Endodontic Practice US - September/October 2015 Issue - Vol8.5

clinical articles • management advice • practice profiles • technology reviews

EXCELLENCE

Nonsurgical endodontic retreatment of extensive periapical lesions

IN

ENDODONTICS Reconstruction of a tooth with composite endocrown following root canal treatment Dr. Monika Dzieciątkowska

Drs. Fernando Muñoz Ayón, Jorge Paredes Vieyra, and Victor Manuel de la Torre Martínez

Understanding what ROI is really about Dr. Brian Trava

Practice profile Dr. Timothy Finkler

TRANSFORMING ENDODONTICS.

PROMOTING

MULTISONIC ULTRACLEANING.™

September/October 2015 – Vol 8 No 5

CBCT 3D imaging: the next endodontic frontier of the great endodontist Dr. John West

Are you transforming endodontics?

Sonendo can help.

Sonendo® SEE PAGE 42

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Is Your Practice State of the Art?

Surface of a root canal cleaned with conventional endodontic instruments (8000x magnification)

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Peters OA et al. (2003). Int Endo J. © 2015 Sonendo. All rights reserved. MM-0058 Rev 02

ASSOCIATE EDITORS Julian Webber BDS, MS, DGDP, FICD Pierre Machtou DDS, FICD Richard Mounce DDS Clifford J Ruddle DDS John West DDS, MSD

T

EDITORIAL ADVISORS Paul Abbott BDSc, MDS, FRACDS, FPFA, FADI, FIVCD Professor Michael A Baumann Dennis G Brave DDS David C Brown BDS, MDS, MSD L Stephen Buchanan DDS, FICD, FACD Gary B Carr DDS Arnaldo Castellucci MD, DDS Gordon J Christensen DDS, MSD, PhD B David Cohen PhD, MSc, BDS, DGDP, LDS RCS Stephen Cohen MS, DDS, FACD, FICD Simon Cunnington BDS, LDS RCS, MS Samuel O Dorn DDS Josef Dovgan DDS, MS Tony Druttman MSc, BSc, BChD Chris Emery BDS, MSc. MRD, MDGDS Luiz R Fava DDS Robert Fleisher DMD Stephen Frais BDS, MSc Marcela Fridland DDS Gerald N Glickman DDS, MS Kishor Gulabivala BDS, MSc, FDS, PhD Anthony E Hoskinson BDS, MSc Jeffrey W Hutter DMD, MEd Syngcuk Kim DDS, PhD Kenneth A Koch DMD Peter F Kurer LDS, MGDS, RCS Gregori M. Kurtzman DDS, MAGD, FPFA, FACD, DICOI Howard Lloyd BDS, MSc, FDS RCS, MRD RCS Stephen Manning BDS, MDSc, FRACDS Joshua Moshonov DMD Carlos Murgel CD Yosef Nahmias DDS, MS Garry Nervo BDSc, LDS, MDSc, FRACDS, FICD, FPFA Wilhelm Pertot DCSD, DEA, PhD David L Pitts DDS, MDSD Alison Qualtrough BChD, MSc, PhD, FDS, MRD RCS John Regan BDentSc, MSC, DGDP Jeremy Rees BDS, MScD, FDS RCS, PhD Louis E. Rossman DMD Stephen F Schwartz DDS, MS Ken Serota DDS, MMSc E Steve Senia DDS, MS, BS Michael Tagger DMD, MS Martin Trope, BDS, DMD Peter Velvart DMD Rick Walton DMD, MS John Whitworth BchD, PhD, FDS RCS CE QUALITY ASSURANCE ADVISORY BOARD Dr. Alexandra Day BDS, VT Julian English BA (Hons), editorial director FMC Dr. Paul Langmaid CBE, BDS, ex chief dental officer to the Government for Wales Dr. Ellis Paul BDS, LDS, FFGDP (UK), FICD, editor-in-chief Private Dentistry Dr. Chris Potts BDS, DGDP (UK), business advisor and ex-head of Boots Dental, BUPA Dentalcover, Virgin Dr. Harry Shiers BDS, MSc (implant surgery), MGDS, MFDS, Harley St referral implant surgeon

PUBLISHER | Lisa Moler Email: lmoler@medmarkaz.com GENERAL MANAGER | Adrienne Good Email: agood@medmarkaz.com MANAGING EDITOR | Mali Schantz-Feld Email: mali@medmarkaz.com Tel: (727) 515-5118 ASSISTANT EDITOR | Elizabeth Romanek Email: betty@medmarkaz.com

he field of Endodontics has achieved tremendous clinical success in saving teeth. Technology has been a great partner in improving our ability to diagnose and treat the most challenging cases. The innovative drive in research and development of endodontic instruments and equipment has contributed to an increasing trajectory of success over time.

I propose that we have entered the new age of “Energized Endodontics.” Energy is helping us in all aspects of our clinical treatment. The advent of three-dimensional imaging with CBCT uses energy to capture sub-millimeter images into voxels.

Computer-generated reconstruction of the voxels provides a more Brett E. Gilbert, DDS comprehensive and spatially realistic view of the dental structures.

This incredible technology allows us to understand the specific anatomy and pathology of the oral structures in a way that our predecessors could have only dreamed possible.

The ultimate goal of complete cleansing of the intricate apical canal anatomy has been our greatest challenge. In our efforts to reach this goal, we have seen an evolution in instruments to apply energy into our irrigation protocols. Manual agitation, sonic, ultrasonic, and laser energy have all been used to increase the effectiveness of our irrigation efforts. Each of these modes of applying energy into our irrigation solutions has raised the bar in our ability to remove the canal contents from the dentinal structures.

The latest and most innovative effort to Energize Endodontics comes with the use of broadband sound energy to continuously deliver irrigants and energy throughout the root canal system. This Multisonic Ultracleaning™ technology1 uses degassed solutions to allow the broadband energy to reach the canal walls without the barrier of air bubbles or having energy dissipated by them. Upon applying the handpiece, which creates a sealed environment, energy and a sequence of solutions are safely delivered to the complex apical anatomy.

This new technology brings us as close to our goal of complete canal cleansing as we have ever been before.

The practice of Endodontics requires great personal energy and focus. To be the effective and successful practitioners that we want to be, we must extend ourselves to our patients to ensure that they receive our best care. I am very encouraged that our clinical success will continue to improve as we use our training and implement the remarkable technology of today and tomorrow. I firmly believe that the specialty of Endodontics is energized for a brilliant future.

EDITORIAL ASSISTANT | Mandi Gross Email: mandi@medmarkaz.com NATIONAL ACCOUNT MANAGER | Michelle Manning Email: michelle@medmarkaz.com CREATIVE DIRECTOR/PRODUCTION MANAGER | Amanda Culver Email: amanda@medmarkaz.com

Dr. Brett E. Gilbert

1. Technology provided by Sonendo® and the GentleWave™ System

FRONT OFFICE MANAGER | Theresa Jones Email: tjones@medmarkaz.com

MedMark, LLC 15720 N. Greenway-Hayden Loop #9 Scottsdale, AZ 85260 Tel: (480) 621-8955 Fax: (480) 629-4002 Toll-free: (866) 579-9496 Web: www.endopracticeus.com www.medmarkaz.com

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© FMC 2014. All rights reserved. FMC is part of the specialist publishing group Springer Science+Business Media. 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 Orthodontic Practice US or the publisher.

Volume 8 Number 5

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 at Chicago, College of Dentistry and on staff at 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 lectures nationally and internationally on clinical endodontics. Dr. Gilbert has a full-time private practice limited to endodontics in Niles, Illinois.

Endodontic practice 1

INTRODUCTION

Energized Endodontics

September/October 2015 - Volume 8 Number 5

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TABLE OF CONTENTS

Clinical Perforation repair Dr. Godfrey Cutts discusses repair of a perforation of the floor of the pulp chamber with Biodentine®...............18

Practice profile Timothy Finkler, DDS, MSD

8

Endodontics engineered with excellence

Reconstruction of a tooth with composite endocrown following root canal treatment Dr. Monika Dzieciątkowska presents a case demonstrating the reconstruction of a tooth with composite endocrown following an endodontic procedure ....................................................... 21

Endo insight CBCT 3D imaging: the next endodontic frontier of the great endodontist Dr. John West discusses the effect of 3D scans on endodontic decision-making.............................. 24

Understanding what ROI is really about Dr. Brian Trava discusses his research before making a CBCT purchase ........................................................28

Case study

14

XP-3D Finisher™ file — the next step in restorative endodontics Drs. Martin Trope and Gilberto Debelian discuss reaching areas of the canal impossible with standard files

ON THE COVER Image on cover of a patient referred to Dr. John West for endodontic retreatment. See article on page 24.

4 Endodontic practice

Volume 8 Number 5

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TABLE OF CONTENTS

Continuing education An endodontic restorative update Dr. Geoffrey L. Sas focuses on treatment planning decisions and the best evidence to properly restore endodontically treated teeth.............33

Industry news................. 37 Technology 3D imaging in the endodontic practice Dr. Bruno Azevedo discusses imaging that is revolutionizing the endodontic practice...........................................38

Are you transforming endodontics?

Continuing education Nonsurgical endodontic retreatment of extensive periapical lesions

29

Drs. Fernando Muñoz Ayón, Jorge Paredes Vieyra, and Victor Manuel de la Torre Martínez demonstrate a nonsurgical endodontic retreatment of an extensive periapical lesion of endodontic origin with Vitapex®

Embracing technology is an essential part of practice growth.................... 42

Carestream’s CS 8100 3D system Developed with endodontic needs in mind................................................44

Materials & equipment.................... 45, 55 Practice management Dealing with drama: how to cancel the daily soap opera and get your team back to work Paul Edwards discusses how to regain control of your practice.................... 46

6 Endodontic practice

Product profile

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Dr. Rich Mounce encourages colleagues to be informed and involved for future practice growth .......................................................54

ASI’s Momentum™ line of specialty seating Maintain your daily momentum........50

Product profile Planmeca Romexis® software

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Mani® D Finders: exploring the path Dr. Rich Mounce discusses strategies using “stiff” hand files...................... 52

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PRACTICE PROFILE

Timothy Finkler, DDS, MSD Endodontics engineered with excellence

What can you tell us about your background?

I grew up in the then small town of Chester, Virginia. It was a great place for me to grow up. It is about 30 to 40 minutes from where I currently practice. I enjoy seeing people whom I grew up with and knew from around town. Seeing people whom I knew when I was younger will often bring up pleasant memories that otherwise are lost.

In 1990, I graduated from the Virginia Military Institute (VMI) in Lexington, Virginia, with a Bachelor of Science in Electrical Engineering. I choose electrical engineering because it was supposed to be one of the most difficult, and I wanted a challenge. I did not understand the pathway to becoming a dentist; plus, I was excited to finish college and enter the workforce. That was my plan. I was set.

After I graduated from VMI, I joined the Virginia Air National Guard as a traditional guardsman and also worked full time for the Department of the Navy in Norfolk, Virginia. I studied diligently and passed the test to become a registered professional engineer (PE) in the Commonwealth of Virginia. Having my professional engineering license gave me the opportunity to pursue other interests because I could always return easily to engineering if desired; it was a safety net.

I enjoyed being an electrical engineer but felt a desire to pursue a career that I thought would be more fulfilling. I was concerned that I was losing interest in that type of work. I was concerned that I would not be interested in engineering as a profession for the rest of my career. Adding to my concerns was an engineer who worked in the cubicle beside mine who would fall asleep during the day.

I was afraid that was my future. While I was young, not married, and without children, this was my chance to make a change.

I actually made a list of my likes and dislikes about engineering. My first concern about 8 Endodontic practice

Dr. Finkler with his assistants, June and Joanna

engineering was that the business owners I knew seemed to work long days and weeks, which was a strain on their families. Design projects also lasted for months, which I found less than exciting. I also did not care for the relative isolation of a design engineer.

Dentistry seemed to be the opposite. My childhood dentist was Dr. William F. Callery.

He was well respected in the community. He had favorable hours. He always seemed to enjoy his work, and it was obvious that he cared about his patients. Even more than caring, you could tell that the interaction with his patients was important to him. Remembering all those things, I felt that working in a field that helps people more directly would satisfy the personal interactions that I enjoy.

So, I packed my bags.

I returned to the Richmond area and attended dental school at Virginia Commonwealth University (VCU). I found out that I had been accepted into dental school while deployed with the Air Force in Kuwait.

That was a funny experience because I was excited to tell my friends back home, but they were all asleep.

I completed a 2-year general practice residency at the McGuire Veterans Administration Medical Center (VAMC) in Richmond following dental school in 2003. I stayed on as the interim director of the residency for a year as I transitioned into private practice.

Being the interim director of the program gave me a deeper appreciation for the rewards of teaching. I still love teaching at the VAMC and in the VCU Department of Endodontics.

When did you become a specialist, and why?

I received my certificate in endodontics from Virginia Commonwealth University School of Dentistry in 2011.

I enjoyed root canal therapy as a general dentist. I liked that I could focus on one treatment for a period of time instead of having several interruptions for hygiene checks. I liked that the procedures were always behind the rubber dam, which meant at the end of the day, I was not covered with saliva.

I found it fulfilling to diagnose and treat patients with acute needs. I liked helping Volume 8 Number 5

Is your practice limited solely to endodontics, or do you practice other types of dentistry?

I am in a group practice, Commonwealth Endodontics in Richmond, Virginia, with four great partners. Our practice is solely limited to saving teeth through endodontic procedures and microsurgery. I have been trained in IV conscious sedation, which is helpful to patients with dental anxiety, a strong gag reflex, and special needs patients. Being in a large group with a very large patient pool allows enough patients to keep my skills sharp. Treatment at our office can also be completed with a deep sedation/general anesthesia that is administered by a couple of great anesthesiologists who care for our patients.

our children in the same schools, and she loves the Richmond area. Any hesitation on my part was only that I was pretty far into my plans for a solo practice. I thought highly of the partners at this practice and was excited that they would be interested in my joining.

I knew most of them from their participation in the VCU Endodontic Residency. They were kind and always interested in sharing the knowledge and experiences.

I have benefited from being in a group practice in ways that I would not have appreciated prior to this experience. The benefit of working with a group of people who are open and sharing has helped mature my practice.

Because they have a great collective experience, I have avoided some of the difficult learning experiences that a new endodontist might have to learn when first entering practice. My partners support me and want me to succeed. We have all served in the U.S. Armed Forces, which gives us a common frame of reference.

need to feel that I am treating and advising patients appropriately.

Do your patients come through referrals?

Most of our patients are referral based.

How long have you been practicing endodontics, and what systems do you use?

I have been practicing as an endodontist for 5 years. We use the BrasselerÂŽ EndoSequence file system. I was exposed to this system as a resident and have enjoyed its consistent function.

We have an ORTHOPHOS Sirona XG 3D for our cone beam computed tomography.

Having a CBCT when indicated allows for better patient care. I do not want to imagine practicing without one.

Why did you decide to focus on endodontics?

I like saving teeth. My engineering background and interest blended with this field. As a general dentist, my plan was to do as many different procedures as I could; however, ultimately my comfort was found in performing one specialized set of procedures for which I had received in-depth training.

I often felt as a generalist that I could do a wide variety of procedures but was lacking the knowledge of which treatment choice is the best. Studying one field gave me the knowledge base that I

Commonwealth Endodontics office

Who are your partners?

My partners are Drs. Harold Martinez, Ron Vranas, Madelyn Gambrel, and Steven Barbieri. Initially, my plan was to start a solo practice; however, when this opportunity became available, I decided I would give it a try. Of course, my wife could not be any more excited about the prospect of keeping Volume 8 Number 5

Drs. Barbieri, Martinez, Gambrel, Vranas, and Finkler with the staff of Commonwealth Endodontics Endodontic practice 9

PRACTICE PROFILE

patients with their pain while maintaining their teeth. It should sound foreign to have to rip a body part out of a patient’s month to replace it with metal as the first choice.

I felt an affinity toward the electronic apex locator because of my background as an electrical engineer. Electrically speaking, I understood why it can indicate a perforation, root end, and give various false readings as fundamental principles from my engineering background and not as something that that I had to memorize anew.

I enjoyed the series of steps to complete a root canal. It is more like a familiar engineering process to me. In general, I am most comfortable in a routine. Being a specialist, you see all the odd stuff frequently, so everything is relatively routine.

Being in the Virginia Air National Guard during our country’s heavy involvement with Iraq left me with insecurities about opening a general dentistry practice. Opening a practice was risky due to the probability of being deployed. I had heard stories of deployed dentists losing their practice as a result of being away for a significant period of time.

Ironically, going back to a residency with three young children seemed a less risky choice in comparison and allowed me an opportunity to pursue my interest in endodontics. The endodontic residency gave me a feeling of growth instead of being in a holding pattern.

PRACTICE PROFILE Partners in Commonwealth Endodontics Harold J. Martinez, DDS, was born and raised in San Juan, Puerto Rico. He attended Kansas State University and, in 1989, received dual Bachelor of Science degrees in Exercise Physiology and Foods and Nutrition.

In 1995, he obtained his Doctor of Dental Science degree from the Baltimore College of Dental Surgery, University of Maryland Dental School.

He continued his dental education as a Dental Officer in the United States Air Force where he completed an Advanced Education in the general dentistry program in 1996 while stationed at Barksdale AFB in Louisiana. After serving 2 additional years as a general dentist in Tyndall AFB in Panama City, Florida, he came to Richmond, Virginia, to attend Virginia Commonwealth University School of Dentistry, where he earned his Certificate in Endodontics in 2000. Since graduating from the endodontic program, Dr. Martinez has been in private practice with Commonwealth Endodontics and serves as a part-time clinical instructor with the Endodontic Department at Virginia Commonwealth University School of Dentistry.

Dr. Martinez’s work and accomplishments have been recognized by his peers. He was honored as one of Richmond’s Top Dentists in the Richmond Magazine and Virginia Living magazine. He strongly believes in giving back to the local community by supporting different organizations and volunteering his services to the CrossOver Clinic and the Free Clinic of Goochland.

Dr. Martinez belongs to the American Dental Association, Virginia Dental Association, Richmond Dental Society, American Academy of Endodontists, Virginia Academy of Endodontists, Hispanic Dental Society, Pierre Fauchard Academy, and several local dental study clubs.

He has been involved in organized dentistry as a Richmond Delegate for the Virginia Dental Association House of Delegates and as a member of the Richmond Dental Society Board of Directors.

Dr. Martinez lives in Short Pump with his wife, Conchy, and their two children. He enjoys sports and nutrition, baseball, traveling, and spending quality time with his family and friends.

Ronald N. Vranas, DDS, was born and raised in Mesa, Arizona. He attended the University of Arizona and received a Bachelor of Science degree in Chemistry in 1990. In 1996, he obtained his Doctor of Dental Science degree from the Medical College of Virginia.

After completing dental school, Dr. Vranas joined the United States Navy as a dental officer and completed an Advanced Education in General Dentistry program in 1997 while stationed with the Marines at Parris Island in South Carolina. After serving 3 additional years as a Navy dentist at the Naval Air Facility, Atsugi, Japan, he returned to the Medical College of Virginia where he earned his Certificate in Endodontics in 2002.

Dr. Vranas has been with Commonwealth Endodontics since 2002.

His affiliations include multiple local dental study clubs, the American Dental Association, the Virginia Dental Association, the Richmond Dental Society, the American Association of Endodontists, and the Virginia Academy of Endodontists.

As a way to serve others, Dr. Vranas has taken multiple trips to the Dominican Republic as a member of a medical/dental church mission team in order to provide needed dental services to the community of Hato Mayor and the surrounding bateys. Closer to home, he participates in the VDA’s Mission of Mercy projects, providing endodontic care to Virginia’s population that have limited or no access to dental care. Dr. Vranas also teaches part time as an adjunct professor in the Endodontic Department at the VCU School of Dentistry and provides free endodontic care for patients at the CrossOver Healthcare Ministry in Richmond.

Away from the office, Dr. Vranas enjoys spending time with his wife, Elizabeth, and their four children. He is an avid fan and supporter of CharacterWorks, a Richmond children’s theater that his family

10 Endodontic practice

participates in. As the only Arizona Cardinals fan in Richmond (he has yet to meet another one), Dr. Vranas enjoys traveling to stadiums around the country to watch his beloved Cardinals.

Madelyn G. Gambrel, DDS, was born and raised in Bonham, Texas, a small town northeast of Dallas. Dr. Gambrel received a Bachelor of Arts degree in Spanish from Baylor University in 1993 and graduated from the University of Texas Health Science Center San Antonio Dental School in 1997. After receiving her Doctor of Dental Surgery degree, she joined the United States Navy and served as a dental officer in Rota, Spain, until 2001. She then attended Virginia Commonwealth University School of Dentistry, where she received her Certificate in Endodontics and Master’s degree in 2003. During her endodontic residency, Dr. Gambrel was an instructor for the dental school endodontic department from 2001-2003. She also completed research for her Master’s degree and has an article published in the Journal of Endodontics.

Upon graduation from endodontic residency, Dr. Gambrel moved to San Diego, where she completed her obligated service to the U.S. Navy in 2005. Dr. Gambrel then returned to Richmond, Virginia, in the fall of 2005 and joined Commonwealth Endodontics. She recently earned her Board Certification from the American Board of Endodontics. In order to obtain Diplomate status, Dr. Gambrel successfully completed a rigorous three-part examination that included a review of her education, knowledge, skills, and ability to apply new research and advances to the practice of endodontics, as well as her commitment to providing the highest quality of patient care. Becoming a board-certified Diplomate reflects Dr. Gambrel’s commitment to the specialty and is the highest status that an endodontist can achieve.

Dr. Gambrel strongly believes in giving back to her local community and serves through her church, teaching at VCU graduate endodontics clinic, and providing free endodontic care to patient’s referred from CrossOver Healthcare Ministry. She is active in many local dental study clubs and belongs to the American Dental Association, Virginia Dental Association, Richmond Dental Society, American Association of Endodontists, Virginia Academy of Endodontists, and Richmond Association of Women Dentists.

Dr. Gambrel enjoys spending her free time with her two young sons. Her hobbies include attending live music concerts, skiing, sailing, traveling, and interior decorating.

Steve Barbieri, DDS, was born and raised in Queens, New York. He attended Queens College and obtained a Bachelor of Arts degree in Biology with a minor in Philosophy in 1980. He received his Doctor of Dental Surgery degree from the Medical College of Virginia School of Dentistry in 1984. Upon graduation, Dr. Barbieri joined the United States Army as a dental officer. He completed a Dental General Practice Residency at Fort Bragg, North Carolina, in 1985. After serving 2 additional years as a dental officer at Camp Hialeah in Pusan, South Korea, and at Fort Stewart, Georgia, he returned to the Medical College of Virginia where he earned his Certificate in Endodontics in 1989.

Dr. Barbieri established a private practice limited to endodontics in Richmond, Virginia, in 1990. After 18 years in solo practice, Dr. Barbieri joined Commonwealth Endodontics in January 2009. He is a member of the American Dental Association, Virginia Dental Association, Richmond Dental Society, American Association of Endodontists, Virginia Academy of Endodontists, and the McKee-Dominion Dental Study Club. Dr. Barbieri is a past President of the Virginia Academy of Endodontists and has had the honor of being selected as one of Richmond Magazine’s Top Dentists. He volunteers his time, skills, and finances to the CrossOver Clinic.

Dr. Barbieri resides in Henrico, Virginia, with his wife, Shari, and their two children. He enjoys history, traveling, and spending time with family and friends.

Volume 8 Number 5

PRACTICE PROFILE

Wise Misson of Mercy tents. Photo courtesy of Scott Carey

Dental tent

Wise endodontic group

What training have you undertaken?

What is the most satisfying aspect of your practice?

I was initially trained for IV conscious sedation at the GPR. After I joined Commonwealth Endodontics, I took the IV conscious sedation program at the Mylan School of Pharmacy to update my skills. It was great to have the opportunity to retrain because it allows greater growth after having many clinical experiences.

Who has inspired you?

My parents first and foremost have always encouraged me to challenge myself.

They did not push me in directions that I did not want to go. When I would approach them with what sounded like a crazy idea to me, they would always say ,“You’re young; do it.”

From an endodontic perspective, my inspirations were great. Possibly the busiest person in the world, Dr. Gary Hartwell, would always give me his time when he had none to give. Dr. Ellen Byrne has had a tremendous impact on my life. She has impressive accomplishments and great sense of humor.

Dr. Richard Wood is a great general dentist who volunteered in the Endodontic Department. He also went to VMI, and I always enjoy our interactions and his great advice.

He has always been a role model for me in the professional and respectful manners in which he treats his friends, colleagues, and patients alike. I could list another 20 people from dental school and my residency who have inspired me endodontically. I have been fortunate to know such a great group of people throughout my life.

Volume 8 Number 5

I love working in a big group. The staff, partners, and I have fun at work. I cannot believe that I considered practicing solo.

One of the most satisfying aspects of our practice is undoubtedly our staff. We have the greatest staff on the planet. I am sorry if you thought you did until now! They do everything they can to empty our cup. Their support is nonstop and never appears to be tiring. We have empowered them in all aspects of our practice, and they have made our practice shine.

Professionally, what are you most proud of?

I am proud that our practice gives back to the community and helps those in need. As an example, Dr. Ron Vranas and I recently went to the Mission of Mercy (MOM) project with the Virginia Dental Association Foundation in Wise County, Virginia. Some of his and my children volunteered at this outreach program in age-appropriate ways.

Our assistants also volunteered their time and expertise.

This is a great experience on many different levels. My children and I together had the opportunity to spend a weekend aiding others. For my children, it was also an opportunity to gain a more tangible idea that their dad performs a function when he leaves in the morning for work. For me, it is also rewarding to work with so many skilled dentists who would volunteer their time. It

was rewarding to be able to complete a root canal, and half an hour later the patient would return excited that the black tooth in the front had been restored and looked brand-new again.

From the VCU Department of Endodontics were Drs. McKay Parker, Nic Schoeder, Riley Sturgill, and Syrous Ardalan. Dr. John Shamul also brought a team to help. He practices endodontics in Long Island, New York. The 3-day Wise Mission of Mercy 2015, treated 1,181 patients.

What do you think is unique about your practice?

Our practice size gives us opportunities to participate in projects that would be more difficult to accommodate in a solo practice. Our practice is comprehensive in the endodontic care that we provide to a diverse patient population. We have a great opportunity to care for patients with acute pain quickly. We can support charitable organizations like the CrossOver Healthcare Ministries (http://www.crossoverministry.org/), treating their patients’ endodontic needs in our office.

What has been your biggest challenge?

My biggest challenge is balancing home and work. My wife, Kim, is a licensed pediatrician. We both have chosen careers that do not easily allow us to miss work, which is so often needed when you have children.

Kim stays home with our children, and I am grateful for her sacrifice. It is so comforting Endodontic practice 11

PRACTICE PROFILE

June Adams, assistant, with Dr. Finkler at the Wise MOM project. Photo courtesy of Scott Carey

Top 10 favorites 1. Family 2. Friends 3. Dog 4. Endodontics 5. Flux capacitors 6. Fishing 7. Water sports 8. Snow sports 9. Student loans 10. Personal development

to know they are cared for by her. With our youngest entering kindergarten, I am hopeful that Kim will be able to find something rewarding for herself outside of the home as she desires.

What would you have been if you had not become a dentist?

This is an interesting question because dentistry is what I chose over engineering. I had at one point considered medicine. Fortunately, I stuck with the dental track. Dentistry stood out as being the clear choice at the end. Had I not gone into dentistry, I probably would not be here today. I would likely have been on a military airplane that crashed carrying many of my fellow members of the 203rd Red Horse. Sometimes we can forget how delicate life is and how fortunate we are to live it for as long as we do.

What is the future of endodontics and dentistry?

The future of endodontics is bright.

Natural teeth are still the first option. People in general value their teeth and other natural body parts. Endodontists are performing only 20% of the root canals; therefore, there is plenty of room for growth.

12 Endodontic practice

Daughters Julia, Emily, and Kate with Dr. Finkler. Photo courtesy of Scott Carey

I am always surprised when someone asks if they should just extract an otherwise restorable tooth and replace it with an implant. Nowhere in medicine do we do that. Do knees get replaced at age 60 without symptoms? Of course not! And that is because the knees you were born with are always the first option when possible.

Patients are becoming more aware of the specialist’s role in the health professions in general. Patients also generally want to be treated by the person who has had the most training doing their needed procedure. As other treatment options become available, endodontists will expand their procedures.

I just cannot see a time when there are a bunch of endodontists in a room fighting to do the last root canal. In my experience, endodontists are too bright, resourceful, and innovative to find themselves without a function.

What are your top tips for maintaining a successful specialty practice?

As a practice, we are constantly trying to improve. Our staff is highly involved in that process. It includes everything from improving patient interactions to infrastructure. Being in a group practice, the effects of problems are magnified due to practice size; and as a consequence, when improvements are made, the benefits are dramatic.

We are currently working with the Culture Company. They are helping document our processes and develop procedures to become better organized. We are also learning how to better communicate with each other, which is something that can be applied to many relationships in life. I believe it is imperative to understand that no matter how good you are, it is important to continue to be coached. This can come from outside companies and colleagues. If you question this importance, ask how many professional athletes do not currently and regularly have coaches that hone different aspects of their game.

What advice would you give to budding endodontists?

Do good work. Treat people with respect.

Get patients in quickly. Take care of your referring dentists.

What are your hobbies, and what do you do in your spare time?

I have four children from the ages of 5 to 11. The hobbies that I focus mostly on today involve my children. I enjoy coaching soccer. I love taking the kids fishing. I am trying to get them into fly-fishing, but it may be too early.

They love exploring the James River or any other body of water we are around. LEGOÂŽ night is always fun. EP Volume 8 Number 5

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CASE STUDY

XP-3D Finisher™ file — the next step in restorative endodontics Drs. Martin Trope and Gilberto Debelian discuss reaching areas of the canal impossible with standard files Introduction Microbes are the cause of periradicular periodontitis. Root canal treatment is focused on preventing the contamination of the root canal in the treatment of vital (noninfected) tooth or the elimination of microbes when the canal is infected prior to the initiation of treatment. The prevention or elimination of microbes from the root canal poses many challenges. While the vast majority of the microbes are in the main canal and in the planktonic (loose) form, there are complex anatomical irregularities such as accessory or lateral canals and canal isthmuses intercommunicating with the main canals. In addition, the dentinal walls of the root canal are often covered by biofilm that is particularly difficult to eliminate.

Biofilm in the root canal is structurally the same as dental plaque found on the outside of the root. In periodontics, it is well established that biofilm is infinitely more difficult to remove than the “swimming” planktonic microbes. In fact after many attempts to do otherwise, it is still accepted that periodontal and endodontic biofilm must first be physically disrupted before disinfectants can work on the exposed microbes within the biofilm.

While periodontal scalers are used for physical disruption of plaque in periodontal therapy, root canal therapy relies on the instrumentation of the canal with endodontic files. The major challenge faced in endodontics is that almost all canals contain a

wider buccolingual dimension compared to the mesiodistal one1 (Figure 1).

Although there are a multitude of file systems with various metallurgical properties and geometric designs available on the market, they all finally produce a round shape on any given canal cross section (Figure 2).

Thus in root canal instrumentation, the practitioner tries to machine a round shape into a non-round canal.

The smaller mesiodistal diameter limits the round files from touching the walls, and thus disrupts biofilm, on the larger buccolingual diameter. Thus it has been considered impossible to safely touch all parts of the canal and disrupt all biofilm in a root canal.

If one instruments to the mesiodistal dimension, safety is ensured, and the chances of excessively thinning or perforating the root wall is minimized. However, the buccolingual dimension of the canal is likely to still be contaminated (Figure 3).

Figure 1: Canal where the buccolingual diameter is much longer than the mesiodistal canal. While this is an extreme example, every canal is longer in one dimension compared to the other

Figure 2: Cross-sectional shape of different file systems. All result in a round shape after filing the canal

Martin Trope, BDS, DMD, is a Diplomate of the American Board of Endodontics. He has served as Chair of Endodontology, Temple University, Philadelphia, and Chair of Endodontics, University of North Carolina, Chapel Hill. He served as Editor-in-Chief of the journals Dental Traumatology and Endodontic Topics. He is presently in private endodontic practice in Philadelphia and is a Clinical Professor at University of Pennsylvania.

Gilberto Debelian, DMD, PhD, received his DMD degree from the University of Sao Paulo, Brazil, in 1987. He completed his specialization in Endodontics from the University of Pennsylvania, School of Dental Medicine, in 1991. He concluded his PhD studies at the University of Oslo, Norway, in 1997 in endodontic microbiology. He is an adjunct visiting professor at the postgraduate program in endodontics, University of North Carolina in Chapel Hill and University of Pennsylvania in Philadelphia. Dr. Debelian maintains a private practice limited to endodontics as well as an advanced endodontic microscopy center, EndoInn, in Bekkestua, Norway. He is an author of books and 50 scientific and clinical papers and is currently a member of the scientific advisory panel for the Journal of Endodontics and Endodontic Practice Today, director of the Oslo Endodontic Study Club, and the vice-president of the Norwegian Endodontic Society.

Disclosure: Dr. Trope serves as Clinical Director at Brasseler USA®.

14 Endodontic practice

Figure 3: Diagram to illustrate the challenge of instrumenting an oval canal with round files. If a file is used that is safer, there will be untouched areas (upper right).

However, if the canal is instrumented to the longer dimension, the chances of perforation are greater Volume 8 Number 5

Volume 8 Number 5

CASE STUDY

In fact, a study by Paqué, et al.,2 found that by using popular instrumentation methods, only 20% to 40% of the canal is touched. If, on the other hand, the longer buccolingual dimension is the aim of instrumentation, the chances of procedural errors in the thin mesiodistal dimension is vastly increased (Figure 3). For these reasons, most practitioners instrument to sizes that they subjectively consider to be safe and add adjunct technologies like passive ultrasonic agitation and negative pressure irrigation to try to disrupt the biofilm without actually physically coming in contact with it.

The XP-3D Finisher™ file (Brasseler USA®, Savannah, Georgia) has been recently introduced to the market with a similar aim of the Self-Adjusting File (SAF) — i.e., to contact areas in the longer aspect of the canal for which reach by any round file is not possible. It is used after shaping of the canal with at least a No. 25 size conventional endodontic file.

The XP-3D Finisher instrument is a NiTi file No. 25 without taper, making it extremely flexible and resistant to cyclic fatigue. Below 30°C, it is in its pliable martensite form and can be straightened or manipulated to any shape. Above 35°C (body temperature), it transforms to its austenite phase and is straight until the last 10 mm where it has a spoon shape with a depth of 1.5 mm (Figure 4).

When rotating, this extremely flexible file has a natural diameter of 3 mm in the last 10 mm (Figure 5).

In addition, when the tip is squeezed, the bulb can be expanded to 6 mm; and when the bulb is compressed, the tip will expand to 6 mm.

Figure 6 shows the method of use and action of the 3D finisher. It is placed inside the canal while in the most convenient martensite (pliable) form. When at body temperature or above inside the canal, it will change to the austenite phase and “try” to get to its austenite shape. However, since it is so flexible, it is unable to shape the canal to its shape — instead the canal shapes the file to its shape. When the instrument is now moved up and down for 7 mm to 8 mm inside the canal, the natural constrictions and expansions in the canal will alternately cause the bulb and tip to expand and contract. The action of the tip and the bulb is to scrape and to disrupt the biofilm and, in addition, to cause turbulence of the irrigant for maximal effect on the exposed microbes.

Figure 4: The XP-3D Finisher in martensite phase that can be straightened or formed into any convenient form. In the austenic phase, it has a spoon shape in the last 10 mm

Figure 5: When rotating at canal temperature, the XP-3D Finisher exhibits a total expansion of 3 mm

Figure 6: The Finisher is placed into the canal in the M phase (left). When inside the canal, the body temperature transforms it to the A phase, which causes it to transform into the original shape of the canal (middle). The finisher is then moved up and down 7 mm-8 mm to allow the natural shape of the canal to expand/contract the tip or bulb and thus disrupt debris, tissue, or biofilm that is then removed by the turbulent irrigant Endodontic practice 15

CASE STUDY Case examples Example 1 3D plastic models of mesial canals of mandibular molar cut at 1 mm, 3 mm, 5 mm, and 7 mm from the apex. Group 1 shows the wide buccolingual diameter compared to the mesiodistal diameter at every level. Group 2 shows the roots prepared to size No. 35/.04

with standard round NiTi files. These show that the canals are not cleaned in the buccolingual dimension and also that the round file causes significant thinning of the narrow mesiodistal diameter. Group 3 was instrumented with a small diameter and tapered initial file and finished with the XP-3D Finisher. Here we can see that the original shape of the canal is maintained, and the canal is thoroughly cleaned.

Example 2 In this second example, the distal (left) and mesial (right) canals of an extracted lower molar were viewed with a micro CT preoperatively (left), after initial instrumentation with round files (middle), and after finishing with the XP-3D Finisher (right).

As is seen after initial instrumentation with round files, dentinal debris and presumably microbes still remain. These are removed with the 3D finisher without changing the shape of the canal.

Example 3 Tooth with extensive internal root resorption that is impossible to treat with round diameter files without extensive chemical adjunctive therapy. Here the soft tissue is removed in one visit and the canal filled completely, illustrating the effectiveness of the 3D finisher to reach areas that are impossible for a standard round file. EP

REFERENCES 1.

Wu MK, R’oris A, Barkis D, Wesselink PR. Prevalence and extent of long oval canals in the apical third. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2000;89(6):739–743.

2.

Paqué F, Balmer M, Attin T, Peters OA. Preparation of oval shaped root canals in mandibular molars using nickel-titanium rotary instruments: a micro-computed tomography study. J Endod. 2010;36(4):703-707.

Figure 7: Example 1. 3D plastic models of mesial canals of mandibular molar cut at 1 mm, 3 mm, 5 mm, and 7 mm from the apex

Figure 8: Example 2. Courtesy of Dr. Gilberto Debelian (Norway) 16 Endodontic practice

Figure 9: Example 3. Courtesy of Dr. Gilberto Debelian (Norway) Volume 8 Number 5

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CLINICAL

Perforation repair Dr. Godfrey Cutts discusses repair of a perforation of the floor of the pulp chamber with Biodentine® Case study A 43-year-old female patient was referred for possible endodontic treatment to the UL6 by her dental practitioner who stated in the referral letter that there was a possible perforation of the floor of the pulp chamber, which had been “temporized with amalgam” (Figure 1). Upon examination, there was some buccal tenderness, and the tooth was slightly tender to percussion. Radiographic examination showed loss of the floor of the pulp chamber and a considerable amount of amalgam in the furcation (Figure 2).

Local anesthetic was administered and the tooth isolated with rubber dam. After removal of the coronal temporary dressing, the extent of the perforation was revealed.

It involved the whole of the floor of the pulp chamber, including the orifice of the palatal and distobuccal canals (Figure 3).

The amalgam could not be removed intact since it was convex and locked in the furcation. With judicious use of ultrasonic instruments from the Satelec® Endo Success™ range (Figure 4), the amalgam was gently fragmented and the majority removed.

Figure 1: The referral letter sent from the patient’s general dental practitioner

A change of plan The initial treatment plan was to carry out conventional endodontic treatment before repairing the perforation; however, this was not possible since the irrigants were leaking through the furcation and past the rubber dam. Repair of the perforation became the priority, and this was carried out using Biodentine® (Septodont).

Before attempting the repair, a paper point was placed in the distobuccal canal to preserve patency. The perforation was dried gently using large paper points before placing the Biodentine passively in increments using a Thymozin instrument (Figures 5-7). Upon completion of repair of the perforation, the

Godfrey Cutts, LDS (Dunelm), qualified from the Sutherland Dental School, Newcastle-upon-Tyne in 1961, and had practiced in Nuneaton since 1964. In 1998, the practice was sold to Oasis Dental Care, Ltd., and Dr. Cutts became clinical director, clinical advisor, and was involved in the acquisition of practices. Dr. Cutts has an endodontic referral practice in the United Kingdom.

18 Endodontic practice

Figure 2: Radiographic examination demonstrates loss of the floor of the pulp chamber and a considerable amount of amalgam in the furcation

Figure 3: The extent of the perforation was revealed. It involved the whole of the floor of the pulp chamber, including the orifice of the palatal and distobuccal canals

Figure 4: Endo Success kit (Satelec) Volume 8 Number 5

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CLINICAL

Figures 5-7: A paper point was placed in the distobuccal canal to preserve patency. The perforation was dried gently using large paper points before placing the Biodentine passively in increments

Repair of the perforation became the priority, and this was carried out using Biodentine速 (Septodont).

Figure 8: The access cavity was reopened at the second visit to perform conventional endodontic treatment

Biodentine was allowed to set for 10 minutes before temporization of the access cavity.

Second visit At the second visit, 1 week later, the access cavity was reopened (Figure 8) to perform conventional endodontic treatment with glass ionomer cement used to restore the floor of the access cavity followed by a bonded amalgam core (Figure 9). The tooth was removed from the occlusion, and the patient was advised to have a full coverage crown as soon as possible. EP 20 Endodontic practice

Figure 9: Radiographic exam 1 week after treatment Volume 8 Number 5

CLINICAL

Reconstruction of a tooth with composite endocrown following root canal treatment Dr. Monika Dzieciątkowska presents a case demonstrating the reconstruction of a tooth with composite endocrown following an endodontic procedure

T

his patient attended for root canal treatment and reconstruction of tooth LL6. According to the classic procedure, following root canal treatment, reconstruction includes a post and a crown. This, however, is associated with excessive hard tissue removal on the lingual and labial surfaces. (A composite restoration carried out on the distal surface prior to endodontic treatment was present on the distal surface.) Contemporary evidence supports this view; at the present time it is considered that durability of non-vital teeth decreases along with the loss of hard tissue — i.e., the greater the loss, the greater their susceptibility to breaking or fracturing.

This is why reconstruction techniques, which allow for preserving the tooth’s hard tissues, are of great interest.

In this case, there exists a sufficient amount of hard tissue to justify producing an endocrown. An endocrown is an onlay made for a tooth undergoing endodontic treatment. The preserved lingual and palatal walls and the deep tooth chamber provided sufficient retention for such a prosthetic solution. An endocrown may be produced from composite or mineral ceramic, and because of the slightly lower cost and ease of repair of any potential damage, the patient chose the composite endocrown.

A photograph with a shade guide (one or two basic shades were chosen) and an impression made with a polyvinyl siloxane (or polyether) material were sent to the laboratory. The next appointment involved implementation of the cementation procedure. A rubber dam (Optidam™ [Kerr] and a universal SoftClamp clamp [Kerr]) are indispensable for adhesive procedures. It is placed on the tooth to be reconstructed and the neighboring teeth, making it possible to control the contact point. Careful control of a close fit to adjoining teeth is very important.

In this case, contact points were too tight, and the onlay would not stay in place. In order to find and control contact points in

Figure 1: A tooth prepared for an endocrown. The preparation at a 90° angle was completed with a mini chamfer-type preparation from the lingual and labial sides

Preparation and treatment The preparation at a 90° angle was completed with a mini chamfer-type preparation from the lingual and labial sides. Such a preparation is consistent with the prism course and ensures a good fusion of the bonding system with the enamel. All the sharp edges are smoothed out. The preparation was completed using a 40-micron diamond drill.

Figures 2A-2B: Photographs showing the two chosen basic shades

Dr. Monika Dzieciątkowska graduated from the Faculty of Dentistry of the Lodz Academy of Medicine in 1994. She achieved grade 1 specialty in general dentistry. Dr. Dzieciątkowska has always been passionate about endodontics and for some time has also been fascinated by esthetic dentistry and prosthetics.

She runs her own private dental practice in Lodz, Poland.

Figures 3A-3B: Prepared endocrown fabricated from Premise Indirect™ composite (Kerr) Volume 8 Number 5

Endodontic practice 21

CLINICAL the mouth, occlusion spray is used. Thus, the areas that may hinder the procedure are eliminated.

To embed the endocrown, a sixthgeneration self-etch bonding system (OptibondÂŽ XTR [Kerr]) was used, which was spread on the surface of the preparation and then light-cured. A dual-cured composite resin cement (NX3) was also spread on the surface of the preparation.

Results Following the mounting procedure and the initial removal of any excess, the cement was polymerized. The initial short polymerization was completed by a long polymerization (40 seconds for each surface) using a gel that stopped the creation of an oxygeninhibition layer. This ensured that the material would not change color or dissolve. This type of dual-cured composite resin cement (NX3) was indispensable because of the thickness of the endocrown and the difficulties associated with light from the curing unit penetrating into the deepest spaces. EP

Figures 4A-4B: Control of contact points using occlusion spray

Figure 5: The tooth following application of Optibond XTR bonding system

Figure 6: NX3 composite cement on the prepared surface

Figure 7: Curing of the cement by a layer of gel that prevents the formation of an oxygen inhibition layer

Figures 8A-8B: Endocrown — final view 22 Endodontic practice

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ENDODONTIC INSIGHT

CBCT 3D imaging: the next endodontic frontier of the great endodontist Dr. John West discusses the effect of 3D scans on endodontic decision-making Introduction In the field of endodontics, dentists have always “worked in the dark.”

Most of our treatments are performed without using the sense we can most control — our ability to see the situation. In fact, when you think about it, we can simultaneously “see” and “do” in almost all areas of dentistry: anesthesia, crown prep, evaluation of prep margins, impression taking, placing restorative dentistry, occlusal analysis, etc. However, as endodontists, we often rely instead on the sense of “feel.” The combination of feel, previous experience, two-dimensional radiographs, microscopes, and apex locators has raised our endodontic success rates to approximately 90%. Closing the gap between 90% or 95% and 100% has not happened, however, since the recognition of endodontics as a specialty by the ADA in 1963! And so the real question in endodontics is not “what you can get away with,” but “what can technology get us to?”

The answer to closing the endodontic gap toward 100% capacity for healing lesions of endodontic origin (LEOs) where they exist and preventing LEOs where they do not exist is by improving our ability to see.

Scotomas, or blind spots, render us unable to see things that are right in front of us.

(Think about looking for your car keys, only to find them on the table you were staring at). In the case of endodontics, the scotoma is actual tooth structure, which our eyes are not capable of seeing through. With cone beam computed tomography (CBCT), we can, for the first time, begin to see through teeth. A whole new world opens up, and we are able to make diagnoses, treatment plan, and treat better than ever before.1 The following eight patient diagnoses and treatment planning decisions are not unique. These examples

A.

John West, DDS, MSD, is founder and director of the Center for Endodontics in Tacoma, Washington. He graduated from the University of Washington Dental School and received his MS degree and endodontic certificate at Boston University, where he was awarded the Alumni of the Year Award. He is an educator, a clinical visionary, and inventor with focus on interdisciplinary endodontics.

He has authored several textbook chapters and is an editorial board member for the Endodontic Practice US, Journal of Esthetic and Restorative Dentistry, and the Journal of Microscope Enhanced Dentistry. John is lead author of Endodontics and Esthetic Dentistry in Ron E. Goldstein’s 2016 Esthetics in Dentistry, 3rd edition.

He can be reached at 800-900-7668, via email at johnwest@ centerforendodontics.com, or visit centerforendodontics.com.

24 Endodontic practice

Carestream Dental CS 9000 CBCT imaging system

are rich in the everyday practice of endodontists benefiting from CBCT 3D imaging (Image 1). In the simplest terms, 3D makes us better. Period.

Eight patient examples of CBCT influencing diagnostic and treatment decision-making

B.

Figures 1A-1C: Do we see and then believe, or do we believe and then we see? 1A. Patient reports pain in all four quadrants and pain in implant area ever since implant was placed 3 years ago. 1B: Digital pano reveals no specific endodontic pathology. 1C: CBCT demonstrates healthy implant and obvious lesion of endodontic origin apical third of maxillary first molar and proven by negative pulp tests and negative test cavity. Symptoms promptly subsided when endodontic treatment was started

C. Volume 8 Number 5

B.

C.

Figures 2A-2C: CBCT saves the day. 2A. Upon palpation and percussion, patient feels pain in the maxillary left second molar. Pulp tests vital and probes within normal limits. 2B. CBCT shows obvious oblique fracture of distobuccal (DB) root. 2C. DB root fracture of extracted unrestorable tooth

A.

B.

C. Figures 3A-3E: CBCT makes impossible diagnosis possible. 3A. Pretreatment image of maxillary right central incisor. Endodontic treatment and restoration was 1 year prior. Tooth is palpation tender. 3B. Clinical image of sinus tract mid-root. 3C. CBCT brings clinician closer to reality upon showing a facially perforating post. 3D. Post is nonsurgically removed, perforation repaired with MTA, and nonsurgical endodontic retreatment completed. 3E. Sinus tract closed 3 weeks posttreatment. (Courtesy of Dr. Jordan West, Center for Endodontics, Tacoma, Washington) D.

E.

A.

D.

B. Volume 8 Number 5

C.

Figures 4A-4D: CBCT contributes to minimally invasive approach. 4A. Pretreatment image of maxillary left first molar.

4B. CBCT reveals previously undiscovered mesiopalatal (MB2) canal and low-density radiolucent area lingual to MB root further suggesting patent MB2 underfilled portal of exit present (see arrow). 4C. Minimally invasive access focused in MB area preserving possible loss of ferrule elsewhere. 4D. Posttreatment image of shaped, cleaned, and vertically compacted MB2 root canal system. (Courtesy of Dr. Jordan West) Endodontic practice 25

ENDODONTIC INSIGHT

A.

ENDODONTIC INSIGHT

A.

B.

C.

D.

G.

Figures 5A-5G: CBCT enables proper diagnosis and treatment sequence. 5A. Pretreatment image of maxillary right lateral E. F. incisor and lesion of endodontic origin (LEO). Lingual sinus tract traced to apical area of the lateral. 5B. Two surgical seals later. 5C. Six months after second endodontic surgery, facial sinus tract appears. 5D. Gutta-percha cone tracer does not make definitive diagnosis. 5E. CBCT does make definitive diagnosis pointing to lateral lesion of endodontic origin emanating from maxillary right cuspid that had been treated 10 years prior. 5F. Nonsurgical retreatment of underfilled cuspid root canal system and obturated lateral portal of exit. 5G. Two-week clinical of healed sinus tract! (Courtesy of Dr. Jason West, Center for Endodontics, Tacoma, Washington)

B.

A. 26 Endodontic practice

Figure 6A-6B: CBCT enables diagnosis. 6A. Pretreatment periapical image of percussion sensitive maxillary left lateral incisor. Lamina dura and periodontal ligament appear to be radiographically intact. 6B. CBCT tells a different story — the LEO is hidden and camouflaged lingual to the root tip, and therefore, diagnosis is underfilled root canal system Volume 8 Number 5

A.

Figures 7A-7B: CBCT reduces chance for misdiagnosis. 7A. Pretreatment image suggesting possible LEO mesial to apical area of maxillary right central incisor. 7B. CBCT demonstrates low-density radiolucent area is actually nasopalatine foramen

A.

B.

Figures 8A-8C: CBCT improves risk assessment. 8A. Posttreatment of nonsurgical retreatments of maxillary first and second premolars. Note possible underfilled maxillary first molar. 8B. Subsequent pretreatment images of adjacent first and second asymptomatic molars. 8C. CBCT shows undiscovered MB2 orifi in both first and second molars (see arrows). Patient informed that these two teeth should be observed over time to identify developing LEOs and sinus tracts. Request for previous treatment films was made for comparison. Patient was instructed to call if symptoms developed. CBCT in this instance is playing the role of cautious observer and could play a role in preventing an acute alveolar abscess

Take-home message In order to remain competitive over the next decade and in order to be at the top of our endodontic game, all new and meaningful technologies must be mastered. The question for each of us is not if, but when will we commit and when will we become CBCT adopters. The early adopters are here.

The technologies are proven. Don’t be the last one on the block because as with all of today’s technologies, you will never be able to catch up. The growth curve is exponential, and each day, you can lag further and further behind.

Volume 8 Number 5

CBCT imaging improves diagnosis, improves risk assessment, improves treatment outcomes, improves treatment efficiency, and reduces treatment complications. CBCT literally brings the endodontist closer to reality; enhances reputation, patient engagement, education, and treatment understanding and acceptance; gives the dentist confidence; and can be invaluable in surgical endodontics and safe implant placement. Patients resonate with a live 3D tour of their teeth. If a picture is worth a 1,000 words, a 3D scan is priceless.

In conclusion, I am reminded of the old

C.

question: “When is the best time to plant a tree?” Answer: 25 years ago. “When is the second best time to plant a tree?” Answer: Today! EP

REFERENCE 1. McClammy TV. Endodontic applications of cone beam computed tomography. Dent Clin North Am. 2014;58(3):545-559.

Endodontic practice 27

ENDODONTIC INSIGHT

B.

ENDODONTIC INSIGHT

Understanding what ROI is really about Dr. Brian Trava discusses his research before making a CBCT purchase

T

here are two acronyms of CBCT that are very different in their meaning, but correlate very well together in the real world.

The diagnostician will tell you that ROI would be defined as Region of Interest. The businessman will tell you it would be Return on Investment. You really are investing in the capability to see detail. But if you don’t understand the details of your purchase, you may come up short in your investment and, most important, in your diagnosing.

Many practitioners do very little research before making a purchase, which leads to very little understanding both before and after the purchase. Having an underutilized CBCT taking up space is like an exercise bike at home with clothes hanging on it. In the decisionmaking process, price should be at the bottom of the list. Multimodality and software capability should be at the top of your list. With the diversity of financing, Section 179 of the tax code, and added value to office resale, the long-term numbers are insignificant. If the machine you choose is not upgradable, or limiting, it may be no different than an old dental chair that costs you to dispose of. Evaluate your current practice needs, and make your decision based on your future needs.

Here is a really good tip before purchasing a CBCT machine for your practice. Artifacts influence clinical diagnosis and treatment.

Detail gives higher patient acceptance and increased accuracy. When studying an ROI (Region of Interest), how does the software handle metal artifacts to provide detail and not distort it? You know, those nasty highdensity objects such as amalgam fillings, PFM crowns, posts, and implants with high-attenuation coefficients that create all the streaks, starbursts, and dark shadows corrupting the imaging detail. Unavoidable, most all of your scans will be on patients with a wide range of dental work. Diagnosing is about detail; you are purchasing detail, and Brian Trava, DMD, is an endodontist in New Jersey. You can learn more about his practice at http://njrootcanal.com/.

Disclosure: Dr. Trava is a paid lecturer for Planmeca®.

28 Endodontic practice

you expect detail to be delivered. Can your machine manage this? Without any compromise of detail?

So, when studying an ROI, how are artifacts handled within the field of view (FOV), and how is that related to detail? A CBCT machine can run an algorithm artifact removal program to reduce the streaks.

But the actual metal object that is causing those streaks must be within the FOV for the artifact removal algorithm to work. In Figure 1, the image shows a small volume 5 cm x 5 cm FOV. An artifact removal was run, but streaks and interference are present.

Why? Any metal objects that are outside the FOV volume, the artifact removal algorithm program has no effect on, and your region of interest (ROI) can be detail compromised (Figure 1). So, if you are looking for a fracture in a tooth in a small volume size, you need to consider what high-density objects are in the contralateral and surrounding teeth.

When considering and researching CBCT machines, our office made the decision on the Planmeca® ProMax® 3D for many reasons.

With regard to FOV and artifact removal, the software platform is the most versatile. You have the option of a small FOV to a larger field of view of 8 cm x 8 cm if needed to capture within and process out high-density metal artifacts pending their proximity to your ROI. Next, the Planmeca ProMax 3D gave us the option to have a raw volume with no artifact removal or to run a scaled integrated amount of artifact removal depending on the quantity of high-density artifacts that may interfere with the ROI. These programs may be nonforgiving because they cannot distinguish between important and not important in the ROI. Endodontics is about detail. We did not want a CBCT machine that locked us into a standard artifact removal program that we had no control over. In Figure 2, no artifact removal program with an obvious fracture.

In Figure 3, an artifact removal program was run showing a dilution of detail with regard to the fracture. In many patient cases we need that edge and prefer not to run any artifact removal.

As our practice grew, a second CBCT was needed. More companies and machines had entered the marketplace. When doing the research, again, versatility was an

Figure 1: Small volume with streaks

Figure 2: Raw volume, no artifact removal

Figure 3: Artifact removal program

important factor. It was decided to add a second Planmeca ProMax 3D. Endodontics is about detail.

CBCT is really about detail, diagnosis, and treatment planning. Educate yourself before your purchase, recognize your needs in the future, become a better diagnostician, and your ROI (Return on Investment) will always be long-term. EP Volume 8 Number 5

Drs. Fernando Muñoz Ayón, Jorge Paredes Vieyra, and Victor Manuel de la Torre Martínez demonstrate a nonsurgical endodontic retreatment of an extensive periapical lesion of endodontic origin with Vitapex®

A

pical periodontitis and its accompanying periapical bone resorption are inflammatory disorders of periradicular tissues caused by persistent microbial infection within the root canal system of the affected tooth (Safavi and Nichols, 1993). Incessant apical periodontitis after root canal treatment often portrays a more complex scenario than primary apical periodontitis (Nair, 2006).

The most common causes for failure in endodontics include the inability to eradicate bacteria from the root canal system after treatment, reinfection of the root canal by coronal leakage (Haapasalo, et al., 2007), extraradicular infection, foreign body reaction, and true cysts (Cohen, Hargreaves, and Berman, 2011). In such cases where primary endodontic therapy does not succeed, a nonsurgical endodontic retreatment approach is the best option.

The main difference between treating primary endodontic disease versus posttreatment disease is the need to regain access to the apical third of the root canal previously treated. Once this is achieved, all of the principles of endodontic therapy apply to the completion of the retreatment case (Cohen, Hargreaves, and Berman, 2011), including cleaning, shaping, and interappointment dressings. The most widely used intracanal medication to date continues to be calcium hydroxide Ca(OH)2. Its antimicrobial mechanism and high pH (12.5) provide an environment where few microorganisms are able to survive. Another drug used with high antibacterial activity is iodoform (CHI3), which Dr. Fernando Muñoz Ayón is in private practice limited to endodontics in Mexicali, Baja California, Mexico.

Dr. Jorge Paredes Vieyra is an endodontist and professor of endodontics and pulp therapy at the School of Dentistry, Universidad Autónoma de Baja California, Campus Tijuana, Tijuana, Baja California, Mexico.

Dr. Victor Manuel de la Torre Martínez is a professor at the School of Dentistry, Universidad Autónoma de Baja California, Campus Mexicali, Mexicali, Baja California, Mexico.

Disclosure: The authors deny any conflicts of interest related to this study.

Volume 8 Number 5

Educational aims and objectives

This clinical article aims to present a case report on a nonsurgical endodontic retreatment with a large periapical lesion fully repaired.

Expected outcomes

Endodontic Practice US subscribers can answer the CE questions on page 32 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Realize that large periapical lesions of endodontic origin can be treated with conservative nonsurgical endodontic retreatment allowing complete repair without surgical intervention.

• Realize come common causes for failure in certain cases of endodontic treatment.

• Identify some differences between treating primary endodontic disease versus posttreatment disease.

has been used successfully as a medicament and filling paste for many years (Pallota, et al., 2010). Vitapex® (Neo Dental International, Inc.) is a commercial Ca(OH)2 paste used as root canal dressing in primary and permanent teeth; it also contains CHI3 and inhibits or kills the pathogen in the root canal; furthermore, it can promote bone repairment and regeneration, as shown by Xia and colleagues (2013).

Although very effective eliminating bacteria inside the canal, removal of these Ca(OH)2 pastes is often difficult. Passive ultrasonic irrigation (PUI) has proven to be effective in Ca(OH)2 removal (63.3%) from the root canal wall due to its cavitation and microstreaming effect on NaOCl compared with syringe delivery. However, whether PUI can effectively remove Ca(OH)2 from the root canal wall is not well-known (van der Sluis, Wu, and Wesselink, 2007).

During root canal treatment, Ca(OH)2 pastes might sometimes unintentionally escape through the apex of the tooth. The deliberate placement of Ca(OH)2 beyond the confines of the root canal in the presence of large and chronic periapical lesions has been advocated. Some speculate that this favors periapical healing and encourages osseous repair. Such deliberate overextension is not, however, widely advocated (Orocoglu and Cobankara, 2008).

Case report A 42-year-old female patient was referred to our office for treatment of maxillary left

lateral incisor tooth. The reason for consultation was completion of root canal therapy, which had been left unfinished 2 to 3 years to date.

Upon questioning, the patient reported mild pain with the presence of a sinus 3 months previously. The patient also reported pain on mastication 3 days prior to this appointment, and clinical examination confirmed the presence of purulent exudate on palpation at the gingival margin, as well as a palatal groove and composite filling on access cavity (Figure 1). The right lateral incisor was slightly sensitive to percussion and palpation. Radiographic evaluation (Schick CDR, Schick Technologies) demonstrated a very acceptable endodontic treatment accompanied with a radiolucent lesion approximately 10 mm in diameter around the apex (Figure 2).

Figure 1: Patient reported pain on mastication, but no contact surfaces could be observed. Palatal groove housing bacteria (caries) could be seen with microscope Endodontic practice 29

CONTINUING EDUCATION

Nonsurgical endodontic retreatment of extensive periapical lesions

CONTINUING EDUCATION

Figure 2: Previously acceptable root canal filling with a persistent large periapical lesion (approximately 10 mm in diameter)

Figure 6: After more than a year (17 months), the patient returned with mild pain and a cast post crown restoration on the tooth. Lesion was smaller, showing healing process but still present. Coronal leakage as well as poor sealing of crown was present

Figure 3: Gutta-percha filling was removed, and calcium hydroxide powder was placed inside the canal to control exudate. The tooth was re-evaluated 10 days later and was asymptomatic

Figure 7: Canal preparation, as well as Vitapex removal, was performed with F4 and F5 ProTaper universal files

Nonsurgical retreatment approach was planned, and informed consent was given and signed by the patient. Treatment was performed without local anesthesia and with rubber dam in place. The access cavity was prepared with carbide bur No. 2 (Mani®, Inc.) and Endo-Z™ (Dentsply International).

Removal of gutta percha was attempted via ProTaper® Universal Retreatment files (Dentsply Tulsa Dental Specialties). Once inside the canal, a calcium hydroxide paste was found, removed, and 2.5% sodium hypochlorite irrigating solution was administered as final rinse. Canal was dried with sterile paper points (Coltène Whaledent Group, Hygenic®), and calcium hydroxide powder (Sultan Healthcare Inc.) was placed into the canal to control the exudate. The tooth was temporarily restored with intermediate restorative material (IRM® Caulk; Dentsply).

Clinical evaluation was performed after 10 days (Figure 3). The tooth was asymptomatic and isolated in the same manner as 30 Endodontic practice

Figure 4: Working length with Root ZX apex locator

Figure 5: Vitapex was placed as intracanal medication and intentionally extruded past the apex

Figure 8: One month after finishing treatment, the lesion appears to have mild repair even though no permanent crown has been placed on the tooth

Figure 9: One year after finishing treatment, the lesion appears to be healing correctly with total integration and proper function of the dental structures

that described in the previous appointment.

Working length was then determined by an electronic apex locator (Root ZX®, J. Morita) with a No. 45 K-file (Mani, Inc.) (Figure 4).

During this appointment 2.5% NaOCl was administered; the canal was then dried in the same manner as previous appointment, and Vitapex was placed as intracanal dressing and intentionally placed in the periradicular area through the apex (Figure 5). A cotton pellet was placed in the pulp chamber, and the tooth was temporarily restored with intermediate restorative material (IRM Caulk; Dentsply).

The patient lost all contact with our practice and returned 17 months later with mild pain and a cast post and metal porcelain crown in the unfinished root canal treatment.

After removal of cast post and crown, the canal preparation was accomplished with F4 and F5 ProTaper Universal files (Figures 6-7). Canals were obturated by means of the lateral condensation technique and Sealapex™ sealer. After 1 month (Figure

8), the patient was asymptomatic, and mild healing of the perirapical lesion was observed, even though no permanent crown had been placed.

The patient lost contact once again, but 1 year later returned, asymptomatic, and the tooth and periapical tissues appeared to be healing correctly with total repair and proper function of the tooth (Figure 9).

Discussion From a microbial perspective, after pulp necrosis, infection of the root canal system occurs. Microorganisms then inhabit the oral cavity like bacteria, and fungi invoke a protective inflammatory response in the periradicular tissues. However, when host defense systems cannot enter the necrotic root canal and eliminate the invading microbes, the inflammatory process results in the formation of abscesses, granulomas, and/or periapical cysts, as shown by Love and Firth (2009) and Soares and colleagues (2008).

Volume 8 Number 5

Volume 8 Number 5

In such cases where primary endodontic therapy does not succeed, a nonsurgical endodontic retreatment approach is the best option.

(Estrela, et al., 2001; Zmener, Pameijer, and Banegas, 2007; Han, Park, and Yoon, 2001).

Although the use of these Ca(OH)2 pastes is highly effective, its removal from the root canal is often a difficult task. Removal of pastes like Vitapex is often done by instrumentation of the root canal with the master apical file combined with abundant irrigation of both NaOCl and EDTA. In a recent study, passive ultrasonic irrigation (PUI) proves to be effective in Ca(OH)2 removal (63.3%) from the root canal wall due to its cavitation and microstreaming effect on NaOCl compared with syringe delivery (van der Sluis, Wu, and Wesselink, 2007).

In the present case, the extrusion of Vitapex through the apex possibly delayed the apical healing, but did not prevent it. Our case results agree with findings by Arslan, Broon, Soares, Thomas, van der Sluis, and Xia (2012; 2007; 2006; 2012; 2007; 2013), as the large periapical lesion was retreated without surgical intervention, the intentional extrusion of Vitapex promoted the periapical healing, and PUI served as an excellent Ca(OH)2 paste (Vitapex) remover from the root canal as well as the diffusion of NaOCl into the dentinal tubules.

Conclusion When endodontic therapy cannot eliminate bacteria from the canal, and large periapical lesions develop on previously treated teeth, nonsurgical root canal retreatment should always be considered before a surgical approach. In the present case, a nonsurgical approach in combination with calcium hydroxide/iodoform paste as an intracanal medicament contributed effectively in limited healing of the periapical lesion at 1 month and nearly fully repaired at 1 year. This confirms that large periapical lesions can respond positively to nonsurgical retreatment. EP

Acknowledgment We thank Professor Dr. Michael Hülsmann (Göttingen, Germany) for his valuable assistance in reviewing this manuscript.

REFERENCES 1.

Arslan H, Karataş E, Barutcugil Ç, Topçuoğlu HS, Aladağ H. Treatment of large periapical lesions without surgical approach: report of three cases. Int Dent Res. 2012;2(1):17-22.

2.

Broon NJ, Bortoluzzi EA, Bramante CM. Repair of large periapical radiolucent lesions of endodontic origin without surgical treatment. Aust Endod J. 2007;33(1): 36-41.

3.

Estrela C, Bammann LL, Pimenta FC, Pécora JD. Control of microorganisms in vitro by calcium hydroxide pastes.

Int Endod J. 2001;34(5):341-345.

4.

Haapasalo M, Qian W, Portenier I, Waltimo T. Effects of dentin on the antimicrobial properties of endodontic medicaments. J Endod. 2007;33(8):917-925.

5.

Han GY, Park SH, Yoon TC. Antimicrobial activity of Ca(OH)2 containing pastes with Enterococcus faecalis in vitro. J Endod. 2001;27(5):328-332.

6.

Love RM, Firth N. Histopathological profile of surgically removed persistent periapical radiolucent lesions of endodontic origin. Int Endod J. 2009;42(3):198-202

7.

Nair PN. On the causes of persistent apical periodontitis: a review. Int Endod J. 2006;39(4):249-281.

8.

Orucoglu H, Cobankara FK. Effect of unintentionally extruded calcium hydroxide paste including barium sulfate as radiopaquing agent in treatment of teeth with periapical lesions: report of a case. J Endod. 2008;34(7):888-891.

9.

Pak JG, Fayazi S, White SN. Prevalence of periapical radiolucency and root canal treatment: a systematic review of cross-sectional studies. J Endod. 2012;38(9):1170-1176.

10. Pallotta RC, de Lima Machado ME, dos Reis NS, Rosa Martins GH, Nabeshima CK. Tissue inflammatory response to implantation of calcium hydroxide and iodoform in the back of rats. Rev Odont C. 2010;25(1):59-64.

11. Petersson A, Axelsson S, Davidson T, Frisk F, Hakeberg M, Kvist T, Norlund A, Mejáre I, Portenier I, Sandberg H, Tranæus S, Bergenholtz G. Radiological diagnosis of periapical bone tissue lesions in endodontics: a systematic review. Int Endod J. 2012;45(9):783-801.

12. Roda RS, Gettleman BH. Nonsurgical Retreatment. In: Cohen S, Hargreaves KM, Berman LH eds. Pathways of the Pulp. 10th ed. St. Louis, MO: Mosby, Inc; 2011: 890-952.

13. Safavi KE, Nichols FC. Effect of calcium hydroxide on bacterial lipopolysaccharide. J Endod. 1993;19(2):76-78.

14. Soares J, Santos S, Silveira F, Nunes E. Nonsurgical treatment of extensive cyst-like periapical lesion of endodontic origin. Int Endod J. 2006;39(7):566–575.

15. Soares JA, Brito-Júnior M, Silveira FF, Nunes E, Santos SM. Favorable response of an extensive periapical lesion to root canal treatment. J Oral Sci. 2008;50(1):107-111.

16. Tavares WL, de Brito LC, Henriques LC, Teles FR, Teles RP, Vieira LQ, Ribeiro Sobrinho AP. (2012) Effects of calcium hydroxide on cytokine expression in endodontic infections.

J Endod. 2012;38(10):1368-1371.

17. Thomas K, Dhanapal PT, Simon EP. Management of large periapical cystic lesion by aspiration and nonsurgical endodontic therapy using calcium hydroxide paste. J Contemp Dent Pract. 2012;13(6):897-901.

18. Torabinejad M, Kutsenko D, Machnick TK, Ismail A, Newton CW. Levels of evidence for the outcome of nonsurgical endodontic treatment. J Endod. 2005;31(9): 637-646.

19. Van der Sluis LW, Wu MK, Wesselink PR. The evaluation of removal of calcium hydroxide paste from an artificial standardized groove in the apical root canal using different irrigation methodologies. Int Endod J. 2007;40(1): 52-57.

20. Xia X, Man Z, Jin H, Du R, Sun W, Wang X. Vitapex can promote the expression of BMP-2 during the bone regeneration of periapical lesions in rats. J Indian Soc Pedod Prev Dent. 2013;31(4):249-253.

21. Zmener O, Pameijer CH, Banegas G. An in vitro study of the pH of three calcium hydroxide dressing materials. Dent Traumatol. 2007;23(1):21-25.

Endodontic practice 31

CONTINUING EDUCATION

Such lesions can only be detected radiographically when alveolar bone loss has been accompanied by cortical bone involvement during lesion development (Soares, et al., 2008; Arslan, et al., 2012). The mean diameter of apical lesions ranges from 5 mm8 mm; lesions of 10 mm or more are considered granulomas or apical cysts (Soares, et al., 2008; Soares, et al., 2006). Even though the incidence of radicular cysts is approximately 15% of all periapical lesions, healing of all apical periodontitis ranges from 80%–95% after root canal treatment, which alone suggest that cysts may heal without surgery (Love and Firth, 2009; Soares, et al., 2008; Arslan, et al., 2012; Soares, et al., 2006). Therefore, management of large periapical lesions by nonsurgical procedures should always be considered.

Because surgical procedures come with many drawbacks (for example, possible damage to adjacent vital teeth and anatomic structures in the vicinity, pain, and discomfort), its use is limited in the management of periapical lesions, as shown by Thomas, Dhanapal, and Simon (2012). However, nonsurgical endodontic treatment focuses on the removal of all bacteria and their byproducts from the root canal system (Tavares, et al., 2012; Torabinejad, et al., 2005); adherence to these treatment objectives should result in maintaining normal radiographic and clinical conditions in teeth with and without preoperative periradicular lesions (Torabinejad, et al., 2005). Based on available studies that offer the best evidence, it appears 92%-98% of teeth without periapical lesions remain free of disease after root canal therapy, and 74%-86% of teeth with apical lesions completely heal after initial treatment or retreatment. In addition, similar data shows that 91%-97% of teeth that have had root canal treatment remain functional over time (Torabinejad, et al., 2005). Still, in some cases, a bone lesion takes a considerable time to heal, which means that conclusions about outcome are sometimes uncertain.

Apical periodontitis may also heal with fibrous tissue rather than bone. Such scar tissue healing is usually thought to have a typical radiographic appearance and is mostly seen after endodontic surgical procedures (Peterson, et al., 2012).

Broon and colleagues showed that the inability to achieve infection control after root canal treatment can result in a chronic inflammatory process (2007). For such cases, the use of intracanal medication is widely advocated. Various studies found that the use of Ca(OH)2 dressing for 1 to 4 weeks efficiently removed bacteria from the root canals

Approved PACE Program Provider FAGD/MAGD Credit Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement 12/1/2012 to 11/30/2016 Provider ID# 325231

REF: EP V8.5 AYON

CONTINUING EDUCATION BROUGHT TO YOU BY

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Nonsurgical endodontic retreatment of extensive periapical lesions AYON/VIEYRA/MARTINEZ

1. Apical periodontitis and its accompanying _____ are inflammatory disorders of periradicular tissues caused by persistent microbial infection within the root canal system of the affected tooth. a. sinus infection b. periapical bone resorption c. coronal leakage d. swelling of the pulp chamber 2. The most common causes for failure in endodontics include the inability to eradicate bacteria from the root canal system after treatment, ______, and true cysts. a. reinfection of the root canal by coronal leakage b. extraradicular infection c. foreign body reaction d. all of the above 3. The main difference between treating primary endodontic disease versus posttreatment disease is the need to regain access to the ______ of the root canal previously treated. a. apical third b. tissue debris c. gingival sulcus d. overhanging ledges 4. The most widely used intracanal medication to date continues to be ________.

32 Endodontic practice

a. b. c. d.

sodium hypochlorite (NaOCl) ethylenediaminetetraacetic acid (EDTA) calcium hydroxide Ca(OH)2 chlorhexidine (CHX)

5. The deliberate placement of Ca(OH)2 beyond the confines of the root canal in the presence of large and chronic periapical lesions ________. a. has been advocated b. has been advised against c. has been deemed dangerous d. can cause tissue damage 6. From a microbial perspective, ______, infection of the root canal system occurs. a. before pulp necrosis b. after pulp necrosis c. in the absence of pulp necrosis d. when NaOCl is utilized 7. However, when host defense systems cannot enter the necrotic root canal and eliminate the invading microbes, the inflammatory process results in the formation of ____, as shown by Love and Firth and Soares and colleagues. a. abscesses b. granulomas c. periapical cysts d. all of the above

8. Even though the incidence of radicular cysts is approximately 15% of all periapical lesions, healing of all apical periodontitis ranges from __________ after root canal treatment, which alone suggest that cysts may heal without surgery. a. 15%-20% b. 30%-45% c. 50%-65% d. 80%-95% 9. Various studies found that the use of Ca(OH)2 dressing for ______ efficiently removed bacteria from the root canals. a. 1 to 4 weeks b. 2 to 3 months c. 6 months d. 1 year 10. When _____, nonsurgical root canal retreatment should always be considered before a surgical approach. a. endodontic therapy cannot eliminate bacteria from the canal b. large periapical lesions develop on previously treated teeth c. the patient has a history of noncompliance d. both a and b

Volume 8 Number 5

CE CREDITS

ENDODONTIC PRACTICE CE

Dr. Geoffrey L. Sas focuses on treatment planning decisions and the best evidence to properly restore endodontically treated teeth

T

he primary objective of endodontic therapy is to prevent and treat apical periodontitis.1 To effectively achieve this goal, proper cleaning and shaping of the canals, irrigation, and a coronal seal are essential. The objectives of restorative dentistry are to properly restore teeth to function, comfort, and in specific cases, esthetics. Although the materials and methods of both treatment modalities have changed, the ultimate goals have remained constant. The relationship between endodontic treatment and restorative dentistry has been established. However, the concepts and related treatment plans have been contentious. With the increasing publicity regarding “implant” dentistry, there is an emphasis on evaluating the restorability of teeth prior to endodontic treatment. It is not beneficial to the patient if the root canal therapy (RCT) is successful, but the tooth ultimately fails. With the advancement of implant dentistry, diseased teeth that previously may have had root canal therapy and a crown now may be replaced with implants, provided the longterm restorability is in question or is dictated by the overall treatment plan. This article focuses on treatment planning decisions and the best evidence to properly restore endodontically treated teeth.

Long-term success of endodontically treated teeth is dependent on the ensuing restorative treatment.2 Microorganisms that may cause apical periodontitis and contamination of the root canal system during or after endodontic therapy can alter the ultimate success of the diseased tooth.3 The growth of bacteria through the exposure of gutta percha to saliva results in endotoxin at the apex within days of endodontic treatment.

Delays in final restoration after completion of

Geoffrey Sas, BMSc, DDS, FRCD(C), is an endodontist who received his postgraduate training at Nova Southeastern University. He is a Fellow of the Royal College of Dentists of Canada. Dr. Sas maintains a private practice in Toronto and is a clinical instructor, part-time, at the University of Toronto. He can be reached at glsas@yorkhillendo.com.

Volume 8 Number 5

Educational aims and objectives

This clinical article aims to focus on treatment planning decisions and the best evidence to properly restore endodontically treated teeth.

Expected outcomes

Endodontic Practice US subscribers can answer the CE questions on page 36 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Identify the primary objectives to endodontic therapy.

• Recognize methods to effectively achieve the goal of successful endodontic therapy.

• Realize some of the barriers to successful completion of endodontic treatment.

• Discuss advantages and disadvantages of various types of posts.

• Discuss importance of obtaining an adequate seal.

RCT have been indicative of lower success rates.4 There are differing opinions regarding endodontic access and its role in restorative dentistry. Many “Coke™ bottle” preparations used in the past unnecessarily removed cervical dentin2 (Figure 1). Access designs should focus on conserving as much tooth structure as possible without compromising the RCT (Figure 2). Adhesive materials used in the coronal restoration provide an immediate seal and strengthening of the tooth. A

major benefit of adhesive dentistry is that it does not solely rely on mechanical retention, and therefore, tooth structure can be preserved.5 Notwithstanding the numerous advantages to bonding within the root canal system, there are also limitations such as the geometry of the canal. The ratio of bonded to unbonded surfaces is called the configuration factor or “C” factor. A higher percentage of unbonded surfaces results in less stress on the bonded surfaces from polymerization contraction. A Class IV preparation has a

Figure 1: This radiograph shows canals prepared with a “Coke bottle” design. Excessive dentin was removed in the cervical one-third of the root canal system Endodontic practice 33

CONTINUING EDUCATION

An endodontic restorative update

CONTINUING EDUCATION

Figure 2: Pre- and postoperative radiographs showing a conservative, restoratively driven access (Courtesy of Dr. Limosani, Weston, Florida)

The application of a combined endodontic seal/buildup procedure in a timely manner combined with an adequate ferrule effect will significantly improve the long-term success of endodontic and restorative care.

C factor of less than 1:1, which is favorable compared to the root canal system that may be as high as 100:1.6 With an unfavorable geometry, it is not possible to achieve an ideal gap-free interface between the gutta percha and adhesive materials, and therefore, the long-term seal could be altered.

As well, it is technically challenging to apply primer and adhesive deep in the root canal system.

The principle of cuspal coverage is a consistent factor throughout the literature and is the most consistent factor when predicting survivability of root canal (RC) treated teeth. Aquilino and Caplan showed that when tooth type and presence of caries at the time of access were controlled, at a 9-year follow-up exam, teeth with cuspal coverage had a 6 times greater survival rate than teeth without cuspal coverage.7 Aquilino and Caplan concluded that although treatment recommendations should be made on an individual basis, the associations between crowns and the survival of RC treated teeth should be recognized.7 Coronal tooth structure should be preserved just as much as radicular. For teeth that require posts as part of their coronal restoration, no additional dentin should be removed beyond what is necessary for root canal treatment. As an example, if the canal is prepared to a 0.04 preparation, a 0.04 tapered post should “fall” right in without mechanically preparing the canal to fit the post. There is near consensus 34 Endodontic practice

that the ferrule effect is very important when treatment planning a single diseased tooth. Ferrule is cervical tooth structure that provides retention and resistance form to the restoration, which prevents fracture.

Ferrule is best when it is at least 1.5 mm-2 mm or more and is important to long-term success when a post is used.8 If the height of the remaining tooth structure does not have adequate ferrule, options may include crown lengthening, orthodontic extrusion, or extraction and replacement.

The function of a post is strictly to retain a core in a tooth with extensive loss of tooth structure.9 Although custom cast posts or prefabricated metal posts have become the standard for decades, in recent years, fiber-reinforced composite posts are increasingly more prevalent. Placing posts comes with inherent risks such as disturbing the root canal filling material, which may lead to microleakage, increased risk of perforation, and iatrogenically removing tooth structure.

The RC system should never be shaped to fit posts, and no instrument should be used in a canal unless it is intended to shape the canal for its endodontic obturation. Although metal posts do not reinforce the strength of the root structure, there is increasing evidence that fiber posts may increase resistance to fracture.10 The concept of a fiber post is that it has a modulus of elasticity similar to that of dentin and therefore can absorb more impact force and distribute force better than more

rigid metal posts. As well, if failure occurs in a fiber post, the results are less severe.11 There are also esthetic advantages to using nonmetallic posts, particularly for anterior abutments.

Retention of posts is directly proportional to the length of the post. Several concepts have been suggested for passive fitting posts, such as ensuring that the post is at least apical to the crest of the alveolar bone, or at least equal to the crown height. When placing a post, it is important to maintain the endodontic seal. To maintain a long-term seal, 4 mm-5 mm of gutta percha (GP) is superior compared to 2 mm-3 mm.12 Hand instruments, rotary instruments, and heat can be used to remove GP without disrupting the apical seal. Goldfein, et al., confirmed that when a rubber dam was used during post placement, there was a significantly lower chance of developing a periapical lesion at the 2.7-year mark.13 A primary objective of endodontic therapy is to establish an adequate seal with the root canal filling material, as coronal microleakage is a leading cause of endodontic failure. The current trend of “temporizing” with cotton and cavit or another temporary material following endodontic treatment can result in various complications. First, patients may not return to their restorative dentist in a timely manner, and thus the provisional coronal restoration will rapidly break down and potentially cause microleakage. Placing an immediate core at the time of endodontic obturation is recommended to further the coronal seal, which is an integral part of endodontic therapy. The clinician’s knowledge of the canal angulations, anatomy, and curvature is greatest at the time of obturation, which makes that point the optimal time to place the buildup. Because the rubber dam is already present, the immediate buildup becomes an extension rather than an invasion of the endodontic seal. Ray and Trope evaluated the relationship between the quality of the coronal restoration and the quality of the root canal filling by examining the radiographs of endodontically treated teeth.14 They observed that a combination of good restorations and good endodontic treatments resulted in the absence of periapical inflammation in 91.4% of the teeth examined, whereas poor restorations and poor endodontic treatments resulted in the absence of periradicular inflammation in only 18.1% of teeth. Furthermore, where poor endodontic treatments were followed by good permanent restorations that appeared radiographically sealed, the Volume 8 Number 5

REFERENCES 1. Siqueira JF. Aetiology of root canal treatment failure: why well-treated teeth can fail. Int Endod J. 2001;34(1):1-10.

2. Ree M, Schwartz RS. The endo-restorative interface: current concepts. Dent Clin N Am. 2010;54(2):345-374.

3. Kakehashi S, Stanley HR, Fitzgerald RJ. The effects of surgical exposure of dental pulps in germ-free and conventional laboratory rats. Oral Surg Oral Med Oral Pathol. 1965;20:340-349.

4. Alves J, Walton R, Drake D. Coronal leakage: endotoxin penetration from mixed bacterial communities through obturated, postprepared root canals. J Endod. 1998;24(9):587-591.

5. Van Meerbeek B, De Munck J, Yoshida Y, Inoue S, Vargas M, Vijay P, Van Landuyt K, Lambrechts P, Vanherle G. Buonocore memorial lecture. Adhesion to enamel and dentin: current status and future challenges. Oper Dent. 2003;28(3):215-235.

6. Carvalho RM, Pereira JC, Yoshiyama M, Pashley DH. A review of polymerization contraction: the influence of stress development versus stress relief. Oper Dent. 1996;21(1):17-24.

7. Aquilino SA, Caplan DJ. Relationship between crown placement and the survival of endodontically treated teeth. J Prosthet Dent.

2002;87(3):256-263.

8. Stankiewicz N, Wilson P. The ferrule effect. Dent Update. 2008;35(4):227-228.

9. Goodacre CJ, Spolnik KJ. The prosthodontic management of endodontically treated teeth: a literature review. Part 1. Success and failure data, treatment concepts. J Prosthodont. 1994;3(4):243-250.

10. Naumann M, Preuss A, Frankenberger R. Reinforcement of effect of adhesively luted fiber reinforced composite versus titanium posts. Dent Mater. 2007;203(2):138-144.

11. Butz F, Lennon AM, Heydecke G, Strub JR. Survival rate and fracture strength of endodontically treated maxillary incisors with moderate defects restored with different post-and-core systems: an in vitro study. Int J Prosthodont. 2001;14(1):58-64.

12. Madison S, Wilcox, LR. An evaluation of coronal microleakage in endodontically treated teeth. Part III. In vivo study. J Endod.

1998;14(9):455-458.

13. Goldfein J, Speirs C, Finkelman M, Amato R. Rubber dam use during post placement influences the success of root canal-treated teeth. J Endod. 2013;39(12):1481-1484.

14. Ray HA, Trope M. Periapical status of endodontically treated teeth in relation to the technical quality of the root canal filling and the coronal restoration. Int Endod J. 1995;28(1):12-18.

15. Mavec J, McClanahan SB, Minah GE, Johnson JD, Blundell RE Jr. Effects of an intracanal glass ionomer barrier on coronal microleakage in teeth with post space. J Endod. 2006;32(2); 120-122.

This article was originally published in Oral Health Journal (reprinted with permission).

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Endodontic practice 35

CONTINUING EDUCATION

resultant success rate was 67.6%. Consequently, Ray and Trope concluded that apical periodontal health depended significantly more on the coronal restoration than on the technical quality of the endodontic treatment.14 Mavec, et al., evaluated the bacterial microleakage of the remaining gutta percha in teeth prepared for a post space with and without the use of an intracanal glass ionomer cement barrier. They discovered that the length of time between obturation and placement of the permanent restoration is critical to prevent recontamination of the remaining apical gutta percha.15 In this study, Vitrebond™ (3M) proved an acceptable intracanal barrier material and should provide a superior secondary seal for the temporary coronal restoration. In conclusion, the application of a combined endodontic seal/buildup procedure in a timely manner combined with an adequate ferrule effect will significantly improve the long-term success of endodontic and restorative care. EP

Approved PACE Program Provider FAGD/MAGD Credit Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement 12/1/2012 to 11/30/2016 Provider ID# 325231

REF: EP V8.5 SAS

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An endodontic restorative update SAS

1. The growth of bacteria through the exposure of gutta percha to saliva results in endotoxin at the apex within _______ of endodontic treatment. a. seconds b. days c. weeks d. months 2. A(n) ___________ of unbonded surfaces results in less stress on the bonded surfaces from polymerization contraction. a. lower percentage b. higher percentage c. equal amount d. configured number 3. Aquilino and Caplan showed that when tooth type and presence of caries at the time of access was controlled, at a 9-year follow-up exam, teeth with cuspal coverage had a ______ survival rate than teeth without cuspal coverage. a. 3 times greater b. 6 times greater c. 10 times greater d. 50 times greater 4. There is near consensus that the ___________ is very important when treatment planning a single diseased tooth.

36 Endodontic practice

a. b. c. d.

Hertwig’s syndrome hollow tube theory Langerhans effect ferrule effect

5. Placing posts comes with inherent risks such as disturbing the root canal filling material, which may lead to ________. a. microleakage b. increased risk of perforation c. iatrogenically removing tooth structure d. all of the above 6. Goldfein, et al., confirmed that when a rubber dam was used during post placement, there was _______ of developing a periapical lesion at the 2.7-year mark. a. a significantly lower chance b. a significantly higher chance c. an equal chance d. no chance 7. A primary objective of endodontic therapy is to ______ with the root canal filling material, as coronal microleakage is a leading cause of endodontic failure. a. avoid filling the canal b. temporize the area c. establish an adequate seal d. none of the above

8. The clinician’s knowledge of the __________ is greatest at the time of obturation, which makes that point the optimal time to place the buildup. a. canal angulations b. anatomy c. curvature d. all of the above 9. They (Ray and Trope) observed that a combination of good restorations and good endodontic treatments resulted in the absence of periapical inflammation in _____ of the teeth examined, whereas poor restorations and poor endodontic treatments resulted in the absence of periradicular inflammation in only 18.1% of teeth. a. 45.7% b. 60.3% c. 75.2% d. 91.4% 10. They (Mavec, et al.) discovered that the length of time between obturation and placement of the permanent restoration is critical to _______ of the remaining apical gutta percha. a. ensure compaction b. prevent brittleness c. prevent recontamination d. ensure against shrinkage

Volume 8 Number 5

CE CREDITS

ENDODONTIC PRACTICE CE

Three of the five professional consumables brands within the KaVo Kerr Group — Kerr, Kerr TotalCare, and Axis | Sybron Endo — have reorganized into a unilateral organization designed to be more collectively meaningful and distinctive in its service to customers. This rebranding has resulted in four core identities: Kerr Restoratives, Kerr Endodontics, Kerr Rotary, and Kerr TotalCare. The businesses have been realigned to eliminate boundaries and enforce greater collaboration.

For more information, visit www.kavokerrgroup.com.

Lisa Ashby named president of Carestream Dental Lisa Ashby has been appointed president of Carestream Dental. As a member of the executive leadership team, she will lead the company’s global dental organization. Ashby brings more than 26 years of corporate business expertise acquired during a successful career at Cardinal Health — a $100 billion healthcare products and services provider — where she was president, medical devices and diagnostics with responsibility for six companies generating $3 billion in revenue with a product portfolio ranging from laboratory diagnostics to surgical devices and critical care products. She served on Cardinal Health’s operating committee, several company advisory councils, and was active in several industry organizations to help influence legislative policy and create awareness across the global healthcare community. She will relocate to Atlanta, Georgia, for her role with Carestream Dental.

Share your good (endodontic) news!

Submit your press release for consideration to managing editor Mali Schantz-Feld via email at Mali@medmarkaz.com.

Planmeca begins open registration for Power of Digital Dentistry conference Planmeca has announced open registration for The Power of Digital Dentistry conference, the first-ever conference bringing together Planmeca Romexis® imaging and CAD/CAM users. The conference will be held October 16-17, 2015, at the Gaylord Texan Resort in Grapevine, Texas.

Topics include: • Restorative success with digital dentistry • Advanced utilization of 3D technology • Patient virtualization — digital implant diagnosis • The ultimate dental assistant • The power of teamwork in restorative diagnosis and care • Marketing your high-tech practice To register, visit www.powerof digitaldentistry.com.

Volume 8 Number 5

Endodontic practice 37

INDUSTRY NEWS

Kerr Corporation introduces new identity for dental consumables brands within KaVo Kerr Group

TECHNOLOGY

3D imaging in the endodontic practice Dr. Bruno Azevedo discusses imaging that is revolutionizing the endodontic practice

3

D imaging technology is revolutionizing the endodontic practice by allowing endodontists to better diagnose, treat, and follow up cases. Since the year 2001, when the J. Morita Manufacturing Corporation launched the first-ever small field-of-view, low-dose, high-resolution cone beam computer tomography (CBCT) scanner, endodontists started to see the value of being able to evaluate a tooth in 3D. For the first time, clinicians were able to evaluate and assess root canal anatomy and endodontic complications such as resorptions, perforations, and root fractures. It became evident that 3D technology allowed better visualization of apical periodontitis, especially apical lesions in close proximity to the maxillary sinus floor, which have a high probability to be missed using only 2D imaging. For the past 15 years, endodontists have had a fantastic diagnostic tool at their disposal, and just recently, the American Association of Endodontics together with the American Association of Oral Maxillofacial Radiology has released a joint position statement highlighting the importance of 3D imaging in endodontics. According to this document, Use of Cone Beam Computed Tomography in Endodontics 2015 Update, 3D imaging should be considered the imaging modality of choice when: • Evaluating contradictory or nonspecific clinical signs and symptoms associated with untreated or previously endodontically treated teeth • Treating teeth with the potential for extra canals and suspected complex morphology • Identification and localization of calcified canals and root resorptions • Detecting vertical fractures

Figure 1: CBCT scan showing invasive cervical resorption of tooth No. 9. High-resolution scan allows visualization of intact pulp canal

Figure 2: CBCT scan demonstrating perforation of the distal root of tooth No. 30 and apical resorption associated with teeth Nos. 28 and 29

• Evaluating the non-healing of previous endodontic treatment to help determine the need for further treatment, such as no surgical, surgical, or extraction • Considering nonsurgical retreatment to access endodontic treatment complications, such as overextended root canal obturation material, separated endodontic instruments, and localization of perforations

Bruno Azevedo, DDS, MS, is an Assistant Professor at the University of Louisville School of Dentistry in the Department of Surgical and Hospital Dentistry since 2014. Immediately prior to this, he was a founding faculty at Western University of Health Sciences, College of Dental Medicine in Pomona, California. He attended the University of Texas Health Science Center in San Antonio where he received both a certificate in Oral and Maxillofacial Radiology and Master’s in Dental Diagnostic Science in 2009. He is a Diplomate of the American Board of Oral and Maxillofacial Radiology. Dr. Azevedo has presented at over 50 national and international scientific meetings about dental 3D technology with particular emphasis on endodontic diagnosis and CBCT interpretation. Dr. Azevedo operates an intramural CBCT imaging facility at the University of Louisville and provides consulting services in oral maxillofacial radiology.

Disclosure: Dr. Azevedo is a consultant for J. Morita USA.

38 Endodontic practice

• Presurgical treatment planning • Placing dental implants • Diagnosing and managing limited dental alveolar trauma, acute fractures, luxation, and/or displacement of teeth and localize alveolar fractures Longtime users of CBCT imaging in the endodontic practice have reported that on top of the undisputed diagnostic value of this technology, they have gains on chair time leading to an increase in productivity since 3D imaging allows clinicians to better predict outcomes avoiding start procedures where endodontic therapy is contraindicated. It is also important to note that several articles in the literature demonstrate that incorporating 3D imaging technology during the treatment plan phase can change the clinical approach in over 50% of the time in comparison to when treatment plans are done when CBCT is not available.

Volume 8 Number 5

Thinking ahead. Focused on life.

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TECHNOLOGY

CBCT scanners designed for the endodontic practice, such as J. Morita’s Veraviewepocs 3D F40, allows for smallvolume, high-resolution, and low-dose scanning of specific areas in the mouth.

With the help of new technologies such as panoramic scout view, clinicians can scan a particular area of the mouth with sniper precision. Another advantage is the fast acquisition time, which is 9.4 seconds.

Faster acquisition time in high-resolution scans tends to avoid motion artifacts that can decrease the final resolution of the volume.

Since imaging is an indispensable part of all the phases of the endodontic treatment, endodontists should consider CBCT imaging for their patients when available.

This technology will continue to evolve and integration with rapid prototyping manufacturing, surgical planning software and bioprinting will allow new treatments to emerge soon. The sky is no longer the limit. EP

Figure 3A-3B: Case was referred for apical surgery on tooth No. 14. CBCT scan demonstrates an unfilled MB1. Tooth was treated, and no apical surgery was performed

REFERENCES: 1. Venskutonis T, Plotino G, Juodzbalys G, Mickevičienė L. The importance of cone-beam computed tomography in the management of endodontic problems: a review of the literature. J Endod. 2014;40(12):1895-1901.

2. American Association of Endodontists; American Academy of Oral and Maxillofacial Radiography. AAE and AAOMR joint position statement: use of cone beam computer tomography in endodontics 2015 update. http://www.aae.org/uploadedfiles/ clinical_resources/guidelines_and_position_statements/cbctstatement_2015update.pdf. Accessed August 18, 2015.

3. Estrela C, Bueno MR, Leles CR, Azevedo B, Azevedo JR. Accuracy of cone beam computed tomography and panoramic and periapical radiography for detection of apical periodontitis. J Endod. 2008;34(3): 273-279.

Thinking ahead. Focused on life.

CBCT for Endodontists

Guidelines, indications and software overview

Attend a Free Webinar Thursday, October 22, 2015 | 4:00 PM (Pacific) / 7:00 PM (Eastern) Presenter: Bruno Azevedo, DDS, MS Assistant Professor at the University of Louisville School of Dentistry

This webinar is designed to provide information for participants to understand 3D imaging applications for endodontics. The lecture will cover evidencebased practice techniques and protocols for improved diagnostic accuracy.

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At the conclusion of this activity, participants should be able to:

Understand 3D imaging applications in endodontics Compare & contrast CBCT scanners regarding their unique hardware features Explain image resolution & voxel size Manage images – file size, sharing & referrals Use i-Dixel software – powerful 3D imaging software

40 Endodontic practice

Register Online

www.morita.com/usa/webinar 1-888-JMORITA (566-7482) Volume 8 Number 5

AUTHOR GUIDELINES Endodontic Practice US is a peer-reviewed, bimonthly 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.

Submitting articles 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 3,000 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 Volume 8 Number 5

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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.

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Number tables consecutively and provide a brief title and caption (if appropriate) for each.

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Aesthetic & Implant Dentistry. 2000;1(1):92-96.

(Online) Author(s). Article title. Journal Name. Year; vol(issue#):inclusive pages. URL. Accessed [date].

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.

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Endodontic practice 41

TECHNOLOGY

Are you transforming endodontics?

Embracing technology is an essential part of practice growth

E

ver have an odd ache or pain that you just couldn’t figure out? It almost always gets you thinking about what it could be. Maybe it was something you ate — or maybe it’s appendicitis. If you’re like most people these days, the first place you go to research your mystery ailment is the Internet. For better or worse, more people are doing medical research online, “Googling” their problems well before they consult a physician. People looking for information about endodontic issues are no different.

Endodontists continue to rely on referrals from general practitioners for a significant portion of their practice’s traffic. Between the time that the GP makes the referral and the patient gets in to see the endodontist, he/ she is likely to take some time to search the internet for more information about root canal therapies. The patient’s access to word-ofmouth input and recommendations is now greater than ever as email and social media connects us all in new ways. Simply put, technology has changed the relationship between patient and provider forever.

It may seem as though technological advancements are a double-edged sword for endodontists. For all of the incremental advancements that have occurred in this discipline over the years, patients are now more informed — and possibly more skeptical — than ever before. Patients may be coming to an endodontic practice more aware of the significant amount of bacteria that can be left behind after a conventional root canal therapy, as well as the potentially detrimental effect that bacteria can have on both their long-term tooth care and their bodies’ immune systems. Patients are beginning to challenge the conventional wisdom behind current root canal therapy methods, which is something that is occurring even as more general practitioners are changing their stance on referring patients to endodontists.

All of this suggests that the time is ripe for reconsidering how we bring new technologies into our discipline.

At the most recent annual meeting of the American Association of Endodontists, keynote speaker Dr. Michio Kaku issued 42 Endodontic practice

Palatal root before treatment with the GentleWave System (Image by Dr. Tyler F. Baker)

Palatal root after treatment with the GentleWave System (Image by Dr. Tyler F. Baker) Volume 8 Number 5

TECHNOLOGY

Endodontists need to set the specialty apart and more effectively demonstrate that the services provided simply cannot be offered anywhere else — and that they offer the highest level of care. forth a battle cry that should resonate with just about everyone: “Technology: Embrace it or be lost!” Endodontists need to set the specialty apart and more effectively demonstrate that the services provided simply cannot be offered anywhere else — and that they offer the highest level of care.

Many general practitioners believe that their endodontic skills are at the same level as a specialist, which makes them more likely to attempt to keep their cases in-practice. And given that 40% of bacteria and biofilm can be left behind in conventional root canal therapies,1,2 many general practitioners believe that dental implants are a safer, more effective way to go.

With all of these factors in play, it is in every endodontist’s best interest to embrace new technologies that empower him/her to do more than general practitioners can realistically provide. The successful endodontist will be the one who can demonstrate the ability to actually save more teeth, and superior technology will ultimately be the key differentiator. Multisonic Ultracleaning™ technology from Sonendo® is exactly the sort of technology that truly sets the forwardthinking endodontist apart.

Available only with the GentleWave™ System, Multisonic Ultracleaning represents a radical rethinking of root canal therapies.

By replacing conventional levels of endodontic instrumentation with broad spectrum acoustic energy and a powerful vortex of cleaning solutions, Multisonic Ultracleaning is able to clean and disinfect in an entirely new way. Cleaning solutions are delivered throughout the entire root canal system, from the crown to the apex, eliminating up to 97% of biofilm, bacteria, and smear layer3 — even in complex anatomies where conventional methods are unable to reach, such as isthmi, lateral canals, and dentin tubules. Fluids and energy reach into the apical third, eliminating the biofilm that is a primary cause of reinfection and failure in root canal therapy.

The result is a level of disinfection that goes Volume 8 Number 5

The GentleWave™ System by Sonendo®

a long way toward preventing the need for retreatments over time. In essence, endodontists have the power to save even more teeth for their patients. According to Tyler F. Baker, DDS, MS, “These days, the dental profession should be saving more teeth than ever — not fewer. The GentleWave System’s ability to predictably clean complex canal anatomies while significantly preserving more dentin makes saving teeth a no-brainer.

Add in greatly improved techniques for restoring and bonding, and you see a true paradigm shift, as the clinician’s treatment of choice returns to preservation of the natural dentition.” (See images on page 42.)

In addition, the Multisonic Ultracleaning procedure requires only one treatment session, enabling endodontists who adhere to the more traditional two-treatment method to suddenly find the time in their schedule to see more patients. This means that when it comes to competing for increasingly rare referrals from general practitioners, the technical advantage can translate into a real financial advantage. With extra time added to the schedule, it becomes possible to increase the number of billable visits each month while still decreasing the number of working hours put in each day.

We live in an age of incredible technological advancement, where innovations are poised to make life easier for everyone.

The key is to leverage the breakthroughs that can be of the greatest benefit to the endodontic practice and patients. The GentleWave System, with its Multisonic Ultracleaning technology, provides the power to save patients’ time, save their teeth — and help ensure a more secure future for endodontic practices as they help transform endodontics.

Sonendo has grown from a concept in 2006 to its selective commercial release today. The device is FDA-cleared. For more information, visit www.sonendo.com or info@ sonendo.com. EP

REFERENCES 1. Siqueira JF Jr, Machado AG, Silveira RM, Lopes HP, de Uzeda M. Evaluation of the effectiveness of sodium hypochlorite used with three irrigation methods in the elimination of Enterococcus faecalis from the root canal, in vitro. Int Endod J. 1997;30(4):279-82.

2. Sjögren U, Figdor D, Persson S, Sundqvist G. Influence of infection at the time of root filling on the outcome of endodontic treatment of teeth with apical periodontitis.

Int Endod J. 1997;30(5):297-306.

3. Vandrangi P, Basrani B. Multisonic ultracleaning in molars with the GentleWave System. Oral Health. May 2015;105(5):72-86.

This information was provided by Sonendo®.

Endodontic practice 43

TECHNOLOGY

CS 8100 3D system Developed with endodontic needs in mind

W

hen it comes to the use of cone beam computed tomography (CBCT) in endodontics, there are three features that are crucial: selectable fields of view, the ability to capture high-resolution images, and an intuitive interface. Carestream Dental’s CS 8100 3D system delivers in all three of these areas to ensure that endodontists are able to easily incorporate CBCT imaging into their workflow.

CBCT imaging for endodontists Featuring four selectable fields of view, ranging from 4 cm x 4 cm to 8 cm x 9 cm, the CS 8100 3D has the ability to collimate the region of interest — allowing doctors to comply with the recent CBCT recommendations issued by the American Association of Endodontists (AAE) and the American Academy of Oral and Maxillofacial Radiology (AAOMR).

With the EndoHD mode (5 cm x 5 cm), users are able to capture ultra-high resolution scans to see even the smallest details of root and canal morphology necessary for diagnostic and treatment planning needs.

And, for added flexibility, endodontists can capture high resolution scans of the jaw with the unit’s 8 cm x 5 cm field of view.

5 cm x 5 cm EndoHD mode 75 micron

User-friendly workflow When CBCT imaging is too complicated or cumbersome, it’s unlikely to be used every day. Featuring a user-friendly workflow, the CS 8100 3D is fast and easy to use — making it an ideal imaging tool for endodontic practices.

Simply select the desired program, and the system captures the right image. For further ease of use, the system incorporates a smart bite block with letter landmarks, making it virtually impossible to miss the region of interest and eliminating the risk of retakes.

Patient positioning and comfort are also improved thanks to the unit’s design. Faceto-face positioning enhances the patient experience and improves imaging, while the system’s rigid support with integrated handgrips holds the patient stable. The unit can also accommodate patients of all sizes and is wheelchair accessible.

Intuitive 3D imaging software When capturing high-resolution images, there are a large number of slices that must 44 Endodontic practice

5 cm x 5 cm EndoHD mode 75 micron

be reviewed. For this reason, endodontists need a tool that is capable of evaluating a massive amount of data in an intuitive way.

Fortunately, the comprehensive and userfriendly CS 3D Imaging software (included with the CS 8100 3D) was developed with endodontists in mind.

The software’s 3D rendering view and slice-by-slice views are displayed simultaneously for an enhanced viewing experience, and the software can be easily shared with referrals for improved colleague collaboration. For further convenience, CS 3D Imaging software also integrates with implant planning software.

Of course, patient education and communication are important components of CBCT imaging. With the CS 3D Imaging software, endodontists can easily review images with patients so they are better able

to understand the proposed treatment plan — resulting in improved case acceptance.

Compact technology Featuring an extremely compact footprint and lightweight design, the CS 8100 3D system can be placed in almost any practice — even in the smallest spaces. This means endodontists can take advantage of the many features associated with CBCT imaging without sacrificing valuable real estate.

As a sophisticated piece of technology in a compact unit, the CS 8100 3D delivers the features that matter most to endodontists. To learn more about Carestream Dental’s portfolio of imaging products and software for endodontic practices, please call 800-9446365, or visit carestreamdental.com today. EP This information was provided by Carestream Dental.

Volume 8 Number 5

M AT E R I A L S lllllllllllll & lllllllllllll EQUIPMENT Planmeca introduces the all-new ProSensor® HD intraoral imaging system Planmeca introduced its most recent innovation in intraoral imaging, the Planmeca ProSensor® HD. This system offers excellent image quality and a patient-centered design with multiple convenience features for enhanced usability. For top-notch image quality, Planmeca ProSensor HD has a new CMOS (Complementary Metal-Oxide Semiconductor) chip, as well as a more accurate scintillator with a fiber-optic layer for sharper images, improved contrast, better signal-to-noise ratio at all dose levels, and a theoretical resolution at 33 lp/mm. The sensors feature rounded edges to enhance patient comfort and are hermetically sealed for convenient infection control. For added usability, the sensors are connected magnetically to the control box for easy one-handed use and can also be integrated with the Planmeca ProX intraoral X-ray unit, enabling instant switching between operatories. With innovative design features, as well as support for both Mac and Windows, the new Planmeca ProSensor HD provides high-quality images and a smooth workflow in nearly any treatment situation.

Planmeca Oy has a product range covering digital dental units, CAD/CAM solutions, world-class 2D and 3D imaging devices, and comprehensive software solutions. Headquartered in Helsinki, Finland, Planmeca’s products are distributed in over 120 countries worldwide. With a strong commitment to pioneering innovations and design, it is the largest privately held company in its field.

To learn more, please visit www.planmecausa.com or Facebook at www.facebook.com/PlanmecaUSA.

Kerr launches SonicFill™ 2 Kerr Corporation, a member of the KaVo Kerr Group, has launched SonicFill™ 2, which incorporates a new filler system containing nano-scale zirconium oxide and silica oxide particles.

This change delivers excellent gloss, color matching, wear resistance, and strength to make bulk filling easier and more reliable.

The updated product builds on the product’s promise of delivering a true, single-step bulk fill up to 5 mm.

For more information, or to schedule a free trial of SonicFill 2, visit www.kerrdental.com.

Volume 8 Number 5

ASI Medical’s Momentum™ specialty seating ASI Medical’s new specialty microscope chair was designed with the McKenzie Method in mind, which found that certain movements and postures can relieve pain and restore function.

The convex, flexible backrest strongly supports the natural lumbar curve, even in a relaxed position. Two styles of armrests are available: telescoping, for those who prefer more forearm support, and padded, for more elbow support. An adjustable front seat lowers the knees to below the line of the hips, transferring weight from the spine into the legs. The front edge of the seat then adjusts to the angle of the legs, comfortably supporting the legs while maintaining circulation. The non-slip Valencia™ upholstery with Permablock™ protective finish is durable and easily cleaned.

Multiple cylinder sizes are available to accommodate all heights.

Introductory pricing is available. Visit asimedical.net, or call 1-800566-9953 for details.

In addition, ASI’s newest advanced endodontic delivery system, the Ergo iTech™, integrates, houses, and hides auxiliary equipment, streamlining the use, look, and feel of the operatory.

A door-mounted shelf can house a miniature computer CPU, and the network cable runs hidden alongside the umbilical to connect to the server. Dual USB connections link devices such as digital sensors. Extra storage space hides tabletop instruments such as obturation devices and charging stations. An articulating monitor mount can attach an LCD screen to the cart, which can make explaining treatment plans easier with clear digital imaging. The patient’s experience is enhanced by creating a well-designed, fully integrated setting for a one-on-one consultation.

Visit ASI’s website at www.asimedical.net, or call 303-7663646 for more information.

Vista Dental Products expands product offerings Vista Dental Products has introduced the new Micro-Evac™ tip. This flexible, narrow tip was designed to easily navigate curved canals during endodontic aspiration. Vista’s Micro-Evac™ tips include HVE luer adaptors, for the fast and efficient removal of moisture from canals. Micro-Evac™ tips virtually eliminate the need for paper points. Micro-Evac™ features Vista’s SecureLock™ threads to lock the tip in place for increased safety and ease of use.

Vista Dental Products also has expanded its line of luer lock syringes, now offering 12 cc and 3 cc color-coded syringes.

Vista’s Color-Coded Luer Lock Syringes provide a fast and easy way to organize and identify irrigants and solutions, helping reduce incidences of syringe swap. Increase safety at no added cost. A box of Vista’s Color-Coded Syringes cost no more than a box of standard luer lock style syringes. Vista’s Color-Coded Syringes are latex-free and available in four easy to identify colors: blue, red, yellow, and white.

For more information, visit www.vista-dental.com.

Endodontic practice 45

PRACTICE MANAGEMENT

Dealing with drama: how to cancel the daily soap opera and get your team back to work Paul Edwards discusses how to regain control of your practice

H

ave you ever spent a weekday afternoon at home, flipped through the daytime soap lineup on network television, and suddenly thought to yourself, Why does all this melodrama seem so familiar?

Maybe you’ve even thought up a few modified program titles to describe what goes on from day to day in your practice. I’m pretty sure I could picture the standard plots for soap operas such as, “All My Employees,” “Schedules of Our Lives,” “The Young and the Whining,” and everybody’s favorite, “The Bold and the…Unbelievable.”

After watching such shows play out in the office year after year, many of us have come to feel that workplace drama is just a fact of office life. You’re accustomed to the blowups, the turmoil, the whining, and resistance. You might even dread going to work because each interaction feels like your energy is being sucked down an endless vortex. And somehow the same few people always seem to be behind it all, directing the play, and draining your enthusiasm, your optimism, and your vitality with their constant complaints, negativity, and trouble-stirring gossip.

But is workplace drama really inevitable, or is that exactly what the “Drama Kings” and “Queens” on our teams want us to believe?

I’m here to tell you that it is possible to regain control in your practice and put everybody back to work. Here’s how to understand your own office cast a whole lot better, so you can steal their spotlights and get them to play the role you need.

Paul Edwards is the CEO and Co-founder of CEDR HR Solutions (www.cedrsolutions.com), which provides individually customized employee handbooks and HR solutions to dental offices of all sizes across the United States. He has over 25 years of experience as a manager and owner and specializes in helping dental offices solve employee issues. Paul is a featured writer for The Profitable Dentist, Dental Economics, and other publications, and speaks at employment education seminars, conferences, and CE courses across the country. He can be reached at pauledwards@cedrsolutions.com or 866-414-6056.

46 Endodontic practice

The starring roles “Assisting chairside, we have Katie, hygienist and world-class manipulator! On phones, Trent, the hopeless gossip. Handling billing is Tanya Tattletale …”

You are probably very familiar with the long-term destructive effects of gossipy, whiny, attention-seeking, controlling, negative, or otherwise obstructive employees on your team. And once you’ve got more than one, watch out — they’ve got you outnumbered, and they start to take control.

Before we talk about what on earth your melodramatic employees are actually after, let’s look at the typical cast members, and what management techniques work best with each one. I like the “complainer” categories used by Linda Swindling in her 2013 book, Stop Complainers and Energy Drainers: How to Negotiate Work Drama to Get More Done.

You may not have all of these types right now, and obviously these are generalizations, while every employee is an individual. Overall, though, it’s useful to recognize these dramaprone employee types when you come across them. Like most things, management is easier when you know where to start!

Prima Donnas Prima Donnas love the limelight, just as you’d expect. They seek attention and

are great at relationships. They will use their charm to get other management personnel on their side if you don’t get there first.

Above all, don’t get caught up in the drama that surrounds these employees, and avoid putting them on the spot — they use spotlights to their advantage.

How to handle Prima Donnas Asking them to “tone it down” or “be reasonable” does not work. Instead, acknowledge the good skills or behaviors you like, and publicize any new goals you set with them. Prima Donnas don’t like to lose face, so you may find they’ll rise to the occasion.

Whiners Whiners are easily recognizable. These employees need to vent and whine and sigh about everything. They may be whining about how hard they work, or how nobody else works hard enough. Maybe they’re whining about how they always have to do something, or how they never get to do a particular thing.

How to handle Whiners To deal with Whiners effectively, listen sympathetically to an extent, without judging their reaction. Do not get pulled into their issues or commiserate with them. Once Volume 8 Number 5

Complicators Complicators are always there to point out obstacles or throw a roadblock in the way of the project you’re excited about.

They say things like, “That won’t work,” “We tried that before,” or “It’s more complicated than that.” Trying to change their minds, or asking them to have a positive attitude and be team players, doesn’t work with these employees.

How to handle Complicators Change is hard for Complicators, and you may have to slow down your efforts to get them to accept it. Try to get them to slowly upgrade rather than change. Enlist their help and acknowledge their efforts, both publically and privately.

Controllers Controllers, otherwise known as bullies, are vying for power. They may say things that are downright rude, such as “What’s your point?” or “I don’t have time for this.”

If they are in a position of some power, their “requests” may be intimidating: “Don’t make excuses — just get it done,” or “Do it right this time.”

How to handle Controllers Be assertive with these employees, and stand your ground with confidence. Don’t get defensive, antagonize them, or finger-point.

Give them narrow options, and deliver on your warnings and promises.

Toxics Toxics are master manipulators, and they don’t necessarily care whether their behavior is right or wrong. Don’t bother trying to show them the negative impact of their actions — they might enjoy seeing it. Instead, minimize their harm, and get them out as soon as possible.

How to handle Toxics Get help from an HR expert. Protect yourself by documenting EVERYTHING. Use stealth and micromanagement if you have to. An overall culture of transparency, candor, and sound management policies is toxic to Toxics!

Stirring the pot So now that we know who the key players in a typical office soap opera are, what are they really after?

Volume 8 Number 5

Above all, make it clear in your own actions and management style that you care about fostering a positive, supportive, and rewarding work environment.

The exact aims will vary, and not all employees are equally conscious of their own motivations. However, here are some of the most common goals of those who exhibit negative or obstructive behavior: • Attention and recognition, whether from you or the rest of the team.

• Preventing change by generating drama, fear, or obstacles.

• Destabilizing relationships within the practice, so management or team members cannot form alliances that will threaten them.

• Undermining praise or advancement that would otherwise be given to someone else.

• Grasping at power or control and protecting what they feel is their work “territory.”

Note that, aside from the desires for attention and power, most of these other goals are negative in nature. You know the dramatic office environment is bad for your practice when your employees are focusing their energies on preventing, undermining, and destabilizing your team and your business.

Again, not all of your drama-prone employees are consciously undermining the center or your authority — some may be good workers when managed effectively.

But others are truly Toxic, so be careful.

From symptoms to cures You’ve already seen the effects of drama run rampant, and now you have a better understanding of what tactics to use with each character in the cast. But where do you start the healing process?

First, think about which employees seem to be most involved in your practice’s drama club. Who has an ongoing behavior or performance issue that’s stressing you out or creating an atmosphere of drama or negativity? This issue could be anything from chronic excuse-o-rama, to rude or abrupt comments when dealing with patients, to backbiting or backstabbing among your team. (And more!)

Once you’ve identified the major players, figure out what type of complainer or energy drainer each problem employee is most likely to be. Even if the category isn’t an exact match, picking the closest fit will give you some new tactics to try. Then plan your next conversation or interaction with that individual accordingly.

When dealing with each employee type, remember that you are talking to a complex person who has multiple motivations and a collection of good and not-so-helpful traits. Your billing specialist Cindy may be a “Complicator” within your office environment, but that is not all she is, and it is not how she thinks of herself. It’s just a place for you to start, so you can adapt your communication style and thereby manage her more effectively. Use tact as you try the techniques listed previously.

During all coaching interactions, make it clear to the employee what the issue is and what impact the issue is having.

Express confidence that the employee has good intentions, and that you know they will be able to correct the problem. Then make a specific request for improvement.

Setting a specific, measurable goal makes the employee responsible for his/her own self-correction.

In cases where goals are not being met, document the results. Talk with an HR expert when termination begins to seem likely, so you can take steps toward letting the employees go when you need to. Sometimes your best course of action is to cut your losses and hire better next time. For employees who are doing well and succeeding at the goals you set together, let them know that you appreciate their efforts — it’ll improve your relationship and make the coaching more likely to stick.

Above all, make it clear in your own actions and management style that you care about fostering a positive, supportive, and rewarding work environment. With the right tactics and HR practices supporting you, the vast majority of the team will follow your lead. EP Endodontic practice 47

PRACTICE MANAGEMENT

they’ve had their chance to complain, redirect their focus by asking them for solutions.

PRODUCT PROFILE

TRUShape® 3D Conforming Files and Orifice Modifiers Saving more teeth by saving more tooth

R

etaining the natural dentition is an undeniable part of long-term oral health. Every day, endodontists work to save teeth in ways only specialists can, with new and advanced technologies that continually improve the standard of care.

Canal anatomy is truly complex, and a significant amount of dentin is inevitably lost in the process of removing infected pulp and debriding canal walls. Now, endodontists have another sophisticated tool for achieving predictable clinical outcomes — TRUShape 3D® Conforming Files — a revolutionary advancement in root canal therapy from DENTSPLY Tulsa Dental Specialties.

TRUShape 3D Conforming Files allow clinicians to preserve more tooth structure — often removing up to 36% less dentin compared to conventional instrumentation techniques while removing the pulp and debris along the root canal. The file’s design enables it to create a predictable apical shape, while producing 32% less apical transportation than conventional ISOprepared canals.1 TRUShape files have a proprietary design that resembles an “S,” which gives the file a unique ability to flex within the canal rotation and allows it to conform to the anatomy to reduce the amount of tooth structure removed versus conventional ISO rotary.

In addition to conforming to the canal, this

design creates an envelope of motion that better disrupts polymicrobial biofilms in mesial roots of lower molars, leaving significantly less bacteria when compared to conventional ISO rotary file systems.2 “Retaining the natural dentition is the ultimate goal of any dentist because the profession recognizes that there is no substitute for the real thing,” said Dan Ammon, PhD, Research and Development Director for DENTSPLY Tulsa. “TRUShape 3D Conforming Files are designed to preserve more dentin while contacting up to 75% of the canal and improving the disruption of polymicrobial biofilms within canals, resulting in bacteria reduction when compared to conventional ISO rotary file systems.”

The TRUShape 3D Conforming File is a very technique-specific instrumentation sequence that is designed to be used in conjunction with TRUShape Orifice

Modifiers to create an ideal receptacle for the introduction of the conforming file. The orifice modifiers feature an active cutting cross section, a fluted length of 7 mm, maximum fluted diameter of .75 mm, and NiTi for strength and flexibility. TRUShape 3D Conforming Files are sold four per pack and are available in tip sizes 20, 25, 30, and 40 and lengths of 21 mm, 25 mm, and 31 mm.

TRUShape is designed for use by endodontic specialists, and training is required prior to utilizing the instruments in a clinical setting. Discover the TRUShape difference and receive free CE training at DENTSPLY.com.

About DENTSPLY Tulsa Dental Specialties DENTSPLY Tulsa Dental Specialties is widely recognized as the leading marketer, developer, and manufacturer of endodontic products in North America. The company is a division of York, Pennsylvania-based DENTSPLY International, Inc., a global dental and consumable medical device company with operations and sales in more than 120 countries. For more information, visit DENTSPLY.com, or call 1-800-662-1202. EP

REFERENCES 1. Peters OA, Arias A, Paque’ F. Three dimensional analysis of the root canal geometry of oval canals after preparation with a novel rotary instrument. Submitted for publication.

2. Pileggi R, Bruder G, Wallet SM, Sorenson H, Walker C, Neiva KG. Quantitative analysis of a polymicrobial biofilm removal following instrumentation with a new file system. Submitted for publication.

The file’s unique S-shape creates an innovative envelope of motion within the canal that conforms to unconstrained spaces while respecting constrained spaces.

48 Endodontic practice

This information was provided by DENTSPLY Tulsa Dental Specialties.

Volume 8 Number 5

Remove up to 36% less dentin with superior overall shaping*.

Aid disinfection by disrupting polymicrobial biofilms and significantly reducing bacteria*.* Contact up to 75% of walls along the entire canal*.

Create a predictable apical shape with up to 32% less transportation*.

Call to learn more or request a demo today.

Preserving What Matters.

The inner green area indicates the unprepared canal.

TRUShape 3D Conforming Files conform to natural canal anatomies for a more conservative shape (red area).

The file’s unique S-shape creates an innovative envelope of motion within the canal that conforms to unconstrained spaces while respecting constrained spaces.

Traditional ISO files make round shapes, and can unnecessarily remove tooth structure (white line).

Image courtesy of Ove A. Peters, DMD, MS, PhD.

* Peters OA, Arias A, Paque’ F. Three dimensional analysis of the root canal geometry of oval canals after preparation with a novel rotary instrument. Submitted for publication. ** Pileggi R, Bruder G, Wallet SM, Sorenson H, Walker C, Neiva KG. Quantitative analysis of a polymicrobial biofilm removal following instrumentation with a new file system. Submitted for publication.

© 2015 DENTSPLY International, Inc. ADTS Rev. 0 2/15

1-800-662-1202 For the latest information consult

www.TulsaDentalSpecialties.com

PRODUCT PROFILE

ASI’s Momentum™ line of specialty seating Maintain your daily momentum

A

SI has just released a new microscope chair as part of its complete ergonomic solution, complementing its delivery systems.

ASI’s new specialty microscope chair is uniquely designed with an adjustable front seat angle that works in conjunction with the backrest for a customized fit to the operator. This allows the operator to create his/her preferred balance of support from the thighs to the spine without rounding or overloading the spine. The adjustable front seat angle can also allow closer proximity to the patient without reducing back support — the ideal ergonomic configuration. Two styles of armrests are available to further create a customized experience.

Designed in accordance with the McKenzie Method® of Therapy “The McKenzie Method® of Mechanical Diagnosis and Therapy® (MDT) is an approach that is trusted by clinicians and patients all over the world to treat common back, neck, and extremity joint pain.

Most musculoskeletal pain is mechanical in origin, meaning that everyday movements and postures cause pain over time. Through a systematic evaluation of his patients, New Zealand physiotherapist Robin McKenzie found that certain movements and postures can often abolish pain and restore function.”* This ideology is incorporated into the Momentum™ line’s design. *From the McKenzie website. For more information on the McKenzie Method and Therapy, visit McKenzie.org.

Anatomy of the ASI Microscope Chair — 5 key benefits 1. The design of the chair facilitates sitting higher to increase the hip angle from a standard 90 degrees to 110 degrees. This transfers weight from the seat to the legs, thereby reducing pressure on the discs of the back. The simple change of sitting higher and opening the hip angle can transfer up to 25% of a person’s weight from their back to their legs.

2. A common tendency is to sit forward on the edge of the seat, which causes the back to be unsupported 50 Endodontic practice

and causes a slouching curvature of the back, which can cut off proper circulation to the legs.

The Momentum features a unique hydraulically controlled, adjustable front seat angle that can be set to the operator’s desired setting. This motion lets the operator remain seated comfortably at the back of the chair and receive optimal back support, while maintaining excellent proximity to patients. The seat angle can be adjusted in conjunction with the seat height and front angle to the operator’s preference.

3. The adjustable backrest provides increased support and positioning.

Unlike other seat styles that have a wide support with a concave shape, the ASI backrest is a narrower width with a convex shape to fit and support the curvature of the spine even in a relaxed position. The backrest is mounted on specialized rubber bushings that aid in

stretching the back yet support the back fully when sitting normally. The backrest can be adjusted forward into the depth of the chair to fit operator preference.

4. The armrests are designed to support the weight of the arms during procedures, reducing stress on the neck.

Two styles of armrests are available: a padded cushion style for more elbow support and a telescoping cradle for enhanced forearm support. Adjustable vertically and horizontally, the telescoping version can swivel, maintaining support even while performing Class III movements.

5. The slip and stain-resistant, sewn upholstery is available in many colors to complement your current or new design.

For more information, please visit asimedical.net/products/chairs-stools. EP This information was provided by ASI Medical.

Volume 8 Number 5

PRODUCT SPOTLIGHT

Mani® D Finders: exploring the path Dr. Rich Mounce discuss strategies using “stiff” hand files

O

ne of the most common challenges in clinical endodontics is obtaining patency. Blocked, calcified, curved, and transported canals challenge clinicians on a daily basis. This clinical article was written to discuss strategies using “stiff” hand files designed exclusively for these issues such as the Mani® D Finders (DF) (Figures 1-2).

Negotiating the canal to the apex (gaining patency) requires patience, diligence, and an awareness of the three-dimensional nature of the canal before and during canal exploration. Mentally, to optimize apical hand file advancement, the clinician must focus on tactile feedback during file insertion and correlate this feedback with preoperative radiographic images. Blindly forcing hand files arbitrarily to length is the harbinger of all manner of iatrogenic events and should be avoided at all costs.

A critical first step in the achievement of patency occurs during examination of the 2D and/or 3D radiographic images. Open and easily negotiable canals visualized radiographically often are quite forgiving in that they are large enough to remain patent, even if mismanaged. Unfortunately, the reverse is true as complex canals often have one best attempt to achieve patency; hence, the steps recommended below.

Having available the required files is far preferable to imposing onto the canal solely what files the clinician has available.

In other words, a variety of hand files should be available for every case, as indicated by the anatomy encountered. To this end, it is noteworthy that hand files exist for every indication (aside from DF), which can provide the clinician what is needed for the given anatomy. These include hand files for rapid shaping (Mani RT files), reciprocation

Rich Mounce, DDS, is an endodontist who has lectured and written globally in the specialty of endodontics. Dr. Mounce owns MounceEndo.com, an endodontic supply company based in Rapid City, South Dakota. He can be reached by phone at 605-791-7000 or by email at RichardMounce@ MounceEndo.com, MounceEndo.com.

Disclosure: Dr. Mounce is a consultant for Mani Dental and receives an honorarium for his work.

52 Endodontic practice

Figure 2: The “D”-shaped cross section of the Mani D Finder

Figure 1: Mani D Finders

(safe-ended Mani SEC O K files), flexibility (Mani Flexile files), canal obstruction removal (Hedstrom files), gross canal shaping (Mani Reamers), and preparation of canal taper (Mani stainless and nickel-titanium Flare files). Many of the file types are available in “medium” sizes: 12, 17, 22, 27, etc.

Optimal utilization of any hand file has several requirements beginning with profound anesthesia, straight-line access, orifice management (adequate opening and shaping of the orifice), and removal of all pulp chamber contents prior to hand file canal negotiation.

Once the orifice is enlarged, and the other preceding steps are taken, regardless of the anatomy encountered, I virtually always insert the No. 6 Mani K file. Using a No. 6 Mani K file first allows me to determine the complexity of the canal without risk of blockage, especially in complex anatomy. Using larger files first can, in some canals, push tissue apically into the narrowing cross-sectional diameters of the canal and cause blockage. If the No. 6 advances easily to the apex, the clinician can move quickly to the next larger size (No. 8). Alternatively, if the No. 6 meets resistance (of any type), the canal is complex, and a DF is indicated for further negotiation.

Of the many marketplace options for “stiff” hand file options, I use the Mani D Finders for their rigidity, cutting ability, quality of manufacture, and economy. The DF’s cross section resembles the shape of the

Figure 3: The NSK ER-10 reciprocating handpiece (MounceEndo)

letter D, hence its name. While primarily used for canal negotiation, the DF can also be used to prepare a glide path with or without a reciprocating handpiece such as the NSK ER-10 (MounceEndo.com) (Figure 3).

The .02 tapered DFs are available in 21 mm and 25 mm, and in Nos. 8, 10, 12, and 15 tip sizes. DFs are designed to cut with ¼ to ⅓ turns with a reaming motion, accompanied by frequent irrigation. The DF has 16 mm of cutting flutes and a unique safety tip. The DF’s tip has a unique blend of noncutting and cutting features. It is designed to avoid transportation and yet enhance achievement of patency in narrow and highly curved canals.

Empirically, in my hands, a No. 8 DF is approximately 3-4 times stiffer than a standard No. 6 K file and, as a result, allows a significantly greater vertical pressure to be placed on them. DFs are an excellent option to allow apical negotiation in canals where a K file kinks and/or resists apical advancement.

The DF’s cross-sectional design prevents the screwing-in effect that is possible with more heavily fluted files. Less screwing in allows the forces placed on the file to be directed to the file tip, improving tactile sensation and apical movement.

Regardless of whether the clinician is using a K file or a DF, it may be necessary for him/her to insert the file in many orientations in order to initially locate the canal path Volume 8 Number 5

Volume 8 Number 5

PRODUCT SPOTLIGHT

and subsequently gain length, especially in an acute apical curvature. Hand files should never be forced, as doing so can create a false canal path and/or blockage. That said, experience can guide the clinician to put firm but flexible pressure while watch winding the DF to push through debris blockages or advance around curves.

It is axiomatic that all hand files be precurved and that the canal be filled with irrigant during all phases of negotiation and shaping. Personally, I use a new hand file for each individual insertion and subsequently use a new file. While hand files can certainly be sterilized and used in multiple cases, the sharpest and greatest degree of tactile acuity results from use of a new hand file with every insertion.

Once the clinician reaches the apex with the first DF, a glide path is subsequently prepared using the Mani hand files of choice (K, Flexile, RT, SEC O K, D Finders, etc.) followed by bulk canal shaping with, for example, Mani’s new and novel Mani Silk nickel-titanium system. Mani Silk is anatomy-based, shaping canals with threefile “Simple,” “Standard,” and “Complex” anatomy pack configurations (Figure 4).

Figure 4: Clinical case negotiated with a Mani D Finder as described in the article and shaped with Mani Silk

This article has described the negotiation of curved and calcified canals using the Mani D Finders. Emphasis has been placed on straight-line access, optimal orifice management, and the intentional but firm pressure

using pre-curved D Finders in an irrigantfilled canal to reach the apex, followed by subsequent glide path creation and shaping with Mani Silk nickel-titanium files. I welcome your feedback. EP

Endodontic practice 53

ENDOSPECTIVE

A voice for small business Dr. Rich Mounce encourages colleagues to be informed and involved for future practice growth

A

s clinicians, we are focused on patients, our offices, new clinical materials, and techniques. Many of us do not pay close attention to politics. It’s not generally in our DNA. Starting in about 2000, I began to pay attention. Alarmingly, I watched my tax bills rising simultaneously with the rising national debt and observed an evolving dysfunction led by federal and state governments that are either unwilling or unable to solve the nation’s problems.

What’s this got to do with endodontics and dentistry as a whole? A great deal. There are many threats to our profession, but one significant stress is the increasing level of state and federal regulations under which we operate. The burden of rules we are required to follow is rapidly taking us to a tipping point where the regulatory and compliance burden imposed on us by our government threatens our ability to function as independent small businesses, our doctor-patient relationships, and the dental industry that supplies us.

Economic and regulatory policies at the state and federal levels have a direct impact on the economic viability of our communities, directly affect our economic health, and ultimately dictate how we practice. Reasonable and common sense regulation is needed.

Overkill is unproductive, and the statistics don’t lie. Less regulated states are healthier on virtually every economic and social metric compared to more regulated ones.

Two cases in point illustrate this challenge. First off, how many of you right now, without any preparation, would eagerly, and without limits, want the EPA, IRS, OSHA, and/or any government agency, for that matter, to inspect your practice for regulatory compliance? With the breadth of current regulation, is there any doubt that the vast

Rich Mounce, DDS, a practicing endodontist, has lectured and written globally in the specialty.

He owns MounceEndo, an endodontic supply company also based in Rapid City, South Dakota.

Dr. Mounce can be reached by calling 605-7917000, emailing RichardMounce@MounceEndo. com, or visiting MounceEndo.com.

54 Endodontic practice

majority of us would violate any number of laws, many of which we did not even know existed?

Second, recently I received an email from a seasoned American dental industry executive. Illustrating the stifling effect of federal regulation, he wrote: “… it adds tons of cost, barriers, and more often than not, stifled innovation as we wrestle with trying to figure out how to make something ‘evolutionary’ versus ‘revolutionary’... the former being deemed by our regulatory bodies as being an acceptable term because it connoted remarkable equivalence … and the latter being a complete non-starter, because it would suggest that there is no predicate device (again, something that is part of the requirements of getting 510(k) approval (government approval that a device is safe and effective). … Sit in any product pipeline meeting of a medium to large dental company, and you will find 90% of the discussion focused on regulations, verbiage, resource allocation, troubleshooting, and less than 10% about actual innovation. Sad truth.”

Why do we allow this? Is this the present and future America needs? Do we fear our government and hence remain silent? Or do we just not care? I believe we do care, but while we all lead busy lives, we believe that someone else is going to take care of these challenges for us. Hence, we don’t generally pay attention and are ending up like the

proverbial frog in a pot of water with the heat being slowly turned up.

Regardless of one’s politics, there has never been a greater need to be informed, get involved, and work for common sense policy that protects and serves our patients, without undue taxation or regulatory burden.

Start by writing a check to your state dental PAC and/or the ADA PAC, contact your local and national leaders, vote for common sense solutions and pragmatic candidates, and participate in the process.

As for me, I am running for the state legislature in South Dakota to help grow small businesses and protect small businesses like ours.

We must not lie down like lambs accepting government dictates from a faceless, uncaring, distant and feared bureaucracy. Certain defeat looms if we passively stand by and pretend there is nothing we can do and remain silent. We have a voice, and now more than ever, we need to collectively use it to take the best of dentistry today, remove the barriers described above, and move forward toward a better and more sustainable future.

Beyond dentistry, removing these barriers will help arrest our national slide into mediocrity. Our professional futures, the future of dentistry, and ultimately the future of America depend on efforts such as ours. I welcome your feedback. EP Volume 8 Number 5

M AT E R I A L S lllllllllllll & lllllllllllll EQUIPMENT

Applying Endo Pulse — why break another file?

The Endo Pulse RCT handpiece is designed to eliminate file separation during RCT. It is a “non-rotary” reciprocation adjunct to help create the perfect glide path and make RCT safer, faster, and more predictable.

Why break another file?

Using unique Vertical Reciprocation, EP and Master Files have zero “torque stress,” which is the cause of rotary file separation.

EP Vertical Reciprocation moves the file between 1 mm and 0.30 mm depending on resistance. You can cut through all curves and calcifications to the apex and eliminate your hand filing fatigue.

EP is also a Retreatment Machine!

• Irrigation/activation Endo Pulse offers automatic irrigation straight from your low- or high-speed lines. Just step on your pedal and EP washes out debris and lubricates the canal. Activate your sodium hypochlorite using EP to make it more effective while saving chair time.

• Super economy Rotary files are expensive. Master Files cost similar to conventional hand files and can be reused.

• Added plus EP comes with a small, lightweight detachable E-type 20K rpm motor. Use the motor for other contra angle or straight attachments.

Visit Endo Technic at www.endotechnic.com, or call 877-477-8899.

Subscribe to the Endodontic Practice US newsletter!

Each week subscribers can look forward to receiving relevant and innovative information including: • CE articles • Practice Profiles • Case Studies • Cutting-Edge Technology • and more Subscribe for free today: http://endo-us.link/endonewssignup

Volume 8 Number 5

Vista’s SmearOFF™ removes smear layer and bacteria at a fraction of the cost SmearOFF™ by Vista Dental Products effectively replaces two commonly used solutions: EDTA and CHX. SmearOFF™ is an EDTA-based formula enhanced with chlorhexidine. SmearOFF™ not only effectively removes the smear layer, but also kills bacteria in one easy step. SmearOFF™ removes significantly more canal debris compared to standard 17% EDTA and leaves the root canal surface cleaner by opening a greater percentage of dentin tubules. Additionally, SmearOFF™ provides the added benefit of killing root canal bacteria. Unlike other 2-in-1 mixes, SmearOFF™ is compatible with sodium hypochlorite and will not form a precipitate — eliminating steps and saving time with each procedure.

SmearOFF™ is the clear choice among other 2-in-1 solutions: (1) Will not form a precipitate when mixed with NaOCl; (2) Has superior chelation and enhanced cleansing; (3) Has optimal smear layer removal; (4) Kills 99.99% of bacteria in 10 seconds; (5) Offers 30% SAVINGS compared to other leading brands.

For information, visit vista-dental.com, or call 877-418-4782.

Endo-Eze® endodontic hand files and burs Ultradent Products, Inc., has launched Endo-Eze Endodontic Hand Files and Burs, designed with shaping efficiency and superior instrumentation in mind, as well as the comfortable transmission of the operator’s movements. This newest addition to Ultradent’s Endo-Eze line of products offers dental experts the balanced flexibility and resistance of a full range of K-Files; the sharpness and cutting ability (with added flexibility) of NiTi K-Files; and the spiral-designed, fluted, Hedstrom Files (H-Files). EndoEze’s newest offering also features Flex Files, which are made of stainless steel alloy with increased flexibility, and Finger Spreaders, which help to safely open the space for lateral compaction of the gutta percha. The Endo-Eze stainless steel and nickel-titanium files were created using a state-of-the-art alloy treatment, giving them the flexibility to negotiate curvatures and the resistance needed to advance to the apical third. The ergonomic handles help improve clinical performance, offering better tactile feedback and reduced fatigue.

In addition to the new and extensive endodontic file offering, Ultradent is also pleased to offer two new Endo-Eze Endondontic Burs — the Peeso Reamer Bur and the Gates Glidden Bur. The Peeso Reamer Bur is specially designed to prepare the canal orifice for straight-line access and can be used for the initial removal of gutta percha in retreatment. It also features a non-cutting tip for increased safety. The Gates Glidden Bur allows for deeper penetration in straight canals but can also be used in the straight section of curved canals. The Gates Glidden Bur also features a safe, non-cutting tip.

For more information, call Ultradent Products at 800-5525512, or visit ultradent.com.

Endodontic practice 55

PRODUCT PROFILE

Planmeca Romexis® software Open architecture, endless possibilities

T

echnology in dentistry is evolving.

With an ever-growing platform and so many options in the industry, it’s time for a software platform that features all-in-one capabilities and open architecture, allowing you to choose the best technology for your practice.

Built on an open architecture software platform, Planmeca Romexis offers best-inclass integration, providing users with the freedom to use third-party products for a customizable workflow built to fit the needs of any office. TWAIN protocol and DICOM compliance, as well as full support for Windows and Mac OS operating systems, make Planmeca Romexis an ideal fit for any practice.

Your all-in-one software solution Planmeca Romexis is the first software in the world to combine 2D and 3D imaging with complete CAD/CAM workflow and even extended connectivity with Planmeca dental units. Planmeca Romexis software offers these capabilities and more — IO scanning and restorative design, ceph analysis and tracing, orthodontic tasks with Ortho Studio, and Planmeca ProFace true 3D facial photos for case presentations that are more detailed than ever.

plans. Easy mouse-driven navigation means no complicated keyboard combinations to remember: Your necessary functions are in front of you, clearly marked, and ready to use.

Secure image sharing from anywhere Share files from wherever you are with the innovative Planmeca Romexis Cloud, a secure transfer service for Planmeca Romexis users and their partners. The service is easy to use and seamlessly integrated into Planmeca Romexis, saving you even more time and cost by eliminating DVDs and other physical processes.

Exceptional usability

Efficient clinic management

With Planmeca Romexis, versatile applications are easy to use with intuitive features that make it simple to view, edit, and enhance images, as well as create detailed treatment

For larger practices with multiple operatories, Planmeca Romexis also offers its Clinic Management module for an innovative link between software and equipment,

Planmeca 3DMax 3 x 3D = CBCT + ProFace + impression scan 56 Endodontic practice

making it possible to remotely monitor your unit functions, access user-specific presets from any unit, proactively manage unit maintenance for decreased downtime, and more.

A future-proof investment Planmeca Romexis software offers a complete workflow engineered with the flexibility to adapt to you and your patients’ evolving needs. Planmeca Romexis leads the world in image capture and diagnostics for superior treatment planning with the ability to upgrade and make your investment future-proof. Open file architecture and true modularity means you can add technology as you need it, ensuring your practice won’t be left behind as dental technology continues to advance. EP This information was provided by Planmeca.

Planmeca 3Ds large view image Volume 8 Number 5

OWN THE FUTURE™

ProMax 3Ds PRACTICE PLANMECA

®

REVEAL THE FINEST ANATOMICAL DETAIL

The ProMax 3Ds is a versatile and dynamic 2D/3D imaging system that brings new possibilities for diagnostics, treatment planning, and patient counseling. With a new imaging mode for endodontics featuring a 75µm voxel size, it is ideal for diagnostics requiring the finest anatomical details: • Determining root curvature • Diagnosis of periapical pathosis • Diagnosis of trauma: root fractures, luxation, displacement of teeth, and alveolar fractures • Determining exact location of root apex in presurgical planning to mitigate endodontic treatment complications • Obtaining true anatomical measurements

ENDO

Endodontic imaging mode is optional on all ProMax® 3D Models

for a free in-office consultation, please call

1-855-245-2908

or visit us on the web at www.planmecausa.com

TECHNOLOGY THAT WORKS THE WAY YOU DO

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RVG 6200 – FULL RANGE IMAGING FOR DIAGNOSTIC CONFIDENCE RVG 6200 intraoral sensor technology is built with you in mind. Image processing tools can be customized through new user-defined and pre-programmed filters to assist your optimal diagnosis. With an intuitive approach the RVG 6200 delivers: • • • • • •

ENHANCED WORKFLOW – optimized to the extreme: Position. Expose. View.

ROBUST DESIGN – for maximum durability SUPERIOR ERGONOMICS – for best-ever patient comfort BROAD EXPOSURE RANGE – during image capture NEW IMAGE PROCESSING TOOLS – customized to your preference SERVICE MADE SIMPLE – simple installation and compatible

LET’S REDEFINE EXPERTISE The RVG 6200 is just one way we redefine imaging.

Call 800.944.6365 or visit carestreamdental.com to discover more. © Carestream Health, Inc. 2015. RVG is a trademark of Carestream Health. 12962 EN RVG 6200 AD 0815