. CBCT imaging is a vital part of the initial treatment-planning process for implant cases, allowing clinicians to critically think before a patient is even scheduled for treatment. Effective use of CBCT imaging changes the treatment-planning process, with clinicians having all the information needed to choose cases that are appropriate for the skill set and that inform patients of anticipated complications prior to the surgical appointment.1 By utilizing CBCT imaging, clinicians have a comprehensive view of the anatomic field prior to surgery, and in turn, risk of surgical

Educational aims and objectives

This self-instructional course for dentists aims to provide information on how CBCT can be utilized in making treatment decisions by identifying anatomic structures visible on CBCT imaging and understanding the importance of CBCT in implant therapy.

Expected outcomes

Endodontic Practice US subscribers can answer the CE questions by taking the quiz online at endopracticeus.com to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Recognize the importance that CBCT imaging plays in providing implant therapy. • Identify the anatomical structures that are necessary to avoid during implant surgery. • Recognize situations in which only CBCT imaging can identify the proximity of vital anatomic structures to the planned implant position. CREDITS

2 CE

and prosthetic complications are decreased, thereby improving patient outcomes. Endodontic practitioners have an advantage on most GPs in this regard, as they are quite used to viewing and manipulating CBCT images. The tools and planning software may be slightly different, but the general concepts remain the same: Identify anatomy, make measurements, and look for anything outside the ordinary. It is important to understand some patient management benefits of using CBCT in implant planning. These are the ways we can help our patients before evaluating their anatomy and bone quantity/quality. Patients are walking into the practice more educated than ever before, doing research on procedures, and getting advice from their peers. In today’s age, many patients have heard of CBCT imaging, and for those who haven’t, once they understand why we use it, they insist on friends and family members getting the same level of care. The confidence it gives the clinician to present a well thought-out and safely planned implant case to the patient is without a doubt the largest benefit of CBCT imaging. In the endodontic practice setting, many cases quickly become non-restorable, and having a “Plan B” prior to starting endodontic therapy would give many patients a boost of confidence prior to treatment. Imagine the case in which a referring dentist asks you to play “hero” by completing a massively compromised endodontic case. When the tooth can’t be saved, it can reflect on the clinician despite their best efforts. By

Dr. John Pasicznyk practices at Britely Implant Studios in Naples, Florida. A 2010 graduate from Indiana University School of Dentistry, he built a group of technology-focused general dental practices before transitioning into owning his implant-only practice. A leader in digital implant dentistry, his mission is to provide the highest quality of care to his patients using the latest technology and innovative techniques. As a faculty member at 3D Dentists and mentor at Implant Pathways, Dr. Pasicznyk has devoted himself to improving dentists’ lives through education and mentoring on all things implants. Disclosure: Dr. John Pasicznyk is no longer affiliated with CBCT for Dentsply Sirona.

Endodontic Practice US

Volume 15 Number 2

CONTINUING EDUCATION

Figures 2 and 3: 10.5 mm implant planned in No. 18 healed site. 2D imaging alone does not provide a precise way to determine the height of ridge. Implant plan changed to a 9 mm length and placed/guided to ensure appropriate depth of placement

Figure 1: Pre-extraction ridge No. 18. Tooth removed and grafted

identifying specific challenges in the endodontic treatment and by offering an alternative should endodontics not be in their best interest, we can turn what would ordinarily be a difficult patient management situation into a positive end result for the patient. Patients largely follow our treatment advice, based on the confidence they have in us, and CBCT gives the doctor and team an added level of confidence in planning. When the clinician is able to clearly articulate why the patient is a good candidate for implant surgery and can reassure the patient that everything possible is being done to ensure the best outcome, it reduces barriers for patients to decline treatment, which allows us to provide more implant dentistry for our patients. Finally, having a full understanding of the patient’s specific situation allows the doctor and team to prepare fair financial arrangements prior to surgery, based on whether grafting or sinus augmentation is needed. Doctor and team can also provide a more realistic timeline of the process from start to finish by disclosing any situations that may lengthen healing or total treatment time. Safely executing a planned procedure should be the number one priority in any aspect of dentistry. This is especially important in surgery, where tissue is being displaced, incised, removed, and rebuilt with a multitude of important vital structures surrounding the surgical site. Injury to any of these could lead to intraoperative complications that the clinician is unprepared to handle, unable to recognize, or unable to repair. This could lead to significant morbidity or even mortality. CBCT imaging is an imperative aspect of pre-implant treatment planning from a standpoint of safety due to the knowledge it provides the clinician. This information is simply impossible to fully gain from a routine examination consisting of intraoral visual exam, palpation, and two-dimensional radiography. There are five anatomic structures that should be identified as part of any initial implant treatment plan. They are, in the order of importance: submandibular fossa, inferior alveolar nerve (and anterior loop), buccal plate, nasopalatine nerve, and maxillary sinus. There are structures that will not be a consideration based on the planned case — i.e., for a treatment plan to replace tooth No. 14 — the relative location of the submandibular fossa, inferior alveolar nerve (IAN), and nasopalatine nerve will neither influence the treatment plan nor change the safety margins of endopracticeus.com

Figures 4 and 5: Planned implant on the left encroaches on the IAN, replanned with a short implant (7.5 mm) to avoid damaging the nerve. Precise measurement can be made revealing 2.31 mm between apex of planned implant and IAN. Surgical guide was fabricated to place implant guided, giving further control over depth of implant placement to avoid the IAN

the surgery. However, each structure should be identified when appropriate, so clinicians can make the proper clinical decision whether their skill set allows them to move forward with the case. The submandibular fossa lies within the concavity that occurs inferior to the cortical border of the mandible. Oftentimes, the concavity is quite severe, and the scope of the concavity cannot be identified from palpation, visualization, and two-dimensional radiography (Figures 1-3). This area contains a great number of blood vessels and nerves that, if compromised, could create a significant bleed or paralysis. In many instances, the height from alveolar crest to the fossa is 8 mm to 10 mm, which is, quite inconveniently, the same dimension as very commonly used implant length in the lower molar region.2 It would be disastrous to unknowingly have a severe concavity apical to the planned surgical site and begin preparing an osteotomy to the planned implant length, only to drill directly into the submandibular fossa. The results could range anywhere from excessive intraoperative bleeding to severe hemorrhage. Even if handled appropriately, either of these could, in rare circumstances, lead to a delayed submandibular swelling due to bleeding into fascial spaces. In this situation, CBCT imaging would have identified the anatomic situation, and virtually placing an implant with

Volume 15 Number 2

CONTINUING EDUCATION

planning software would allow the clinician to plan for a shorter implant to avoid compromising the submandibular fossa. The inferior alveolar nerve (IAN) is a structure housed within a canal made up of cortical bone, which lends it to typically be quite visible on both two- and three-dimensional radiographs. Unlike the submandibular fossa, compromising the IAN or canal will rarely cause a medical emergency. However, damaging the nerve and causing resulting loss of sensation could be a debilitating situation for the patient and create a serious medico-legal event for the clinician. Despite the ability to visualize the nerve canal on two-dimensional radiography, CBCT imaging is the only way to precisely understand the exact height of bone coronal to the nerve. By viewing a CBCT slice, the clinician can determine the appropriate height of implant that can be used without coming near the IAN (Figures 4 and 5). When the nerve position does not allow the use of typical implant length, 8 mm or greater, a short implant can be used with success.3 Short implants are defined as implants less than 7.5 mm in length and are becoming more and more prevalent from manufacturers. In addition to showing the height of bone above the IAN, CBCT slices can also show the relative buccal-lingual position of the IAN. In this case, the nerve was in almost the lingual-most aspect of the inferior border of the mandible, which made the ideal planned implant position greater than 3 mm away from the nerve — an acceptable safety margin. To improve safety even more, a surgical guide fabricated from the CBCT imaging and a digitized dental model would allow precisely placing the implant in the safely planned position. The buccal plate is a band of cortical bone in both the maxilla and mandible that encapsulates the more cancellous bone within. While violating the buccal plate may not have quite as drastic consequences as injury to the submandibular fossa or IAN, it will have a tremendous impact on the success of the implant surgery. Cortical bone derives most of its blood supply from the periosteum, which means minimizing flap reflection when possible is imperative to preventing bone necrosis. Excessively disrupting the blood supply by denuding bone of its periosteum can cause cortical bone loss.4 This along with the biologic effects of osteotomy preparation, which is known to be a 1.5 mm-2.0 mm band of bone necrosis around the freshly

placed implant body, can quickly lead to a dehiscence of bone around the implant body. When this happens, soft tissue can quickly invade the healing implant site, leading to “spinners” or implants that fail to integrate due to soft tissue ingrowth. CBCT imaging and implant-planning software with precise digital implant replicas allow the surgeon to visualize an implant within the proposed site and safely determine if the diameter of the implant causes a compromise of the 2.0 mm minimum boundary between implant and buccal plate. If the bone dimension is inadequate, there are three options that can be planned for prior to surgery: • First, a narrower implant could be selected if appropriate and visualized on CBCT planning software (Figure 6-8). • Second, by sinking the implant slightly subcrestal, the thin “lip” of buccal plate can be avoided. • Third, ridge augmentation may be the only way to appropriately increase the volume of bone to adequately secure the implant. The benefit to both patients and clinicians is that these considerations are being made prior to finalizing the implant

Figure 8: Digitized model of Figures 6 and 7 showing a ridge thickness of 8.44 mm. Palpation of this ridge without CBCT could easily mislead clinicians into believing there is adequate bone for a 4.6 mm implant centered in ridge. CBCT slices show bone thickness to be 6.8 mm

Figures 9 and 10: 9 mm implant on the left,clearly compromises the sinus. Changing implant to 7.5 mm length still compromises the sinus. Patient must be informed of need for sinus augmentation in order for implant surgery to be successful

Endodontic Practice US

Figures 6 and 7: Implant on the left is 4.6 mm width and compromises the buccal plate. Planning for a 3.8 mm implant on the right gives >1.5 mm of buccal plate thickness. Without the knowledge of how tight the space is during planning, surgery would appear to go well, but because there is less than 1.5 mm of buccal plate, it is possible to lose buccal plate and have an implant that fails to integrate

Volume 15 Number 2

CONTINUING EDUCATION

treatment plan. The patients receive peace of mind that they are receiving only necessary procedures, and clinicians can rest easy knowing what is coming their way on the day of surgery. The maxillary sinus is a unique anatomic structure, exhibiting resilience and self-healing capabilities, with a relatively lower risk of seriFigures 11 and 12: Panoramic projection shows outline of right maxillary sinus, but only CBCT slice can give exact measurement of ridge height, in this case 6.58 mm ous complications due to damage. Despite this, the sinus is still imperative to manage appropriately, as compromising this structure can significantly increase total time for treatment to be completed. Additionally, being prepared in advance for variation in sinus anatomy allows clinicians to appropriately plan for the procedure prior to the day of surgery.5 There are many instances where the maxillary sinus has pneumatized, which causes the floor of the sinus to impinge on an otherwise Figures 13 and 14: Ideal implant width of 4.2 mm (left) compromises both buccal plate and nasopalatine canal. useful implant site. In these cases, Implant changed to 3.4 mm width (right), but even still, a compromise of buccal plate or nasopalatine canal is a decision can be made whether a likely. Figure 15: 4.2 mm width implant planned intentionally compromising nasopalatine canal and avoiding shorter implant is appropriate and buccal plate. Canal will be obliterated and grafted during surgery avoids the sinus entirely, or the sinus exposed and the contents within obliterated entirely to allow for can be moved out of the way, building bone in the space between bone grafting material to fill the canal and stabilize the implant the sinus lining and the maxilla (Figures 9 and 10). In any case, (Figure 15). the sinus must be adequately visualized prior to implant surgery. Implant dentistry is one of the most rapidly growing clinical While two-dimensional radiography gives some information as aspects of dentistry, and this is driven by many barriers of entry to the extent of the borders of the sinus, it alone is not adequate being lowered or eliminated. CBCT imaging is arguably the most to fully visualize septa, undulations, and the exact measurement useful piece of technology to an implant practice, and its routine of available bone from crest to sinus (Figures 11 and 12). This use in treatment planning will provide the doctor and team many measurement of available bone allows clinicians to determine advantages in patient communication and surgical execution. whether the case meets their selection criteria and, ultimately, Effective use of CBCT in presurgical treatment planning leads helps patients understand the extent of treatment required. to decreased risk of complications and increased patient safety, The final anatomic structure to discuss in implant planning which will help implant practices and clinicians no matter how is the nasopalatine canal. This structure carries a mixed vascufar along they are in their implant journey. EP lar-neural bundle that exits on the midline palatal to the central incisors. Interestingly, despite being a neurovascular bundle, there is little to no sensory innervation, which reduces the risk of compromising the tissue contained within. In fact, it is the one REFERENCES anatomic structure discussed that can be and, occasionally, is 1. Karthik K, Sivaraj S, Thangaswamy V. Evaluation of implant success: A review of past required to be removed entirely.6 Central incisor implants often and present concepts. J Pharm Bioallied Sci. 2013;5(suppl 1): S117–S119. come close to invading the space of the nasopalatine canal, and 2. Parnia F, Fard EM, Mahboub F, Hafezeqoran A, Gavgani FE. Tomographic volume evaluation of submandibular fossa in patients requiring dental implants. Oral Surg Oral care must be given to unintentionally place an implant in the Med Oral Pathol Oral Radiol Endod. 2010;109(1):e32-e36. canal. The borders of the canal are made of cortical bone, and 3. Karthikeyan I, Desai SR, Singh R. Short implants: A systematic review. J Indian Soc will react and atrophy in a similar fashion to the buccal plate if Periodontol. 2012;16(3):302-312. the implant is placed in too close proximity. By utilizing CBCT 4. Mehta H, Shah S. Management of Buccal Gap and Resorption of Buccal Plate in slices, clinicians can visualize the proximity of the canal to the Immediate Implant Placement: A Clinical Case Report. J Int Oral Health. 2015;7(suppl 1):72-75. planned implant position, and adjust the proposed size or the 5. Kim, GS., Lee, JW., Chong, JH. et al. Evaluation of clinical outcomes of implants placed position of the implant in order to avoid the canal (Figures 13 into the maxillary sinus with a perforated sinus membrane: a retrospective study. Maxiland 14). In cases with such limited space, the implant is placed lofac Plast Reconstr Surg. 2016;38(1):50. in the ideal position, even if that means compromising the 6. Verardi S, Pastagia J. Obliteration of the nasopalatine canal in conjunction with horizontal ridge augmentation. Compend Contin Educ Dent. 2012;33(2):116-20, 122. canal. During implant surgery, the canal will be intentionally endopracticeus.com

Volume 15 Number 2

CONTINUING EDUCATION

Continuing Education Quiz CBCT — recognizing anatomic structures before implant surgery PASICZNYK

The ________ lies within the concavity that occurs inferior to the cortical border of the mandible. a. submandibular fossa b. inferior alveolar nerve c. buccal plate d. nasopalatine canal

In many instances, the height from alveolar crest to the fossa is ________, which quite inconveniently, is the same dimension as very commonly used implant length in the lower molar region. a. 1 mm-2 mm b. 5 mm-6 mm c. 8 mm-10 mm d. 11 mm-13 mm

______ is the only way to precisely understand the exact height of bone coronal to the nerve. a. CBCT imaging b. Tomography c. Palpation d. A surgical procedure

When the nerve position does not allow the use of typical implant length, _______ or greater, a short implant can be used with success. a. 4 mm b. 5 mm c. 6 mm d. 8 mm

n To receive credit: Go online to https://endotpracticeus.com/continuingeducation/, click on the article, then click on the take quiz button, and enter your test answers. AGD Code: 690 Date Published: June 6, 2022 Expiration Date: June 6, 2025

The ________ is a structure housed within a canal made up of cortical bone, which lends it to typically be quite visible on both 2-dimensional and 3-dimensional radiographs. a. submandibular fossa b. inferior alveolar nerve c. buccal plate d. nasopalatine canal

a. b. c. d.

The ________ is a band of cortical bone in both the maxilla and mandible that encapsulates the more cancellous bone within. a. submandibular fossa b. inferior alveolar nerve c. buccal plate d. nasopalatine canal

2 CE CREDITS

1.5 mm-2.0 mm 2.3 mm–3.3 mm 3.8 mm-4.0 mm 5.2 mm-5.8 mm

CBCT imaging and implant planning software with precise digital implant replicas allow the surgeon to visualize an implant within the proposed site, and safely determine if the diameter of the implant causes a compromise of the _________ minimum boundary between implant and buccal plate. a. 2 mm b. 4 mm c. 6 mm d. 8 mm

While two-dimensional radiography gives some information as to the extent of the borders of the sinus, it alone is not adequate to fully visualize _______. a. septa b. undulations c. the exact measurement of available bone from crest to sinus d. all of the above

10. The ________ carries a mixed vascular-neural bundle that exits on the midline palatal to the central incisors. Interestingly, despite being a neurovascular bundle, there is little to no sensory innervation, which reduces the risk of compromising the tissue contained within. a. submandibular fossa b. inferior alveolar nerve c. buccal plate d. nasopalatine canal

Excessively disrupting the blood supply by denuding bone of its periosteum can cause cortical bone loss. This along with the biologic effects of osteotomy preparation, which is known to be a _______ band of bone necrosis around the freshly placed implant body, can quickly lead to a dehiscence of bone around the implant body.

To provide feedback on CE, please email us at education@medmarkmedia.com Legal disclaimer: Course expires 3 years from date of publication. The CE provider uses reasonable care in selecting and providing accurate content. The CE provider, however, does not independently verify the content or materials. Any opinions expressed in the materials are those of the author and not the CE provider. The instructional materials are intended to supplement, but are not a substitute for, the knowledge, skills, expertise and judgement of a trained healthcare professional.

Endodontic Practice US

Volume 15 Number 2

CONTINUING EDUCATION

Managing controlled substances in dental practice: prescribing and record keeping Tyler Dougherty, PharmD; Michael O’Neil, PharmD; and Nikki Sowards, PharmD; review key considerations when prescribing and storing controlled substances Introduction Prescription medication misuse, substance use disorder (SUD), and diversion continue to remain problematic across the United States. Dental practitioners are often targeted by patients since they are a potential source of potent prescription opioids. Additionally, dental practitioners are subject to investigations by the Drug Enforcement Agency (DEA) as part of routine inspections or for potential violations of the Federal Controlled Substance Act (CSA).1 Dental practitioner prescribing and office management of controlled substances require vigilance, careful scrutiny of all records, and well-organized record keeping of both patient medical records and controlled substance records. This article will review key considerations when prescribing and storing controlled substances.

Educational aims and objectives

This self-instructional course for dentists aims to provide an overview of necessary practices to consider when prescribing and storing controlled substances.

Tyler Dougherty, BA, PharmD, BCACP, received his Bachelor of Arts degree in Biochemistry from Maryville College in 2011 and his Doctor of Pharmacy degree from the University of Tennessee College of Pharmacy in 2015. He completed a postgraduate residency at South College School of Pharmacy in 2016. Dr. Dougherty is a Clinical Community Pharmacist and Assistant Professor of Pharmacy Practice where he specializes in community pharmacy practice and teaches ethics and pharmacy law. Dr. Dougherty is an invited speaker for healthcare professionals teaching ethics and law with emphasis on medication management.

Expected outcomes

Endodontic Practice US subscribers can answer the CE questions by taking the quiz online at endopracticeus.com to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Define key terms used when prescribing and storing controlled substances. • List methods to minimize diversion and fraud of controlled substances. • Outline federal requirements for storing controlled substances. • Identify specific records that must be readily retrievable should a dental practice be audited or investigated. • List common violations of the Controlled Substance Act by dental practitioners.

Michael O’Neil, PharmD, received his Doctor of Pharmacy from the University of North Carolina at Chapel Hill, North Carolina. Dr. O’Neil has extensive experience in pain management, substance misuse, and medication diversion. Dr. O’Neil was editor and lead author for the American Dental Association’s book titled The ADA Practical Guide to Substance Use Disorders and Safe Prescribing, published in 2015. Dr. O’Neil has served as a consultant for prescription drug misuse and diversion for several entities including the Federal Drug Enforcement Agency. He is currently Professor and Chair of Pharmacy Practice at South College School of Pharmacy in Knoxville, Tennessee. Nikki Sowards, PharmD, earned her Doctor of Pharmacy degree in 2012 from the University of Tennessee College of Pharmacy in Memphis, Tennessee. She completed a PGY-1 Pharmacy Practice residency in Knoxville, Tennessee. Dr. Sowards joined South College School of Pharmacy as an Assistant Professor in 2013. In 2015, Dr. Sowards worked as a Director of Hospital Pharmacy in Knoxville, Tennessee. Dr. Sowards is currently an Assistant Professor of Pharmacy Practice at South College School of Pharmacy. She practices at Blount Memorial Hospital where she focuses on pharmacy operations and pharmacy management.

endopracticeus.com

2 CE CREDITS

Definitions Understanding of medical and legal terminology surrounding controlled substances is important when interpreting the medical/legal literature, and when trying to maintain compliance with state and federal statutes and regulations. The following terminologies provide guidance regarding safe and effective controlled substance management and prescribing practices.

Volume 15 Number 2

CONTINUING EDUCATION

Prescription Medication Misuse Prescription medication misuse may be defined as taking a prescription medication outside of the boundaries of the initial prescription’s “intent for use” or directions. This may include a different diagnosis, taking the medication in larger doses or more often than prescribed, or to significantly alter/enhance one’s mental status.2

Substance Use Disorder (SUD)

Table 1: Common “Red Flags” Patients traveling extremely long distances between dental practicehome-pharmacy Early refills Utilizing multiple prescribers (emergency medicine, dental practices, hospitals, private practices) Out-of-state patients

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), no longer uses the terms substance abuse and substance dependence. Rather, it refers to substance use disorders, which are classified as mild, moderate, or severe. The level of severity is determined by the number of diagnostic criteria met by an individual.”3

Random, escalating/de-escalating doses of opioids or benzodiazepines Common “cocktails” consisting of opioids, benzodiazepines, muscle relaxants, and sedative hypnotics Morphine-Equivalent Daily Doses (MEDD) exceeding 90 mg/day Patients presenting “old” dental injuries as “new” injuries

Prescription Medication Diversion The movement of a prescription medication in any direction other than how legally allowed to be transferred by law.4

Prescription Drug Monitoring Program (PDMP) Prescription Drug Monitoring Programs are state-regulated electronic databases that store outpatient dispensing records for specific controlled substances.5

Red Flags Red flags are observations that potentially may deter prescribing or dispensing of a medication. Red flags require further questioning of the patient or clarification prior to writing or dispensing a prescription medication.6

Due Diligence “The practice of performing reasonable verification that the information presented is accurate and reliable in order to prevent deceptive or criminal practices. Reasonable implies that the practitioner is doing what any practitioner would and should do in the routine activities of the healthcare professional.”7

Readily Retrievable “Readily retrievable means the record is kept or maintained in such a manner that it can be separated out from all other records in a reasonable time or that it is identified by an asterisk, redline, or some other identifiable manner such that it is easily distinguishable from all other records.”7

Prescribing controlled substances Many dental practices prescribe controlled substance analgesics and anxiolytics prior to performing procedures and postoperatively. Recognition of attempts by patients to illegally obtain controlled substances is necessary to decrease risks to the dental practitioner and the dental practice. State and federal agencies require prescribers to practice “due diligence” when prescribing or dispensing prescription medications. The practice of performing “due diligence” for dental practitioners when prescribing controlled substances includes careful review of the patient’s medical history, review of previously prescribed conEndodontic Practice US

Utilizing only cash payments for medications

trolled substances such as that found in the PDMP, evaluation of patient behaviors, patient interviewing, refusing to prescribe or dispense when diversion or fraud is suspected, and reporting these behaviors accordingly. Currently, many states now require prescribers to evaluate a patient’s PDMP report prior to prescribing controlled substances. (For a more in-depth review of utilizing a state PDMP, see the continuing education article in Implant Practice US: “Practical Considerations for Utilizing Prescription Drug Monitoring Programs — A Primer.”) The PDMP provides controlled substances prescribed for patients that have been dispensed from a community pharmacy or outpatient clinic for a specific state. The PDMP is a helpful tool to optimize therapeutic decisions as well as to detect “red flags” that lead to further questioning prior to prescribing. Table 1 lists red flags commonly detected in a PDMP report.8 Dental practitioners should analyze this report for active controlled substances, recent controlled substance prescriptions from other prescribers, duplicate prescriptions, and early refills. It is important to recognize that any anomalies found should lead to further questioning of the patient since the information provided in the PDMP has not been validated by a secondary source and may have errors that occurred at the time of processing the prescription. Any verified abnormal findings should be thoroughly documented in the patient’s medical record. Other methods to divert controlled substances from dental practices include altering written prescriptions or falsifying phone-in prescriptions. Tampering of prescriptions is limited by use of tamper-proof prescription pads, and copying of prescriptions is minimized by utilizing embedded watermarks or photocopying resistant paper. The use of preprinted prescriptions with the medication name, medication strength, dosage, and directions is highly discouraged. The use of presigned prescriptions by the prescriber is illegal. Controlled substance prescriptions should be signed the day the written prescription is provided to the patient. Additionally, utilization of ePrescribing can minimize these types of diversion and fraud. Volume 15 Number 2

CONTINUING EDUCATION

ePrescribing

Dental practitioner prescribing and office manage-

Electronic prescribing of prescription ment of controlled substances require vigilance, caremedications, also known as ePrescribing, began after the passing of the Medicare ful scrutiny of all records, and well-organized record Modernization Act (MMA) of 2003. The keeping of both patient medical records and controlled MMA aimed to enhance the quality of patient care while also increasing the substance records. utilization of electronic medical records. It wasn’t until 2006, when the Institute of Medicine’s July report discussing the role ePrescribing can play on reducing medication errors, that ePrescribing began to the pain medication prescription to the pharmacy and not fill the be widely used.9 antibiotic. Finally, ePrescribing enhances and further improves In 2018, Congress passed the Substance Use-Disorder electronic health record information and exchanges of that inforPrevention that Promotes Opioid Recovery and Treatment for mation. The exchange of electronic health records is becoming Patients and Communities Act (SUPPORT Act), which aimed more vital as healthcare providers, patients, and insurance comto address the opioid epidemic. In addition, this legislation panies look to increase communication to better patient care. required Schedule II-V controlled substances for Medicare Part 10 D beneficiaries be ePrescribed beginning January 1, 2021. The Record keeping Centers for Medicare and Medicaid Services (CMS) has since Laws and regulations for prescribing, storing, administerdelayed the enforcement of the ePrescribing rule until January ing, and disposing of controlled substances are defined at the 1, 2022. Dental practices and other healthcare providers would federal level in Title 21, Code of Federal Regulations (CFR), clearly find it difficult to delineate Medicare and non-Medicare sections 1300-1316.13 The federal Drug Enforcement Agency beneficiary prescriptions, meaning the prescribing of controlled (DEA) is mandated to ensure compliance to these laws and substances must be electronic for all patients going forward. regulations. Compliance is usually under control of the state’s However, individual states are already implementing ePrescribBoards of Pharmacy and Dentistry. Controlled substances laws ing requirements for controlled substances. Currently, 25 states and regulations frequently mirror federal laws and regulations. require ePrescribing with some provider exemptions. More Required records for controlled substances — e.g., purchase states are expected to pass or implement legislation requiring receipts, invoices, DEA222 transfer forms, DEA106 theft loss ePrescribing starting in 2022 and beyond.11 The Centers for forms, and records of detailed disposed controlled substances Medicare and Medicaid Services (CMS) policy does allow for such as wastage or damaged product — must be maintained prescribers to be exempt from ePrescribing controlled subfor 2 years and must be “readily retrievable” should a dental stances in the following situations: The prescriber and dispensing practitioner be audited or investigated. It is also important that pharmacy are the same entity, the prescriber issues 100 or fewer providers remember to take a biennial inventory of all controlled controlled substance prescriptions per year for Medicare Part D substances. Individual states can have stricter requirements surpatients, or circumstances surrounding natural disasters.12 rounding how often inventories must be taken. Dental practices should begin to adopt ePrescribing for all prescriptions, controlled and non-controlled substances, for multiple reasons. Although the federal requirements center around Medicare beneficiaries, the combination of state specific regulations make it logistically difficult for practices to issue prescriptions in two different formats. Adopting ePrescribing can potentially improve medication safety while also preventing prescribing errors. For example, handwritten prescriptions can oftentimes be illegible or difficult to interpret, requiring pharmacists to make judgement calls or delay care for the patient in order to confirm the prescription information. Also, different state and federal requirements exist on the information that must be included on a prescription, including the address of the patient, phone number or address of the practice, and DEA number of the prescriber (for a controlled substance). This information would automatically be included with standardized ePrescribing systems. In addition, electronic prescribing can help with controlled substance diversion or patient selection of medications they want filled or not filled. For example, a patient who is prescribed two handwritten prescriptions for an antibiotic and a pain medication post-dental procedure could provide only endopracticeus.com

Ordering and transferring controlled substances 21 CFR 1305.04 and 1305.05 require dental practitioners to be registered with the DEA if they intend to order Schedule II controlled substances (hydrocodone, oxycodone, etc.). They are referred to as a DEA registrant and are assigned a specific DEA registration number. The registrant may give authorization to other individuals to order Schedule II controlled substances through power of attorney. The ordering and transferring of Schedule II controlled substances requires the DEA222 form. The triplicate DEA222 form has been replaced with a single-sheet DEA222 form effective October 2021. The ordering of controlled substance medication Schedules III-V does not require transfer of the medications with the DEA222 form; however, the entities supplying and receiving the controlled substance must maintain records of the transactions.14,15

Storing and access of controlled substances Title 21, CFR Section 1301.71(a) specifies considerations for storing controlled substances at a business or practice site.

Volume 15 Number 2

CONTINUING EDUCATION

Some of these include the type of building, type/quantity of controlled substances to be stored, type of safe, vault or locked steel cabinet, and alarm systems. Controlled substances purchased for dental office practices must be kept in a “locked, well-constructed metal cabinet or safe.” Access to controlled substances should be limited. Equally important is determining who may have access to controlled substances within the dental practice. The DEA lists very specific individuals who may not have access. This list includes the following: 1. Any person who has been convicted of a felony offense related to controlled substances 2. Any person who has been denied a DEA registration 3. Any person who has had a DEA registration revoked 4. Any person who has surrendered a DEA registration for cause Prior to hiring of personnel for the dental practice, it is prudent to complete thorough background investigations and screen for potential exclusions in this list.16

Summary

The controlled substances act. DEA. https://www.dea.gov/drug-information/csa. Accessed December 22, 2021.

Disposal of controlled substances

O’Neil M. Common Substances and Medications of Abuse. In: The ADA Practical Guide to Substance Use Disorders and Safe Prescribing. Wiley Blackwell; 2015.

Key terms and definitions. SAMHSA. https://www.samhsa.gov/section-223/certification-resource-guides/key-terms-definitions. Accessed December 21, 2021. Accessed March 21, 2022.

Melton S, Orr R. Detection and Deterrence of Substance Use Disorders and Drug Diversion in Dental Practice. In: The ADA Practical Guide to Substance Use Disorders and Safe Prescribing. Wiley Blackwell; 2015.

Prescription Drug Monitoring Programs (pdmps). Centers for Disease Control and Prevention. https://www.cdc.gov/drugoverdose/pdmp/index.html. Published May 19, 2021. Accessed March 21, 2022.

O’Neil M, Winbigler B, Sowards N. Prescription Medication Diversion: Detection and Deterrence. Journal California Dental Association. 2019;47(3):179-185.

Aquinos C. Office Management of Controlled Substances. In: The ADA Practical Guide to Substance Use Disorders and Safe Prescribing. Wiley Blackwell; 2015.

E-Prescribing. Centers for Medicare and Medicaid Services. https://www.cms.gov/ Medicare/E-Health/Eprescribing. Accessed March 21, 2022.

How to appropriately dispose of controlled substances and document the disposals are critical considerations when handling these medications. Whenever controlled substances need to be destroyed due to being leftover following patient administration, are found broken, have become contaminated, or have expired, the risk for potential diversion is high. Ideally, these medications should be transferred to a designated “take-back” facility commonly known as reverse distributors. An alternative method involves having the DEA Special Agent in the practitioners’ area destroy the medications on-site. Other alternative methods for destruction may be found in the controlled Substance Act 21 CFR Part 1317. These records must be “readily retrievable” and maintained for 2 years.17

In summary, management of controlled-substance prescribing practices and record keeping require a comprehensive knowledge regarding methods to detect and deter attempts to divert medications from dental practices. Two important methods to optimize prescribing include use of the state’s PDMP and implementation of ePrescribing. Maintaining detailed records for storage, transfer, and disposal of controlled substances is also necessary to ensure adherence to federal, state, and dental board statutes and regulations. Dental practitioners should only prescribe medications to patients registered with their dental practice. EP

REFERENCES

Reporting theft or loss of controlled substances When dental practitioners suspect theft or loss of controlled substances, they should complete an inventory of controlled substances and immediately file a DEA 106 Theft/Loss form, which is available online or through a downloadable PDF. If theft is suspected by burglary or employee pilfering, local law enforcement should also be notified.

Common violations by dental practitioners Dental practitioners may be investigated and ultimately prosecuted for a variety of reasons. Frequently, this may involve being nonadherent to federal regulations — e.g., failing to maintain up-to-date inventory records, failure to store controlled substances safely, failure to dispose of controlled substances appropriately, and failing to renew registrant license. Out of convenience, dental practitioners may prescribe medications for nondental-related issues. For example, prescribing oral contraceptives for pregnancy prevention or potent analgesics for migraines would be considered prescribing outside the scope-ofpractice. Any prescription ordered by dental practitioners should be within their scope of practice and for a patient with records at the practice site.7 Endodontic Practice US

10. H.R.6 – SUPPORT for Patients and Communities Act. Public Law 10/24/2018. https:// www.congress.gov/bill/115th-congress/house-bill/6/text. Accessed March 21, 2022. 11. Carter L. 2021 Survey of Pharmacy Law. National Association of Boards of Pharmacy. www.nabp.pharmacy. Accessed March 21, 2022. 12. E-prescribing. Centers for Medicare and Medicaid Services. https://www.cms.gov/ Medicare/E-Health/Eprescribing. Accessed March 21, 2022. 13. eCFR: 21 CFR Chapter II -- Drug Enforcement ... https://www.ecfr.gov/current/title-21/ chapter-II. Accessed March 21, 2022. 14. eCFR :: 21 CFR part 1305 -- orders for schedule I and II ... https://www.ecfr.gov/ current/title-21/chapter-II/part-1305. https://www.ecfr.gov/current/title-21/chapter-II/ part-1305/subpart-A/section-1305.04. Accessed March 21, 2022. 15. eCFR :: 21 CFR part 1305 -- orders for schedule I and II ... https://www.ecfr.gov/current/ title-21/chapter-II/part-1305. Accessed March 21, 2022. 16. eCFR :: 21 CFR 1301.71 -- security requirements generally. https://www.ecfr.gov/ current/title-21/chapter-II/part-1301/subject-group-ECFRa7ff8142033a7a2/section-1301.71. Accessed March 21, 2022. 17. eCFR :: 21 CFR Part 1317 -- disposal. https://www.ecfr.gov/current/title-21/chapter-II/ part-1317. Accessed March 21, 2022. 18. Theft/Loss Reporting. Significant Theft or Loss Reporting of Controlled Substances. Diversion Control Division: https://www.deadiversion.usdoj.gov/21cfr_reports/theft/. Accessed March 21, 2022.

Volume 15 Number 2

CONTINUING EDUCATION

Continuing Education Quiz Managing controlled substances in dental practice: prescribing and record keeping DOUGHERTY/O’NEIL/SOWARDS

_______ may be defined as taking a prescription medication outside of the boundaries of the initial prescription’s “intent for use” or directions. a. Prescription medication misuse b. Medication diversion c. Substance abuse/misuse d. Red flag indicator

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), no longer uses the terms substance abuse and substance dependence. Rather, it refers to ________. a. substance misuse b. substance use disorders c. prescription misorder d. prescription diversion

________ is the movement of a prescription medication in any direction other than how legally allowed to be transferred by law. a. Due diligence b. Prescription Medication Diversion c. Substance mis-transfer d. Controlled substance misuse

_________ is the practice of performing reasonable verification that the information presented is accurate and reliable in order to prevent deceptive or criminal practices. a. Red flag deterrence b. Drug program monitoring c. Due diligence d. Dose Monitoring

________ means the record is kept or maintained in such a manner that it can be separated out from all other records in a reasonable time or that it is identified by an asterisk, redline, or some other identifiable manner such that it is easily distinguishable from all other records. a. Readily retrievable b. Due diligence c. Redline ready d. On file

Dental practitioners should analyze the Prescription Drug Monitoring Program (PDMP) report for _________ and early refills. a. active controlled substances b. recent controlled substance prescriptions from other prescribers c. duplicate prescriptions d. all of the above

Each article is equivalent to two CE credits. Available only to paid subscribers. Free subscriptions do not qualify for the CE credits. Subscribe and receive up to 16 CE credits for only $149; call 866579-9496, or visit https://endopracticeus.com/subscribe/ to subscribe today. n To receive credit: Go online to https://endopracticeus.com/continuingeducation/, click on the article, then click on the take quiz button, and enter your test answers. AGD Code: 157 Date Published: June 6, 2022 Expiration Date: June 6, 2025

2 CE CREDITS

The use of preprinted prescriptions with the medication name, medication strength, dosage, and directions is ________. a. highly discouraged b. always encouraged c. illegal d. mandated by the PDMP

According to Title 21, CFR Section 1301.71(a) specifies considerations for storing controlled substances at a business or practice site. … Controlled substances purchased for dental office practices must be kept in _______. a. a cabinet that may be unlocked, depending on its location b. a locked, well-constructed metal cabinet or safe c. a cabinet or box marked “controlled substances” d. a refrigerator that patients cannot see

Dental practitioners may be investigated and ultimately prosecuted for a variety of reasons. Frequently, this may involve being nonadherent to federal regulations — e.g., _________ and failing to renew registrant license. a. failing to maintain up-to-date inventory records b. failure to store controlled substances safely c. failure to dispose of controlled substances appropriately d. all of the above

10. Any prescription ordered by dental practitioners should be ________. a. within their scope of practice b. for a patient with records at the practice site c. handwritten for controlled substances only d. both a and b

endopracticeus.com

Volume 15 Number 2

PRACTICE MANAGEMENT

Reduce management stress by monitoring reviews Dr. Mehmood Asghar suggests ways to manage your practice’s reputation

oday successfully managing a dental practice can be daunting and challenging. In addition to providing quality dental services to patients, dentists must think like seasoned strategists and business people to ensure that their practice runs smoothly while being profitable. The 2021 Dentist Well-Being Survey Report by the American Dental Association reports that the percentage of dentists suffering from anxiety and stress at work tripled in 2021 compared to 2003 (5%).1 Unfortunately, dental schools do not teach budding dentists about the upcoming business challenges. And even established dentists are not aware of how to deal with the effects of modern social media. That is why, despite having state-of-the-art equipment and an experienced team, many dentists struggle with day-to-day glitches related to social media. Today as consumers increasingly rely on social media to buy products and even medical and dental services, the demand for maintaining a good online presence has never been higher. Even with state-of-the-art, fully equipped dental offices, dentists cannot stand out from the rest unless they advertise themselves effectively. One of the factors that should not be overlooked is reputation management. Your dental practice’s reputation can be leveraged as an effective marketing asset, especially when it comes to “word-ofmouth” marketing. Effective and targeted reputation management strategies can help you increase patient flow and profitability. But first, let us look at why online reputation management is so important. To understand how managing your business’s reputation can help you, let us look at some data. BrightLocal conducted a survey on the impact of reviews of Google click-through rates.2 It was observed that businesses having overall positive reviews got more clicks than ones with negative reviews. It was also shown that a jump from 3-star to a 5-star rating resulted in 25% more clicks and visits. Interestingly, 56% of the respondents said that positive reviews were what led them to visit a website. So, a reputable online presence makes all the difference between a successful or struggling endodontic practice.

Reputation management — best practices 1. Encourage your patients to post reviews

In today’s world, your practice’s success is directly proportional to how well-known you are in the online market, and how many 5-star reviews you have. Therefore, it is essential to have as many online reviews — whether on Facebook, Twitter, Yelp, or Google — as possible. While it is not a good idea to ask your patients directly to post positive reviews, you can encourage them to leave their feedback. For example, when a patient is leaving, one of your front desk staff can say, “Thank you for visiting us. If you liked our services, please don’t forget to provide your valuable feedback on our Facebook page. You can also let us know anything that concerns you, or if you feel there is room for improvement in our services. Have a nice day!”

2. Check your online reviews regularly The first step in developing and subsequently maintaining your reputation is keeping a close eye on your online patient reviews. One of your team members must be delegated to check your social media pages, Yelp, and Google reviews regularly and respond to them promptly.

3. Listen to what your patients are saying If you are frequently getting a negative review or complaint regarding a specific issue, there must be a reason. While it is easy to simply jump in and reply to a Facebook post or Google review, you must take time to read each post/review and try to understand the underlying issue — especially if it is something unpleasant. It is very important to take steps to resolve the issue and let your patients know that the matter has been taken care

Dr. Mehmood Asghar is a dentist, an educator, and a researcher in dental biomaterials. He is currently working as an Assistant Professor in Dental Biomaterials at the National University of Medical Sciences, Pakistan, in addition to pursuing a PhD in Dental Biomaterials. Apart from his professional activities, Dr. Asghar loves reading, writing, and working out. He is currently writing for Bond Street Dental (www.dentalimplantsclinic.ca) in Toronto, Canada.

Endodontic Practice US

Volume 15 Number 2

BUSINESS OPERATIONS

HUMAN RESOURCES

INSURANCE

SUPPLIES & EQUIPMENT

PRACTICE MANAGEMENT

of. Patients love it when their voice is heard and their opinion is given weight!

4. Handle negative reviews professionally Negative reviews are part of the deal! Even the best-performing businesses like Apple or Amazon also get negative reviews. So, they are nothing to be afraid of or ashamed of — sometimes they may not be based on facts. On the other hand, some negative reviews carry genuine feedback for improvement. If your Facebook or Google page gets a negative review, analyze the comment first. If it is factual, make sure to thank the customer for his/her opinion, and act upon the advice. On the other hand, if you believe that the comment is unnecessary or incorrect, you can politely set the facts straight. Remember, a nasty confrontation will not get you anywhere!

How will my words or attitude affect my current and future patients? So, instead of lashing out, simply apologizing to an unreasonable patient can do wonders, and save you from hours of online debate and justifications. In today’s world, online effective marketing and reputation management for dentists are requirements, not options anymore.3 Remember, patients choose dental practices in their area based on their positive reviews. If you have already been investing in online marketing but to no avail, perhaps it is time to start developing a good reputation management strategy. EP

REFERENCES 1.

Burger D. Dentist Health and Well-Being Survey Report finds dentists struggle with anxiety, discomfort at work. ADA Council on Dental Practice. Published February 22, 2022. Online at: https://www.ada.org/publications/ada-news/2022/february/dentist-healthand-well-being-survey-report-finds-dentists-struggle-with-anxiety. Accessed April 5, 2022.

Bonelli S. Impact of Reviews and Ratings on Search Click-Through Rates. Brightlocal. Published April 25, 2017. https://www.brightlocal.com/research/review-search-clickthrough-study/. Accessed April 5, 2022.

Reber M. Shift your practice into high gear by turning your endo marketing upsidedown! Endodontic Practice US. 2019;12(2):36. https://endopracticeus.com/shift-yourpractice-into-high-gear-by-turning-your-endo-marketing-upside-down/. Accessed April 5, 2022.

5. Set aside your ego Sometimes proving your point can do more harm than good. Whatever you will say on social media in response to a patient’s comment or negative feedback will be read and scrutinized by hundreds of your followers and patients. So, instead of winning the ego battle or proving someone wrong, look at things from a broader perspective: What is the lifetime value of this patient?

Endodontic Practice US Webinars LEARN about the lastest techniques and technology

from industry leaders with our free live and archived educational webinars. Our online seminars are a convenient way to access great information and upskill. Check out our most recent webinars: •

Safe and Efficient Preparation of Complex Root Canal Systems with host Dr. Ralf Schlichting

•

“Endo Your Way”: How Advanced Bioceramics Can Benefit Your Practice with host Dr. Ryan M. Walsh

•

A Novel Approach to Endodontic Irrigation with host Dr. Brett Gilbert

•

5 Ways to Decrease Overhead and Increase Productivity with host Dr. Jason Streeter

WATCH NOW at https://endopracticeus.com/webinars/

Connect. Be Seen. Grow. Succeed. | www.medmarkmedia.com

Endodontic Practice US

Volume 15 Number 2

MATERIALS & EQUIPMENT

Gemini EVO™ laser: the next evolution in laser dentistry Ultradent Products, Inc., developer and manufacturer of high-tech dental materials, has introduced the latest addition in the Gemini™ laser family, the Gemini EVO™ diode laser. The Gemini EVO laser provides 100 watts of peak power — 5x the power of the original Gemini laser — for faster cutting, less heat, and ultra-clean incisions in soft tissue. User-friendly operation is facilitated through a guided touch interface, and multiple preset procedures are divided into three categories for efficient, intuitive use. Wi-Fi connectivity allows for over-the-air updates with dedicated tech support — there’s also a mobile app and dashboard to monitor usage statistics, including ROI. Three PBM adapters are included with the Gemini EVO laser (3 mm, 7 mm, and 25 mm), so clinicians can take full advantage of laser technology in their office. It also features a 2-year warranty (which can be extended), has three wavelength modes, and uses the same tips as the original Gemini™ laser. For more information about Ultradent, visit ultradent.com, or call 800-552-5512.

Flex Dental announces integration with Dentrix Flex Dental announced a new release offering full and seamless integration with Dentrix G6 and G7. Dentrix customers can use Flex’s innovative and highly automated communication tools to engage with customers and increase revenue opportunities. Benefits for Dentrix users include the following: • Seamless patient communication that includes two-way, real-time texts and email. • Automated patient reminders that have been proven to reduce no-shows. • Digital patient forms that instantly update in Dentrix, eliminating paper and manual data entry for staff. • Compelling treatment plan presentations that increase acceptance and patient recall. • A streamlined and simplified process for requesting patient feedback and positive reviews that link directly to popular social media platforms. For more information on Flex’s integration with Dentrix, visit https://www.flex.dental/flex-with-dentrix.

Enhanced ultrafiltration technology makes dental office water safer Toppen Dental, developer of dental office disinfection and water treatment solutions, has launched its UltraSafe™ ultrafiltration platform. UltraSafe provides a chemical-free answer to keeping dental unit water lines in compliance with CDC and ADA recommendations that protect patients and staff from waterborne microorganisms known to cause disease. UltraSafe incorporates Toppen’s proprietary Energized Fiber Matrix (EFM) technology that imparts an electro-adhesive charge to a specially adapted nanofiber filtration structure. The charged nanofibers form a barrier membrane that removes microorganisms, including bacteria, viruses, and fungi from dental office water. UltraSafe with EFM has been incorporated into a range of dental products. The line includes UltraSafe Micro Straws for chairside bottles and UltraSafe In-Line Cartridges, which can be connected directly to dental chair water lines. To learn more about Toppen Dental and UltraSafe, visit toppendental.com.

Nobio announces the launch of the Infinix™ Advanced Restoratives product line Nobio Ltd. has launched Infinix™, a new line of advanced antimicrobial restorative materials, designed to fight recurrent decay. The Infinix system currently includes universal and flowable composites, as well as a universal bonding system, all incorporating Nobio’s patented QASi™ antimicrobial particle technology. A bulk-fill composite will be added later in 2022. The company’s patented antimicrobial technology is scientifically proven to provide a non-leaching, non-releasing, electrostatic contact kill of bacteria in dental restorative materials. For more information, visit infinix.com/shop or call (844) INFINIX (463-4649). endopracticeus.com

Volume 15 Number 2

ENDOSPECTIVE

The business of healthcare Dr. Robert M. Fleisher discusses advertising, ethics, and professionalism

e find The Top Docs awards in just about every city with a magazine touting the best burger, the best pizza, the best of everything. How does that make you feel if you didn’t go to the TOP DOC? I’m the best! No, I’m the best! So, who is the best when everyone claims to be the best doctor in the land? Patients forever asked if I knew their heart doctor because “He’s the best.” I never heard of him but kept that to myself. In historical tradition, professionals, including healthcare providers and lawyers, weren’t permitted to advertise their services. It was considered unethical and was a reason to refuse entry into professional societies. Advertising by lawyers, doctors, hospitals, and almost every professional began as a legal challenge by lawyers. The ethics of advertising goes back to 1908 when the American Bar Association set its first code of ethics, “The Canons of Professional Ethics,” which forbade all advertising. However, it wasn’t until 1977 with the Supreme Court ruling in Bates v. Arizona State Bar, which stated lawyer advertising is partially protected by the First Amendment. From that case, lots of attempts by various states to reign in advertising failed, with court challenges making the practice of advertising commonplace. While there are still ethical restrictions in place, most have gone by the wayside or are no longer followed. In medicine, professionals deemed the restrictions and ethical importance ever more critical than in the legal profession. Before the lawyers decided to have ethics, in 1847, the American Medical Association wrote its code of ethics. Without ambiguity, the AMA forbade any form of advertising, deemed it “highly reprehensible” and “derogatory to the dignity of the profession.” The ethics rules would save unsuspecting patients from ill-trained, money-motivated providers hawking expensive, unproven cure-alls. By 1975, the FTC accused the legal profession of “restraint of trade.” Then, coupled with the 1977 Supreme Court ruling, the end of ethical restraint of advertising began for all professions. Robert Fleisher, DMD, graduated from Temple University School of Dental Medicine in 1974 and received his certificate in endodontics from the University of Pennsylvania in 1976. He taught at Temple University and the University of Pennsylvania and is now a member of the Affiliate Attending Staff – Albert Einstein Medical Center, Philadelphia, Department of Dental Medicine, Division of Endodontics, Philadelphia, Pennsylvania. Dr. Fleisher is the founding partner of Endodontics Limited, P.C., one of the larger endodontic practices in the United States. After retiring from practice, he now devotes his time to writing about practice management, aging and health issues, and fiction with a medical bent. Disclosure: Part of this article is an excerpt from, Bedside Manner – How to Gain Your Patients’ Respect Love & Loyalty by Dr. Robert M. Fleisher, Uphill Books.

Endodontic Practice US

Healthcare professionals in the early days, even as late as the 1970s, began to practice with great disdain for advertising. These feelings lasted until all the court challenges resulted in what we see today — massive advertising by most healthcare providers, hospitals, and medical device and prescription drug makers. One early example of dental advertising goes back to the days of Painless Parker (born Edgar R.R. Parker but legally changed his name to Painless when accused of false advertising). He was described as “a menace to the dignity of the profession” by our own American Dental Association. As a graduate of Philadelphia Dental College, which would eventually become my alma mater, Temple University School of Dentistry, he began to practice and for 6 months, had no patients. That’s when he hired one of P.T. Barnum’s ex-managers to take his show on the road. As one of the early advocates for advertising, he did manage to establish a chain of dental offices, employing more than 70 dentists and grossing over $3 million per year. It sure seems like advertising pays, and our profession has accepted the practice full-heartedly, backed by legal precedent. From 1997 to 2019, spending on direct-to-consumer healthcare advertising skyrocketed from $2.1 billion to $9.6 billion. Today, advertising by professionals is accepted and wellentrenched. While authorities designed the advertising restrictions to distinguish between a trade and a profession, and all the trust and dignity associated with the latter, advertising has many benefits. For example, awareness of procedures, medicines, and outcomes may be admirable. However, what happens to the patient who just had a procedure by Dr. A at hospital B, only to hear on the radio that Dr. C at hospital D is the best and most highly rated place to go? The level of confusion, the degrading of trust, and the appearance of self-serving promotion goes a long way to take doctors off their pedestals and place them next to lawyers. Is it any wonder that lawsuits against doctors, once a taboo, have become commonplace? There’s something tawdry about advertising healthcare, and while some restrictions and guidelines still exist, we have truly become a business to the potential detriment of professionalism. Since we are not going to change the state of healthcare promotion, let’s look at the business of healthcare. Of course, profit should not be the prime motivator in the healthcare professions. However, there is nothing wrong with selling medicine as long as doctors place the health and welfare of the patient above all else. While we think of the plastic surgeon or the cosmetic dentist as the salespeople of the healthcare industry, every doctor is really selling something to someone, as ignoble as that sounds. Even the oncologist and cancer surgeon are selling their particular protocol and service. After all, who doesn’t go for a second opinion? Most patients don’t understand the medicine, even after explaining it well. What they do understand are the components Volume 15 Number 2

ENDOSPECTIVE

of bedside manner. If you are a doctor with There is nothing wrong with selling medicine as a great bedside manner, they come back to you. When you have it, you’ve essentially sold long as doctors place the health and welfare of the them on you as much as, if not more than, the patient above all else. protocol. Once the student graduates from one professional school or another, they get exposed to an onslaught of programs and lectures Finding patients easy credit for elective procedures may put explaining how to make more money, spend less time in the them in debt for years. You have to be a compassionate practioffice, and accomplish better service. The problem with these tioner and make sure you aren’t part of the vehicle that takes the promises is that the only one achieving these noble goals is the patient to bankruptcy. person on the lecture circuit spending less time in the office, Before advertising in healthcare, patients and doctors had a making a lot of money from all the attendees, and providing betdifferent mindset. Patients came in when they had a problem, ter quality in that they are not in the office performing iatrogenics. The big business of medicine is not all bad. Wherever there is and doctors addressed the problem. Prevention and lifestyle a lot of money, innovation and technology flourish. For example, were encouraged, but there was little, if any, selling. Now gurus once dentists realized that they could sell cosmetics and adverteach you how to advertise effectively, literally chart monthly tise the procedures, money poured into new materials that might production, increase sales of the most lucrative procedures, offer never have been developed without the promise of big profits. financing for better case acceptance, and encourage staff to sell In medicine, many technologies and new and exciting drugs for participating in production goals that have to go up continumay have never come to pass without the extensive research dolally. This protocol sounds a lot more like corporate America than lars generated by the pharmaceutical companies. The promise of the medical profession. vast riches will make an artificial heart and the cure of cancer You have to ask yourself what distinguishes you as a profesrealities. sional. Patients aren’t stupid. They can often see through all the When you develop your selling philosophies and protocols hype and recognize a promoter. Your credibility rapidly fades for elective treatment, you must make sure you are not pushwhen the patient perceives you as a salesperson. It’s imperative ing unnecessary procedures or procedures your patients cannot to learn that a big part of being compassionate is not selling your patients things they don’t need and can’t afford. afford. Many lecturers tell you how to help patients find the We have gone from an era where doctors weren’t allowed to money for procedures you convince them they need. You have make claims of superiority to daily advertising that makes claims, to ask yourself if they truly need the service or if you are pushdirect or implied, that one hospital and its doctors are better than ing it past many other things they may now have to do without all others. So maybe it’s time to rethink professionalism. EP because you sold them a bill of goods.

Endodontic Practice US 3 REASONS TO SUBSCRIBE

dca

149 / 1 year digital only 79

lants

Imp

ners Part

r thedo Endo

fo olora rinNtorthern C

p Blue

re futudontics

the

AST DC PO

Connect. Be Seen. Grow. Succeed. | www.medmarkmedia.com

endopracticeus.com

Volume 15 Number 2

dive

s an

le o Fi End New

nexp

ecte

No 2

com eus.

ctic

opra

end

Vol 15 022 er 2

Sum

e Issu

his in T

ndo

ble

ila Ava dits

3 SIMPLE WAYS TO SUBSCRIBE • Visit www.implantpracticeus.com • Email subscriptions@medmarkmedia.com • Call 1-866-579-9496

.com

/po

USE

. now inges in Endo. eam am r t pn s to the es sod s with s epionversation

ing gniz s reco ture T — struc rgery CBCtomic lant su ana re imp icznyk t befo hn Pas men Jo Dr. g a ge man nitorin o uce Red ss by m stre ws d Asghar revie ehmoo lled M l ntro Dr. g co enta agin s in d Man stance D sub tice ty, PharmD c er pra ough l, Pharm

p Dee

1 year

sts

• 16 CE credits available per year • 1 subscription, 2 formats – print and digital • 4 high-quality, clinically focused issues per year

D ei rD Tyle el O’N , Pharm ha Mic Sowards Nikki

ND IN E

T IC

SERVICE PROFILE

It takes a team to be your best An interview with William B. Looney, DMD, a HighFive Partner What inspired you to become an endodontist?

You try to gravitate toward the things you like and the things you’re good at and hope those two cross. So, endodontics is a little bit mathematical, and I was a math major in school. Not to mention, you truly get to help people that are feeling pretty bad.

Can you tell us a bit about your background?

I went to college at Birmingham Southern College, which had a math/business interdisciplinary major. Then I attended the University of Alabama (UAB) School of Dentistry.

Did taking business classes in college help you run a practice?

Before partnering with HighFive, I would have said yes. But after HighFive came along, I realized how little I truly knew. We all try our best to handle the business side, but we’re usually too occupied with the dentistry part.

What advice would you give to new graduates?

Focus on the dentistry. Stay true to your roots. Work. Strive for perfection in every case, and be kind to your patients. If you focus on that, the rest will fall into place.

How important is it to find the right people for your staff?

William B. Looney, DMD, practices at Endodontic Associates, PC

I couldn’t do it without them. My staff members keep me going. It’s priceless knowing they have my back, so I get to do what I’m good at. And as a referral practice, when you have other offices call, and they know the people on the other end, that really helps develop relationships.

How has your practice and life changed after partnering with HighFive? I’ll tell you I’ve loved every day of it. HighFive has made practicing a lot better. In my opinion, it’s the only way to practice. HighFive takes care of all the stuff behind the scenes that we used to, so we can focus on what we like, and what we are good at. We thought we were good at the business side, but HighFive are pros, and we’re not. I couldn’t go back to the way I used to practice.

What sets HighFive apart from other groups?

HighFive wants to be invisible. The HighFive Healthcare team doesn’t want to tell you how to do root canals. They want you to do what you do, and they just handle the rest. They do Endodontic Practice US

show us opportunities to improve, but they really let you do what you want to do.

How important is having a network of colleagues you can turn to for advice? I joined HighFive right as the pandemic hit. The first thing HighFive did was get everyone on the phone. We worked through our protocols before the state had even put out theirs. A lot of our friends were solo practitioners. They had to figure things out on their own, while we had 20 minds working on the same goal.

What do you think is the future of endodontics?

I think our future is bright. The technology that we have really advances the profession. Everyone knows that people are living longer and are more committed to holding on to their teeth longer. As people get older, I can promise you the root canals get harder, and as you know, that’s kind of our wheelhouse. To learn more, visit www.High5health.com. EP This information was provided by HighFive.

Volume 15 Number 2

AUTHOR GUIDELINES

How to submit an article to Endodontic Practice US Endodontic Practice US is a peer-reviewed, quarterly publication containing articles by leading authors from around the world. Endodontic Practice US is designed to be read by specialists in Endodontics, Periodontics, Oral Surgery, and Prosthodontics.

ance in the text. The majority of references should be less than 10 years old. Provide inclusive page numbers, volume and issue numbers, date of publication, and all authors’ names. References should be submitted in American Medical Association style. For example:

Submitting articles

Journals: (Print) White LW. Pearls from Dr. Larry White. Int J Orthod Milwaukee. 2016;27(1):7-8.

Endodontic Practice US requires original, unpublished article submissions on endodontic topics, multidisciplinary dentistry, clinical cases, practice management, technology, clinical updates, literature reviews, and continuing education. Typically, clinical articles and case studies range between 1,500 and 2,400 words. Authors can include up to 15 illustrations. Manuscripts should be double-spaced, and all pages should be numbered. Endodontic Practice US reserves the right to edit articles for clarity and style as well as for the limitations of space available. Articles are classified as either clinical, continuing education, technology, or research reports. Clinical articles and continuing education articles typically include case presentations, technique reports, or literature reviews on a clinical topic. Research reports state the problem and the objective, describe the materials and methods (so they can be duplicated and their validity judged), report the results accurately and concisely, provide discussion of the findings, and offer conclusions that can be drawn from the research. Under a separate heading, research reports provide a statement of the research’s clinical implications and relevance to endodontics. Clinical and continuing education articles include an abstract of up to 250 words. Continuing education articles also include three to four educational aims and objectives, a short “expected outcomes” paragraph, and a 10-question, multiple-choice quiz with the correct answers indicated. Questions and answers should be in the order of appearance in the text, and verbatim. Product trade names cited in the text must be accompanied by a generic term and include the manufacturer, city, and country in parentheses. Additional items to include: • Include full name, academic degrees, and institutional affiliations and locations • If presented as part of a meeting, please state the name, date, and location of the meeting • Sources of support in the form of grants, equipment, products, or drugs must be disclosed • Full contact details for the corresponding author must be included • Short author bio • Author headshot

Pictures/images

(Online) Author(s). Article title. Journal Name. Year; vol(issue#):inclusive pages. URL. Accessed [date]. Or in the case of a book: Pedetta F. New Straight Wire. Quintessence Publishing; 2017. Website: Author or name of organization if no author is listed. Title or name of the organization if no title is provided. Name of website. URL. Accessed Month Day, Year. Example of Date: Accessed June 12, 2011. Author’s name: (Single) (Multiple) Doe JF Doe JF, Roe JP

Permissions

Written permission must be obtained by the author for material that has been published in copyrighted material; this includes tables, figures, pictures, and quoted text that exceeds 150 words. Signed release forms are required for photographs of identifiable persons.

Disclosure of financial interest

Authors must disclose any financial interest they (or family members) have in products mentioned in their articles. They must also disclose any developmental or research relationships with companies that manufacture products by signing a “Conflict of Interest Declaration” form after their article is accepted. Any commercial or financial interest will be acknowledged in the article.

Manuscript review

All clinical and continuing education manuscripts are peer-reviewed and accepted, accepted with modification, or rejected at the discretion of the editorial review board. Authors are responsible for meeting review board requirements for final approval and publication of manuscripts.

Illustrations should be clearly identified, numbered in sequential order, and accompanied by a caption. Digital images must be high resolution, 300 dpi minimum, and at least 90 mm wide. We can accept digital images in all image formats (preferring .tif or jpeg).

Proofing

Tables

Articles should be submitted to:

Ensure that each table is cited in the text. Number tables consecutively, and provide a brief title and caption (if appropriate) for each.

References

References must appear in the text as numbered superscripts (not footnotes) and should be listed at the end of the article in their order of appearendopracticeus.com

Page proofs will be supplied to authors for corrections and/or final sign off. Changes should be limited to those that are essential for correctness and clarity.

Mali Schantz-Feld, managing editor, at mali@medmarkmedia.com

Reprints/Extra issues

If reprints or additional issues are desired, they must be ordered from the publisher when the page proofs are reviewed by the authors. The publisher does not stock reprints; however, back issues can be purchased.

Volume 15 Number 2

PRODUCT SPOTLIGHT

MANI JIZAI NiTi File System JIZAI can be translated from Japanese to mean “being at will”

he JIZAI system is the newest addition to the Mani endodontic product line. Three foundational concepts form the basis of JIZAI. 1. Smooth designs provide an optimal cutting experience. Radial lands help prevent overinstrumentation and excessive engagement on the root canal walls. The off-center file axis is uniquely designed to provide a larger “pocket” space for debris removal during instrumentation. 2. Flexible respects the original anatomy. The heat treatment that each JIZAI undergoes results in a significantly lower risk of ledging, transportation, and perforation. 3. Simple describes how files shape severely curved canals with ease through procedural-based sequencing. Tip size and taper are etched on the shank. Each file is fully heat-treated, highly flexible, and designed to cut smoothly and efficiently. The cross-sectional shape and flute

pitch help prevent overinstrumentation and file binding. Each file can be pre-bent and will hold its shape. The Japan-manufactured files are available in individual ISO-sized packs of three files or as part of a Standard Kit, which includes a sequence of 25.04, 25.06, and 35.04 files designed to instrument straight and slightly curved canals.

About MANI, Inc. Established in 1956 in Takenzawa, Japan (north of Tokyo), by our founder, Masao Matsutani, MANI is a manufacturer of medical devices and dental instruments. Ever since we began manufacturing suture needles in 1956, we have contributed to society as a medical device manufacturer supplying medical and dental instruments. We made this possible by establishing microfabrication technologies using wire as a base material. Our singular goal is “Contributing to people’s happiness in the world through developing, manufacturing, and delivering the product that can help doctors and patients.” Our products are safe, high-quality medical devices that satisfy the needs of doctors and patients. The products have also passed the strict standards of various countries around the world. EP

SOURCES 1.

http://www.mani.co.jp/en/pdf/dental02_01.pdf

https://exendo.pt/products/jizai-new-niti-rotary-file

https://endopracticeus.com/mani-inc-from-our-hands-to-yours-the-best-quality-inthe-world-to-the-world/

This information was provided by MANI, Inc.

Endodontic Practice US

Volume 15 Number 2

PRODUCT SPOTLIGHT

Using bioactive bioceramics to heal dens evanginatus Dr. Rico D. Short discusses dens evaginatus treatment with a combination of two bioactive bioceramic products Introduction Bioactive bioceramic materials offer two advantages as endodontic procedures. First, their biocompatibility prevents rejection by the surrounding tissues. Second, bioceramic materials’ properties are enhanced by containing calcium-bearing compounds, which react with body fluids to form calcium phosphate on their surface. The calcium phosphate precipitate is similar to tooth and bone apatite mineral and Figures 1 and 2: 1. Preoperative radiograph of tooth No. 29 with an open apex and periapical pathology denoted as bioactivity and supports healing (left). Postoperative image after treatment with NeoSEALER Flo, NeoPUTTY and gutta percha (right). at the apical foramen. 2. Radiograph of tooth No. 29 at 6-month recall with healing on tooth No. 29 and resolution of lesion Dens evanginatus is a developmental and sinus tract. anomaly usually found in mandibular premolars and lingual surfaces of anterior teeth. First, a small amount of bioceramic sealer (NeoSEALER® Flo; It’s characterized by the presence of an enamel tubercle on the Avalon Biomed) was injected with a Flex Flo tip into the canal. occlusal surface, often causing trauma. The occlusal trauma may Second, bioceramic putty (NeoPUTTY®; Avalon Biomed) was fracture the tubercle and expose a pathway for bacteria to infect inserted and pushed down the canal close to the apex using the pulp chamber. If a necrotic pulp infection occurs, root devela gutta-percha cone pre-fit short of the working length. Third, opment will be arrested before maturation, leaving an open apex more NeoSEALER Flo was inserted with the Flex Flo tip, and the in need of endodontic therapy. A recent dens evaginatus case fourth step was backfilling with warm gutta percha. A tempoin my practice was successfully treated by combining two biorary restoration was placed. Figure 1 shows the pre-and post-op ® ® active bioceramic products, NeoSEALER Flo and NeoPUTTY radiographs. (Avalon Biomed). The patient returned for a 6-month recall and was asymptomatic. The sinus tract had completely resolved, and osseous Case discussion healing of the lesion was observed (Figure 2). A 16-year-old Asian-American male presented with discomfort associated with tooth No. 29. The tooth’s apex was open, Conclusion and a large periapical lesion was present extending from the Bioactive bioceramic products by Avalon Biomed are easy to apex up the disto-lateral portion of the root terminating with a use and indicated for a wide range of endodontic procedures. This sinus tract. (Figure 1 [left]). The diagnosis was dens evaginatus case shows the suitability of combining the lower viscosity sealer with a necrotic pulp and apical abscess. with the higher viscosity putty for treating dens evaginatus. EP The tooth was anesthetized, accessed, cleaned, and shaped. A size 140 Hedstrom file was used to gauge the apex size; then the canal was dried with paper points. A four-step obturation REFERENCES technique was used, referred to as a “Bioactive Sandwich.” 1. de Oliveira NG, de Souza Araújo PR, da Silveira MT, Sobral APV, Carvalho MV. Comparison of the biocompatibility of calcium silicate-based materials to mineral trioxide aggregate: Systematic review. Eur J Dent. 2018;12(2):317-326.

Rico D. Short, DMD, FICD, graduated from the Medical College of Georgia School of Dentistry in 1999 and completed his endodontic residency at Nova Southeastern University in 2002. He has performed externships in apical microsurgery at Miami Children’s Hospital and Universidad Autonoma de Tlaxcala in Tlaxcala, Mexico. Dr. Short has published research in the Journal of Endodontics and became a Diplomate of the American Board of Endodontics in April 2009.

Solanki NP, Venkappa KK, Shah NC. Biocompatibility and sealing ability of mineral trioxide aggregate and biodentine as root-end filling material: A systematic review. J Conserv Dent. 2018;21(1):10-15.

Niu LN, Jiao K, Wang TD, et al. A review of the bioactivity of hydraulic calcium silicate cements. J Dent. 2014;42(5):517-533.

Ginebra MP, Fernández E, De Maeyer EA, et al. Setting reaction and hardening of an apatitic calcium phosphate cement. J Dent Res. 1997;76(4):905-912.

This article was provided by Avalon Biomed.

Endodontic Practice US

Volume 15 Number 2

SMALL TALK

What is creative tension? Why does it matter? Drs. Joel C. Small and Edwin McDonald describe a powerful motivator that drives positive change

any of us are familiar with the concept of cognitive dissonance. Described initially by Leon Festinger in 1957, the theory of cognitive dissonance proposes that humans seek psychological consistency between their current reality and their perceived ideal reality. When a gap exists between the two, psychological tension, or dissonance, occurs. The more significance and value people attribute to the perceived ideal state, the greater the tension, and the more they seek to relieve it. For example, smokers may well understand that smoking is unhealthy, and they may desire a healthy lifestyle, and yet they continue to smoke and experience psychological tension because a gap exists between their reality and their perceived ideal state. The more they value becoming a nonsmoker, the greater the degree of tension. It has been our observation that those who are unable to close the ideal/reality gap continue to suffer psychological tension until they finally either close the gap and become nonsmokers, rationalize why smoking is acceptable, or submit to a self-limiting belief that they are simply incapable of reaching the perceived ideal state. The consequences of adopting this self-limiting belief can be significant as they live with constant frustration and loss of self-esteem. Interestingly, this same tension can be used in a more positive and generative way. Peter Senge, author of the book The Fifth Discipline (1990), introduced the concept of creative tension as a potential aid in facilitating creativity and change. According to Senge’s theory, we create positive (creative) tension when we clearly articulate our vision and our current reality, thus making the gap between the two apparent. Cognitive dissonance and creative tension both share a common etiology — tension created by the perceived gap between the ideal and the real. What distinguishes creative tension from chronic cognitive dissonance is the manner in which the tension is resolved.

Drs. Joel C. Small and Edwin (Mac) McDonald have a total of over 75 years of dental practice experience. Both doctors are trained and certified Executive Leadership Coaches. They have joined forces to create Line of Sight Coaching, a business dedicated to helping their fellow dentists discover a better and more enjoyable way to create and lead a highly productive clinical dental practice. Through their work, clients experience a better work/life balance, find more joy in their work, and develop a strong practice culture and brand that positively impact their bottom line. To receive their free ebook, 7 Surprising Steps to Grow Your Practice Through Leadership, go to www.lineofsightcoaching.com.

endopracticeus.com

It is our assertion that creative tension is a powerful motivator that drives positive change within organizations. It is also our belief that the following three essential elements must be present for creative tension to produce positive change.

Vision Jim Clemmer, a renowned leadership opinion leader, once stated, “If you can’t see it, you can’t be it.” Our vision is what allows us to see a preferred future state of being. Having a compelling vision of a preferred future is essential on a personal level, but how we communicate this vision to our team is even more critical.

Desirability Unless our team finds the vision compelling, they will lack the motivation necessary to make the vision a reality. Trusting the leader and believing in an overarching organizational purpose are important when seeking team motivation.

Self-efficacy There is perhaps no greater driving force for creative tension than people’s belief in their ability to attain the desired future state. Those that suffer from chronic cognitive dissonance do so because they either place little value in achieving their preferred future, or even more commonly, they believe that they are incapable of closing the ideal/reality gap. Creating a team’s sense of self-efficacy requires a growth mindset on the part of the leader. Believing in the capabilities of all team members, creating a psychologically safe environment, and allowing them a degree of autonomy will empower our teams and build their confidence in their ability to accomplish any goal. It is the doctor’s/leader’s responsibility to provide clarity of vision, an explanation of the tangible benefits of achieving the desired state, and all the resources and support that are required for the staff to be successful. Clinical practices that harness the power of creative tension are more productive than those that fail to recognize or utilize this valuable tool. Given these three essential elements, creative tension becomes energizing because team members view the task ahead as a means to an extremely desirable future. Once they embrace a clear vision that they find desirable and compelling, and they are confident in their capabilities, there is little that will stop them from achieving the desired result. For the team, the task becomes their mission. EP

Volume 15 Number 2

SERVICE PROFILE

US Endo Partners Building culture delivers financial returns

s today’s endodontists look to the future of their practices and careers, more are exploring the trend of practice partnerships and weighing the notion of an ideal culture and community against a lucrative financial opportunity. At US Endo Partners, we know the two go hand in hand — and we put that philosophy on display in US Endo played host to hundreds with gourmet coffee and great conversation in their booth during AAE22 in Phoenix April at AAE22 in Phoenix. US Endo Partners is a unique model, which allows you to stay uniquely you. Specialty Dental Service Organization With US Endo, you retain your clinical autonomy, (SDSO) founded in 2018 on an exciting practice culture, valued team members, and local mission to drive meaningful opportubrand identity. Dedicated to you, your team, and nity and growth for our team members your work-life balance, our Support Team works Diwaker Kinra, DDS, MS, Contemporary as we pursue excellence together. We with the business side of your practice in areas Endodontics, speaks to a crowd on “Proalso share a compelling vision to spread tecting the Value of Your Practice” in the US from marketing and human resources to revenue the life-changing power of saving teeth, Endo Booth at AAE22 in Phoenix cycle management and compliance. This supwhile proactively shaping our specialty portive-community dimension of US Endo Partners develops and and the next generation of endodontic leaders. We were the insulates our endodontists. In short, we do what we do best, so nation’s first SDSO exclusively for endodontists, and now we you and your team can do what you do best. are proud to announce that we were recently the nation’s first Partners and their practice teams feel the empowering endodontic SDSO to enjoy a successful equity event. connection and support of belonging to a special community “Clarity, alignment, and unity of purpose define our culture invested in each other’s success. Our annual Vision Summit and create value,” said Ronny Rowell, US Endo Partners Chief brings us all together to focus on personal and professional Operating Officer. “Our recent equity event shows that our growth, while building strong friendships, and our innovation of intentional focus on outstanding patient care, united with our a track of comprehensive development programs drives fulfillcommitment to fostering the growth of the whole person, pays ment among our clinicians. big dividends.” We also feel the power of giving back to our local commuThe US Endo Partners model is attractive on multiple levels. nities. US Endo was proud to join forces with the Foundation for First, we believe that the success we generate from our aligned Endodontics to launch the Domestic Access to Care Program in pursuit of excellence should be rewarded. Our Partners have a a quest to provide exceptional treatment to underserved patients stake in the company’s proven financial success. Our Partners across the country. are Class A shareholders in our company, which means you “Partnering with US Endo is so much more than a great busiinvest in your Partners, and they invest in you. Moreover, as a ness opportunity. Our culture is about growth in every aspect practicing endodontist, your work continues to produce for you of our lives — from improving our communication skills to at the same time as your investment. This allows our partners to leadership training, to advanced clinical training courses, and realize the benefits of retirement while they’re still building — beyond,” said Dr. Jeremy M. Young, US Endo Partners Operaand benefiting from — their careers. tional Excellence Leader. “I truly believe that being part of US The additional allure of US Endo Partners for endodontists Endo offers the chance to become not only a better endodontist, in all career stages is multifaceted, starting with our partnership but also a better boss, a better spouse, and a better friend. What we are building is unique; I’m truly thrilled to get to be a part of it.” When it’s time to talk, talk to the first and only SDSO with proven financial results and a supportive, growth-minded culture — US Endo Partners. We’re in active discussions with top-tier endodontists, and we have openings for associates and recent graduates who are looking to start their careers at a flourishing practice. Learn more about US Endo Partners by visiting usendopartners.com. EP More than 400 residents and hiring endodontists enjoyed the US Endo Hiring Social at the Lustre Bar on Thursday night of AAE22 in Phoenix

Endodontic Practice US

This information was provided by US Endo Partners.

Volume 15 Number 2

Commitment

to Patients and Each Other.

At US Endo Partners, we believe patient-centered care starts with saying “YES” to people in need. That’s why we were proud to partner with the Foundation for Endodontics to launch the Domestic Access to Care program in a quest to provide exceptional treatment to underserved patients across the country. Together, we are changing lives – including our own. Join US.

Discover how you can help increase access to care with US. www.aae.org/foundation

“It’s a beautiful thing to see hundreds of the best endodontists committed to the same vision and values – all in the patient’s best interest.” – Olivia Cook, DDS, Highland Endodontics, Partner and believer since 2020

the

The Spirit of US

USEndoPartners.com

PODCAST

AT A LOWER PRICE Versatility for all obturation techniques including warm vertical and cold lateral. Build your own bioceramic sealer kit with your choice of three dispensing tips to truly accomplish ENDO YOUR WAY.

(U.S. Customers Only)

2.2gm Refill Syringe $

Customize with your choice of tips

27.50

15.75

12.50

(20 pack price)

Flex Flo Tip TM

™

MADE IN THE U.S.A.

Basic Flex Tip

Flo Tip TM

avalonbiomed.com info@avalonbiomed.com