Oral Health May 2020 by Annex Business Media

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MAY 2020

Doing less … invasive procedures With more … protection and screening DENTISTRY IN THE CORONAVIRUS ERA ENDODONTIC DISINFECTION: THE SONIC ADVANTAGE

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IMPACT OF THE COVID-19 PANDEMIC ON DENTAL PRACTICE VALUATIONS AND SALES

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Dentistry in the coronavirus era

GUEST EDITO RIAL

Ma nor Haas, DDS, Cer t. Endo.

t’s fair to say that day-to-day life and dentistry as we’ve known it have been turned upside down due to the COVID-19 pandemic. Overnight, we went from normal, day-to-day dental care to a near medically induced coma with many, if not most, dental offices shutting their doors. Even though these are fluid times, the common theme in dentistry has been to look only after our patients’ acute emergencies and to provide no elective treatments. So, for the foreseeable future, this is where dentistry will be. However, I don’t see this as meaning that we need to hide under a table or just watch Netflix all day and wait for normal (dental) life as we recently knew it, to come back. This should be a time to sharpen our pencils and learn more about many aspects of dentistry by means of webinars, literature and blogs. In this Oral Health edition, we cover many aspects of endodontics with great articles on everything from the use of CBCT, to disinfection, guided endo, obturation, endo access and endo emergencies with COVID considerations. We also have a great piece on mindfulness and work/life balance. How appropriate during these unusual times. Furthermore, we should not feel alone while we are in government-directed isolation and away from our offices. I’ve personally seen many dental blogs, online forums, apps, video chats such as Zoom and traditional email groups very active with colleagues communicating with each other. My own dental class’s WhatsApp chat group has been on fire with activity. It’s been a pleasure to connect with classmates from all over Canada and chat about the good, the bad and the ugly that’s going on in dentistry. But also with a healthy sense of humour on life and true support for one another. No six feet of separation needed here. On March 15, 2020, the New York Times published a piece on workers who face the greatest coronavirus risk. And guess who was at the top? Dentists! Great! Hence, if you are seeing emergency cases, be vigilant about your and your staff ’s well-being and not just your patients’. I personally had a fight with the virus. A fight that landed me in intensive care and on life support. But I made it through and am thrilled to be able to look forward at treating patients again. The day I got released from hospital I was already thinking ahead, knowing that life will move forward and we will once again do what we love to do and are so well trained for: caring for our dear patients. So, don’t feel alone. Turn to colleagues for support or offer support, and make the most of this downtime to improve yourselves. This new way of life won’t last forever and we will make it through, coming out better and stronger than we were before.

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Dr. Haas is a certified specialist in endodontics and lectures internationally. He is a Fellow of the Royal College of Dentists of Canada and is on staff at the University Of Toronto Faculty Of Dentistry and the Hospital for Sick Children. He maintains a fulltime private practice limited to endodontics and microsurgery in Toronto. Dr. Haas is a regular contributor to dental journals and online forums. He can be reached via the website: www.HaasEndoEducation.com

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2020-04-27 11:13 AM

MAY 2020

CONTENTS

VOLUME 110 NUMBER 5

ENDODONTICS

ENDODONTICS 10. Continuous wave of condensation revisited: A new cordless obturation system Gary Glassman, DDS, FRCD(C) 15. Endodontic Disinfection: The Sonic Advantage Clifford J. Ruddle, DDS, FICD, FACD 22. “Managing endodontic emergencies in the Covid-19 era” Manor Haas, DDS, Cert. Endo.

28. Limited FOV CBVT in endodontics – 3 years later and never looking back Geoffrey L. Sas, DDS, FRCD(C), Dip. ABE 37. Endodontic microsurgery of an anatomically challenging zone using dynamic navigation: A case report P.A. Villa-Machado, DDS, Endodontist; K.S. Serota, DDS, MMSc; F.A. Restrepo-Restrepo, DDS, Endodontist

VIEWPOINT 6. Handling the stress of practicing dentistry: The story of a recovering perfectionist! Sally Safa, DDS, FRCD(C)

WEB EXCLUSIVE CONTENT Armamentarium for dentin conservation during Endodontic treatment Bobby Nadeau, DDS The Evolving Look of ‘The Look’ John West, DDS, MSD Available at www.oralhealthgroup.com

EDITORIAL 3. Dentistry in the coronavirus era Dr. Manor Haas, DDS, Cert. Endo. 8. Data driven dentistry 59. Dental Marketplace

w w w. o r a l h e a lt h g r o u p. c o m

MAY 2020

Doing less … invasive procedures With more … protection and screening DENTISTRY IN THE CORONAVIRUS ERA ENDODONTIC DISINFECTION: THE SONIC ADVANTAGE IMPACT OF THE COVID-19 PANDEMIC ON DENTAL PRACTICE VALUATIONS AND SALES

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PRACTICE MANAGEMENT

Sponsored by:

EDITORIAL BOARD MEMEBERS

CONTRIBUTING CONSULTANTS

Dr. Jordan Soll • Editor/Co-chairman Dr. Randy Lang • Co-chairman/Orthodontics Dr. Gary Glassman • Endodontics Dr. Mark Nicolucci • Implantology Dr. Bruce Pynn • Oral and Maxillofacial Surgery Dr. Peter Birek • Periodontics Dr. Les Rykiss • Esthetics Dr. Mark Lin • Prosthodontics Dr. Janice Goodman • General Dentistry Dr. Peter Nkansah • Pharmacology/Anesthesiology Dr. George Freedman • Dental Materials & Technology Dr. Fay Goldstep • Preventive Dentistry/Healing Dr. David Farkouh • Paediatrics Dr. Marina Polonsky • General Dentistry/Laser Dentistry Dr. Bruno Vendittelli • Orthodontic Dr. James Yacyshyn • Practice Management Expert

Dr. Carlos Ochoa • Endodontics Dr. Angelos Metaxas • Orthodontics Dr. Blake Nicolucci • Implantology Dr. Iain Nish • Oral & Maxillofacial Surgery Dr. Howard Holmes • Oral & Maxillofacial Surgery Dr. Jack Griffin • Esthetics Dr. Reza Nouri • Pediatrics Dr. Ross Anderson • Pediatrics Dr. Carolyn Poon Woo • General Dentistry Dr. Keith Titley • Pediatrics Dr. Robert Lowe • Esthetics Dr. Gary Radz • Esthetics Dr. Mitra Sadrameli • Oral & Maxillofacial Radiology Dr. Bo Kryshtalskyj • Oral & Maxillofacial Surgery Dr. Indra Narang • General Dentistry/Sleep Dentistry Dr. Barry Korzen • Endodontics Dr. Goth Siu • Prosthodontics Dr. Joseph Fava • Prosthodontics Dr. W. Johnston Rowe Jr. • Esthetics Dr. Aviv Ouanounou • General Dentistry Dr. Sherif Elsaraj • General Dentistry

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Credit Illustration: Don Mackenzie donaldianmackenzie@gmail.com 4 M AY 2020

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A NEWCOM Media Inc. Publication

Managing Editor: Catherine Wilson (interim) and Amy Bielby 416-614-5820, ext. 250 amy@newcom.ca Digital Content Coordinator: Marley Gieseler 416-510-6777 marley@newcom.ca Art Direction: Beverley Richards Catherine McKenny Carolyn Brimer Elaine Borg Circulation: Mary Garufi 416-614-5831 mary@newcom.ca

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Oral Health, published by Newcom Media Inc., is an independent, monthly professional journal, written and edited for the practicing dentist in Canada, and supervised by an Editorial Board of Consultants from both general practice and major specialties of the profession. The editorial content consists of clinical articles and abstracts from the world’s finest dental literature and monthly departments.The editorial purpose is to provide information on clinical advances in all phases of dentistry. Oral Health is not responsible for the quality of graphic images submitted by the authors. The Editorial Board of Oral Health does not necessarily agree with the claims made for any product advertised. Nor should it be construed that the appearance of any product advertisement in Oral Health implies that the Board either approves or accepts the product. Oral Health reserves the right to edit departmental submissions for content and length. The contents of this publication may not be reproduced either in part or in full without the written consent of the copyright owner. ISSN 0030-4204 Yearly subscription rates: Canada 1 year $64.95 + taxes, 2 years $107.95 + taxes (GST/HST #103862405RT0001); U.S. 1 year $70.95; Foreign 1 year $107.95; Single copy Canada & U.S. $10.00; Single copy Foreign $10.00. Printed in Canada. All rights reserved. From time to time we make our subscription list available to select companies and organizations whose product or service may interest you. If you do not wish your contact information to be made available, please contact us via one of the following methods: Phone: 416-614-5831; Fax: 416-614-8861; E-mail: mary@newcom.ca; Mail to: Privacy Officer, Newcom Media Inc., 5353 Dundas St. W. Suite 400, Toronto, ON M9B 6H8. Oral Health is published monthly + a special issue. CANADA POST Publications Mail Agreement No. 40063170. Changes of address notices and orders for subscriptions are to be faxed to (416) 614-8861 or mailed to Circulation Department – Oral Health, 5353 Dundas St. W. Suite 400, Toronto, ON M9B 6H8.

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V I E W POI N T

Handling the stress of practicing dentistry: The story of a recovering perfectionist! Sally Safa, DDS, MSc (Perio), FRCD(C)

I Dr. Sally Safa is a board certified Periodontist. Alumnus of the University of Toronto where she maintains a teaching position as clinical instructor. She maintains private practice in North York where she enjoys all aspects of Periodontal and Implant related patient care. She is also a passionate advocate of wellness for healthcare providers. Her website is www. mindfuldentist.ca Dr. Safa’s Masters research was in the field of Psychoneuroimmunology, understanding the effects of stress on the body. This background combined with her education in the field of Mindfulness Based Stress Reduction, has allowed her to share the science behind both stress and mindfulness and how it can help dentists reduce stress in their day to day lives at home and the office.

6 M AY 2020

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n 2014, I was published in the Ontario Dentist journal pleading for speakers and content that could address the stress that dentists incur day after day and ways in which to successfully handle it. I can’t believe that six years later, that I would actually be that person! When I wrote this letter to the editor, I was frustrated and angry. I was suffering from a great deal of stress and anxiety like many of my colleagues and no one talked about it. I went to meetings, CE courses, seminars, study clubs and not a single thing. My 7 years as a student at U of T Dentistry also never included anything formal on stress in dentistry. Funny enough, I did study stress while I was at the Faculty and my Masters thesis was actually in Stress as it relates to Periodontitis. Its surreal that 13 years after I published my thesis, I would be speaking about stress, but as it relates to dentists. I started a journey six years ago to find ways to cope with stress and anxiety. This is how I came to learn and study Mindfulness Based Stress Reduction (MBSR). A scientifically-based, proven method to help manage stress. I would have never imagined that my passion in Mindfulness would take the turns that it did, and keep me busy speaking to dentists and health-care providers across Canada and soon in the United States. The most humbling experience has been the responses that I get time and again from our colleagues after I share my experience and knowledge of MBSR. Two things stand out: many feel they are alone in the level of stress and anxiety they feel, and, they don’t know where to turn. By sharing my experience, as someone in the trenches, a tribe member, I feel that has made it possible for colleagues to openly discuss their stress. I wanted to point out one common thread that underlies so much of our colleagues’ stress, and that is “perfectionism”. It’s funny, when I was preparing for my Perio specialty interview at U of T, I knew that they would ask me a question that would go something like this: “Sally, what would you say is

your greatest weakness” and I remember thinking of what I would say. I could say the truth, like I have anxiety, that I get overwhelmed easily, etc…but none of this would get me into Perio. So, I came up with the “perfect” answer…”I am a perfectionist”. I would spin it as “its my weakness and my strength!” I find that dentists are notorious for wanting to be “perfect”. Unfortunately, dentistry is a death sentence for those of us who want to be perfect. Why? Because PERFECT isn’t real. We will never be perfect, that’s an unattainable goal. It’s something that we constantly strive for, but will never reach. The perfect prep, the perfect obturation, the perfect margin. We measure ourselves up against this idea of “perfect” work. This often then spills into our personal lives as well. Many studies link perfectionism with burnout. As a recovering perfectionist, I have seen how in my own life, this idea of wanting to be perfect has created a ton of angst and stress as I try to reach something that I can’t achieve. So, I’m now advocating the “good enough” and “tried my best” approach. This doesn’t mean I strive to do mediocre work, not at all. I still try my very best to do “perfect” work, but now, I just recognize what I’m doing (mindfully) and take a breath and say, “I did the best I could”. I did the best I could with a moving target (patient), with a high-speed drill, working in a scale as small as the tip of a pencil. I did my best and that is perfect! My hope is that if we can shift our thinking, the way we teach at our dental schools, bringing in some compassion to these folks who have strived to be “perfect” all their lives. Let’s cut them some slack and bring some compassion to ourselves, our students and our colleagues and just drop the perfect and be ok with “I did my best”. The journey for me has been full of ups and downs. I am grateful every day that I get to share my knowledge of stress and mindfulness as a coping tool. If this work changes even one person’s life, then that’s “perfect” for me.

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2020-04-21 8:18 AM

Dental webinars on demand Earn CE credit from home 3M.com/dentalwebinars

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2020-04-14 2:55:10 PM 2020-04-20 1:09 PM

Don’t Be Afraid to Keep Learning

hen conducting our research for Data Driven Dentistry, we found 72% of patients would choose their own dentist to perform a specialized procedure over a specialist, if their dentist had the applicable skills. It makes sense, as patients would spend less time traveling to additional appointments and have less worry about getting comfortable with a new dentist. This demonstrates how important it is to obtain specialty skills and show them off when you have them. It is incredibly valuable to obtain specialized skills when completing your education, if you have the chance. While this increases the time before you can begin working by 3-5 years and may add to your school debt, the benefits outweigh the negatives in the end. When you possess more skills, you can perform additional procedures, which will increase the revenue of your practice. While many patients are content with being referred to a specialist, most of them would still prefer their own dentist perform treatment. If completing a specialty program is not for you, there is another way to increase your skills: continuing education courses. CE courses are offered year-round from many different organizations on a variety of topics. Whether you physically attend or tune in for a webinar, CE is a way to constantly upgrade your knowledge, allowing you to continually showcase new skills. One of the best places to highlight your specialty skills is obvious: your website. Utilize your website

to prove your skills to your potential or current patients. Here are some of the ways you can do this: • Include a detailed biography that highlights your training and education, including designations • List all the services and procedures you provide • Provide links to clinical articles to which you have contributed • Showcase any awards your practice may have won By including these items on your practice’s website, you will show patients that you have all the necessary skills to treat them. By highlighting your talents to perform specialized procedures, patients will know they won’t have to anticipate being referred to other practitioners very often. Time is extremely valuable, and most patients will opt for the least time-consuming option. Another way to highlight your specialized procedure skills is in person. When describing treatment plans to patients, ensure you are using your communication skills to the best of your ability. Ensure the patient fully understands the treatment and what options are available to them. At this time, you can explain to the patient that you are capable of performing the procedure if they would prefer you perform it over a specialist. If needed, go into detail about the steps of the procedure to prove how familiar it is to you. As they say: if you’ve got it, flaunt it! If you have skills, don’t be afraid to show them as it will certainly pay off!

of patients would prefer their dentist perform specialized procedures over a specialist if they had the necessary training. 8 M AY 2020

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42%

OVER

1/ 2

of patients agree that services/procedures offered by dentist is criteria they search for online when seeking a new dentist.

of patients agree that the ability/skill of a dentist to explain the benefits of a treatment is a factor in treatment acceptance.

of patients stay loyal to their dentist because they trust them.

37%

of patients agree the length and complexity of a treatment is a factor in treatment acceptance.

When asked about daily operational challenges, dentists said pressure to update training/skills ranked at

67%

of dentists agree they would like to take more CE courses to learn about new techniques/procedures.

63%

of patients would like to see information on new procedures and services on the social media of a dental practice.

of patients agree website/ articles is a method they would prefer to learn about new technologies and procedures from.

During an initial phone call, nearly

of paitents agree that the skill level of a dentist is a reason for remaining loyal.

1/ 2

of patients say knowledge of staff helps decide whether to look further into dental practice. Data Driven Dentistry is sponsored by:

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2020-04-23 11:58 AM

In late October and early November, 2018, Bramm Research, a third-party independent research consulting firm, conducted an online survey on behalf of Oral Health. The study was conducted in English

ENDODONTICS

Continuous wave of condensation revisited: A new cordless obturation system Gary Glassman, DDS, FRCD(C)

he main objective of endodontic treatment is the prevention and/or the elimination of apical periodontitis. This is achieved by instrumentation, disinfection, and obturation of the root canal system in three dimensions. Gutta percha is the most widely used and accepted obturation material because of its biocompatibility, inertness, dimensional stability, compactability, plasticity when heated, and ease of removal for post placement or retreatment1 There are a variety of techniques that are used to obturate the root canal system. They can be divided into two basic groups: cold lateral compaction and warm vertical compaction. Warm vertical compaction of gutta percha using the continuous wave of condensation technique is less time consuming, provides less microbial coronal leakage, 2 and adapts better to grooves and depressions of the canal walls and lateral canals than cold lateral compaction.3,4 This article will discuss the technique of Continuous Wave of Condensation using the new GuttaSmartTM cordless obturation system. Figs. 1A, B & C. THE CONTINUOUS WAVE OF CONDENSATION TECHNIQUE USING THE GUTTASMARTTM CORDLESS OBTURATION SYSTEM This technique allows a single tapered electric heat plugger to capture a wave of condensation at the orifice of a canal and ride it, without release, to the apical extent of downpacking in a single, continuous movement. Because the tip moves through a viscosity controlled material into a tapered-like canal form, the velocity of the thermosoftened gutta percha and sealer moving into the root canal system actually accelerates as the down packing progresses, moving softened gutta percha into extremely small ramifications. Fig. 2. The continuously tapered root canal preparation facilitates the fit of a suitably sized Conform FitTM gutta percha cone. (Dentsply Sirona) Figs. 3A & B. The master cone selected should be inserted to full working length and exhibit apical tugback (resistance to displacement) upon its removal. It is simple to fit a master cone into a patent, smoothly tapered, and well-prepared

canal.5-8 The cone may then be cut .5-1mm to accommodate for it apical movement. (distance from apical reference point will vary with canal curvature and size). The intimacy of diametrical fit between the cone and the canal space may be confirmed radiographically. The heated plugger of the downpack device (most commonly a .04 taper with .5 mm diameter) should fit to within 4 to 7 mm from the apical terminus to allow full thermosoftening of the apical gutta percha plug. When the tip of the plugger contacts dentin (the binding point) in the canal, the rubber stop should be adjusted to its corresponding occlusal reference point. Figs. 4A & B. Stainless steel pluggers may be prefit into the canals to their binding point in preparation for the backfilling. Rubber stoppers are adjusted on these pluggers to the occlusal reference point corresponding to 2 mm short of the apical binding point. These pluggers are placed aside to be used later in the back fill phase of canal obturation Fig. 5. SEALER AND MASTER CONE PLACEMENT The amount of sealer used in this obturation technique should be minimal. The radicular portion of the master cone is lightly buttered with sealer and the cone is gently slid to length. Placing the master cone in this manner will serve to more evenly distribute sealer along the walls of the preparation, and importantly, allow surplus sealer to harmlessly vent coronally.5-8 Figs. 6A & B. The activation cuff on the Downpack (Pack) handpiece can be pressed anywhere above the ridge on its 360 degree circumference. A band near the cuff lights blue when the tip is being activated. The tip will remain heated only as long as the activation cuff is being depressed. The master cone is seared at the orifice of the canals with the activated heated plugger, and then gently “seated” with a larger stainless steel plugger. A small “dimple” may be created in the coronal aspect of the master cone to act as a guide for the activated heated plugger. The activated heated plugger

Gary Glassman is the author of numerous publications, lectures globally on endodontics, is on staff at the University of Toronto, Faculty of Dentistry in the graduate department of endodontics. As Adjunct Professor of Dentistry and Director of Endodontic Programming from 2010-2017, Gary helped develop the dental school curriculum for the Oral Health Science programme for the University of Technology, Kingston, Jamaica. Gary is a fellow of the Royal College of Dentists of Canada, Fellow of the American College of Dentists, endodontic editor for Oral Health dental journal, endodontic editor for Inside Dentistry, Faculty Chair for DC Institute and Chief Dental Officer for dentalcorp Canada. His personal/professional website is www.drgaryglassman.com and his office website is www.rootcanals.ca He can be reached at gary@rootcanals.ca. 10 M AY 2020

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ENDO DO NTICS

4A 6A 6B The Gutta SmartTM cordless Obturation System. 1A. is a cordless obturation system that is easy to use. The Downpack (Pack) 1B. and Backfill (Flow). 1C. devices are available to sit in combined docking station that will recharge the batteries. 2. Microcomputed tomography 3D reconstruction of a maxillary molar, illustrating the root canal system’s complex anatomy. These areas must be cleaned of their organic debris and bacterial contaminants by thorough irrigation protocols and then subsequently three dimensionally sealed with thermosoftened gutta percha. Courtesy of Dr. Ronald Ordinola Zapata, Brazil. 3A. Cone Fit. A suitably sized ConformTM Fit gutta percha cone is fit into the tapered root canal preparation making sure that ”apical tug back’’ has been at working length. The cone may then cut .5-1mm to accommodate for it apical movement. (distance from apical reference point will vary with canal curvature and size). 3B. Conformtm Fit Gutta Percha cone and preloaded Gutta Percha cartridges. The ConformTM Fit gutta percha fits intimately at the apical one-third of the root canal and the single use preloaded gutta percha cartridge has enough material to fill an average four canal molar. The cartridge tips are available in 20 gauge, 23 gauge, and 25 gauge sizes with the most popular being the 23 gauge tip size. 4A. Heat Plugger Fit. It is essential that an appropriate Downback (Pack) plugger is prefit into each canal to its binding point. A rubber stop must be placed and adjusted to the appropriate coronal reference point for each canal. 4B. The electric heat pluggers (EHPs) are available in three sizes and are manufactured with annealed stainless steel. The sizes are: Large (60/.06 - Blue; Medium (50/.05 Yellow); Small (40.025 - Black). 5. Stainless steel and/or NiTi hand pluggers may be prefit into the canals to their binding point. Rubber stoppers are adjusted on these pluggers to the occlusal reference point corresponding to 2 mm short of the apical binding point. 6A. The master cone is seated gently in the canal with sealer placed on its apical one third. 6B. Ribbon ThermaSealTM Plus is an epoxy resin sealer characterized by very good mechanical properties, high radiopacity, low polymerization shrinkage, low solubility, and a high degree of stability during storage.

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E N DODON T I CS

7. & 8. Initiation of down pack. With the activation cuff depressed on the Gutta SmartTM Downpack (Pack) handpiece, the prefit, preheated plugger is smoothly advanced without interruption through the mass of gutta percha to within 4-6 mm of the binding point. 9. Sustained apical condensation. The activation cuff on the Pack device should be released once within 3-4 mm of the apical binding point. The plugger should slow and stop within 2 mm short of the binding point. Apical pressure is maintained for a full 10 second ‘’sustained’’ push to prevent the cooling gutta percha mass from shrinking. 10. & 11. Separation burst. The Pack activation cuff is depressed for one second then released. The plugger is held in position for one second after the button is released, after which it is removed with the surplus of gutta percha coronal to the apical plug adhering to the cooling plugger, leaving the apical seal intact. All portals of exit may be sealed, primarily with gutta percha or a combination of gutta percha and sealer, and the canal is ready for backfilling.

is advanced without interruption through the center of the gutta percha in a single motion (about one to two seconds), to a point about 3-4 mm shy of its apical binding point. Figs 7 & 8. While maintaining pressure on the plugger, the activation cuff on the Pack handpiece is released and the plugger will slow its apical descent as the plugger tip cools (about one second) to within 2 mm from its apical binding point. After the plugger stops, short of its binding point apical pressure on the plugger is sustained until the apical mass of gutta percha has set (five to ten seconds), to minimize any shrinkage that occurs upon cooling Fig. 9. SEPARATION BURST After the apical mass has set, the activation cuff on the Pack handpiece is depressed again, for a one second surge of heat. Pause for one second after this separation burst, and then remove the heated plugger along with the middle and coronal gutta percha that adheres to it, leaving behind the 4-6 mm apical plug of gutta percha Figs. 10 & 11. Because these pluggers heat from their tips, this separation burst of heat allows for quick, sure severance of the plugger 12 M AY 2020

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from the already condensed and set apical mass of gutta percha, minimizing the possibility of pulling the master cone out. Be certain to limit the length of this heat burst, as the goal is separation from the apical mass of gutta percha without reheating. Clinicians must be very alert during the first second of the downpack so that the binding point is not reached before completion of the downpack. If heat is held for too long, the plugger drops to its binding point in the canal and then cannot maintain condensation pressure on the apical mass of gutta percha during cooling, possibly allowing it to pull away from the canal walls. If binding length is reached by mistake, the heat plugger should be removed immediately and the small end of the nickel-titanium end of a hand plugger may be used to condense the apical mass of gutta percha until set. Once the downpack has been completed in all canals of the tooth being treated as radiograph may be taken to confirm the objective of apical seal. BACKFILLING The GuttaSmartTM Backfill (Flow) handpiece accommodates disposable pre-

loaded cartridges of gutta percha of with dispensing needle tips available in 20 gauge, 23 gauge and 25 gauge diameters. The one most commonly used is the 23 gauge one as it is suitable for most canals being treated. There is enough gutta percha in the disposable cartridges to fill an average four canal molar. Fig. 3B. Before backfilling, a small amount of sealer is lightly painted on the walls of the root canals with a stainless steel hand file or paper point. The needle tip is placed into the root canal space until it penetrates the coronal aspect of the apical plug of gutta percha for just a moment, to re-thermosoften it’s most coronal extent. This procedural nuance promotes cohesion between each injected segment of warm gutta percha and the apical plug so the two will seamlessly integrate. Segments of 4 to 7 mm of gutta percha are then deposited. Injecting or dispensing too much gutta percha may lead to cooling shrinkage and/or voids which result in poorly obturated canals within the deeper confines of the root canal space8. As gutta percha is extruded from the applicator tip, the viscosity gradient of the back pressure

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E N DODON T I CS

12-18. Back filling. Needle tips for the Gutta SmartTM cordless obturation system are available in sizes #20, #23, and #25 gauges. Additional root canal sealer may be placed in the coronal aspect of the root canal with a hand file or paper point prior to back filling. 4-7 mm increments of gutta percha are injected into the canal space then immediately condensed with the pre fitted stainless steel hand NiTi pluggers in sequence using the sequentially larger pluggers as the coronal aspect of the canal is approached. As thermosoftened gutta percha is deposited in the canal, backpressure is produced and the needle tip (Flow device) is forcibly extruded from the canal space. It is essential that the operator continue injecting as the needle tip is retrieved from the canal in order to avoid inadvertent removal of the newly deposited gutta percha mass prior to condensation.

produced will push the needle tip (and hence the Flow device) coronally from the root canal space. The technique requires a sensitive touch. As the operator feels the pushback from the needle tip of the Flow device, they must maintain contact between the needle tip and the extruding gutta percha. They must also sustain slight pressure on the activation cuff button mechanism to keep the gutta percha flowing as the needle tip moves from the canal. The stainless steel or nickel titanium ends of hand pluggers are then used in sequence to maximize the density and homogeneity of the compressed gutta percha mass. This sequence of thermosoftened gutta percha injection and progressive compaction is continued until the obturation of the entire root canal space is achieved Figs. 12-18. REF EREN C ES 1. Schilder, H. Filling root canals in three dimensions. Dent Clin North Am. 1967; 11: 723–744. 2. Jacobson, H and Baumgartner, J. Gutta-percha obturation of lateral grooves and depressions. J Endod. 2002; 28: 269–271. 3. DuLac, KA, Nielsen, CJ, Tomazic, TJ, Ferrillo, PJ Jr, and Hatton, JF. Comparison of the obturation of 14 M AY 2020

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Even if a post space is to be prepared, the author advises backfilling right to the orifice of the canals to ensure lateral and accessory canals that were not sealed on the downpack but that may be captured on the backfill. DISCUSSION The objective of endodontic obturation is the total three dimensional filling of the root canal system and all of the lateral and accessory canals associated with it. Brothman9 demonstrated that vertical compaction of warm gutta percha (GP) approximately doubled the number of filled lateral canals compared with lateral compaction of GP. The warm vertical technique has shown greater ability to flow into canal irregularities than the cold lateral technique.10,11 Warm vertical compaction was first introduced by Schilder12 in 1967. With

lateral canals by six techniques. Endod Prac. 1998; 1: 7–10 (13-6). 4. Goldberg, F, Artaza, L, and Silvio, A. Effectiveness of different obturation techniques in filling of simulated lateral canals. J Endod. 2001; 27: 362–364. 5. Glassman G, Serota S. The Thermosoftened Millennium Revisited: Continuous Wave of Condensation, Oral Health, December 2002, Pages 9-13.

this method, GP is heated and packed in 3-5 interrupted waves of compaction. In contrast, the continuous wave of condensation technique was introduced with the goal of simplifying traditional vertical compaction13. This technique allows a single tapered electric heat plugger to capture a wave of compaction pressure at the orifice of a canal and ride it, without release, to the apical extent of the downpack in a single, continuous movement.14 The remainder of the canal is then filled with the backfill Flow device. The GuttaSmartTM cordless obturation system satisfies the objective of sealing the root canal system in three dimensions and completes the last part of the triad of the imperative of root canal treatment, that being “shape, clean and pack”. Oral Health welcomes this original article.

6. Glassman G. Three Dimensional Obturation of the Root Canal System: Continuous Wave of Condensation. ROOTS The Journal of Endodontology. Vol 2, Issue 3, 2012:20-26. 7. Ruddle CJ: Advanced Endodontics, Santa Barbara, CA: www.endoruddle.com, 2009. 8. Ruddle CJ. Filling Root Canal Systems. The Calamus 3D obtura-

tion Technique, Dentistry Today, April 2010. 9. Brothman, P. A comparative study of the vertical and the lateral condensation of gutta-percha. J Endod. 1981; 7: 27–30.

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ENDODONTICS

“Managing endodontic emergencies in the Covid-19 era” Manor Haas, DDS, Cert. Endo.

INTRODUCTION magine the following scenario. Due to the COVID-19 pandemic, you can only treat patients with acute emergencies, in order to help slow or stop the spread of the coronavirus. However, a patient calls you complaining of a severe tooth ache or swelling that you must somehow manage. You may wonder if you could or should manage this with over the counter or prescription medications, or if you have to treat this invasively and immediately. In many cases, a true acute emergency of endodontic origin needs to be clinically managed right away.1 This article will review how you should manage an emergency of endodontic origin and how to do so efficiently. I will divide this into the following key steps: diagnosis, anesthesia (especially of “hot teeth”), canal instrumentation and post-op pain and infection management. All while keeping in mind COVID-19 considerations.

DIAGNOSIS AND COVID-19 CONSIDERATIONS The first and obvious step involves figuring out what is and where is the source of the pain, and if it is tooth (endo) related. Make sure to rule out non-endo related symptoms (ie periapical inflammation due to parafunction or pain of periodontal origin). If possible, diagnose as much as possible by phone, in order to minimize direct patient interaction. If needed, perform all the routine diagnostic endodontic tests (ie pulp tests, percussion, palpation, biting on a tooth slooth) clinically. If the emergency is found to be of endodontic origin and you’ve localized the problem tooth, and this cannot be managed by medications, then proceed with root canal treatment.1 If indeed this patient needs to be managed immediately, then make sure to follow your local regulatory and public health bodies’ guidelines for treatment, with respect to COVID-19. It is important to ensure that you and your staff have the proper personal protective equipment and it is also important to minimize or eliminate the production of contaminated aerosols during treatment. Fortunately,

in endodontics this is relatively easy to achieve by isolating the tooth, post-anaesthesia and pre-access, with rubber dam, and then rinsing the crown with chlorhexidine or hypochlorite.2 ANESTHESIA This is often the most difficult and important aspect of the emergency. Without profound pulpal anesthesia, you’ll have a hard time proceeding. Insufficient or lack of anesthesia may turn the appointment into a memorable nightmare for the patient and be very stressful for everyone. MAXILLARY TEETH Traditional local infiltration will suffice for most cases in the maxilla. But, make sure to have the needle tip deposit the anesthetic superior to the apices of the involved tooth. For instance, if you are treating a maxillary first molar, try not to hit the zygoma with the needle. This may result in deposit of the anesthetic inferior to the site of innervation to the involved tooth and compromise pulpal anesthesia. “HOT TEETH” Arguably, the most difficult tooth to anaesthetize is the infamous “hot tooth” and are well known to remain “alive” even after numerous carpules of local anaesthetic. It has been shown by numerous clinical studies that mandibular blocks will only provide pulpal anesthesia in about HALF the cases with irreversible pulpitis. So, if your patient presents with acute lingering pain to cold, there’s only about a 50% chance that any mandibular block will suffice.3 This means that in many cases, you will require supplemental anesthesia. (See Table 1). These include the following: PERIODONTAL LIGAMENT INJECTION (PDL), AKA INTRALIGAMENTARY INJECTION This is performed using a 30 gauge (or possibly 27G) short needle that is placed at the mesial or distal line angles of the tooth’s periodontal crevice and with the

Dr. Haas is a certified specialist in endodontics and lectures internationally. He is a Fellow of the Royal College of Dentists of Canada and is on staff at the University of Toronto Faculty of Dentistry and the Hospital for Sick Children. He maintains a full-time private practice limited to endodontics and microsurgery in Toronto. Dr. Haas is a regular contributor to dental journals and online forums. He can be reached via the website: www.HaasEndoEducation.com

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ENDO DO NTICS

Injection Type

Pros

Cons

Armametaria

– Immediate onset

– Painful (momentary) – Short duration (5 to 15 min) – Post-op pain upon biting

Intra-pulpal

– Immediate onset – High successes rate

– Painful (momentary) – 27G or 30G (preferable) short needle – Short duration 5 to 10 min)

Inta-osseos

– Immediate onset – Profound anesthesia – High success rate – (relatively) long duration (30-45 minutes)

– Technique sensitive – May result in temporary palpations

Periodontal Ligament/ Intraligamentary

– 27G or 30G short needle – Pressure syringe (ie Ligmajet)

– Stabident® – X-Tip®

Table 1. Supplemental anesthesia for “hot teeth”.

bevel towards the tooth. This could be performed with rubber dam isolation. (Figs. 1 & 2). Under pressure, a small amount of anesthetic is injected. Onset is quick but the anesthesia is relatively short lasting. This injection is often uncomfortable and patients may complain of the tooth feeling elevated, post-op. PDL injections may be used as supplemental anesthesia for maxillary and mandibular teeth.4,5

1. PDL/Intraligamentary injection using a 30G short needle. 2. PDL injection using 30G short needles with rubber dam isolation. 3, 4 & 5 (left to right). (left) Slow speed Stabident® perforator oriented at base of papilla between teeth. (center). Perforator drilled fully into site. (right) Corresponding short needle fitting into hole prepared by perforator.

INTRA-OSSEOUS This type of injection has been shown to provide exceptionally high rates of immediate and profound pulpal anesthesia, including in “hot teeth”. It is used primarily for mandibular posteriors. It requires a pilot hole to be drilled with a special slow speed instrument (perforator) into the cortical bone between the teeth at the base of the papilla and angled apically. Into the pilot hole, a corresponding short needle is inserted and the anesthetic is slowly deposited. (Figs. 3, 4 & 5). Its duration is approximately 30 to 45 minutes. Also, it is recommended that an anesthetic with little epinephrine (ie 1:200,000 epi) be used to minimize heart palpitations.4 The two options available are the “X-Tip®” (Dentsply Sirona) and “Stabident®” (Fairfax Dental, Miami). (Figs. 6 & 7). At this point, I suggest pulp testing the tooth prior to your access, to make sure it is anaesthetized. There is nothing worse than a nervous emergency patient with a hot tooth jumping from pain midtreatment. And, once anesthetized, and as stressed earlier, you must isolate the tooth with rubber dam prior to initiating the root canal access. INTRA-PULPAL This is often considered the anesthetic of last resort. When performed properly, it is immediate but will oralhealthgroup.com

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6. Stabident® slow speed perforator and corresponding short needle. 7. X-Tip® short needle seen fitting into perforator that is drilled into place with a slow speed handpiece. 8. Macro view of 30G short needle and syringe used for intrapulpal injection. 9. Close up view of needle engaged in canal for intrapulpal injection. 10. Pre-op buccal abscess over tooth #14. 11. Buccal incision made with #15 scalpel. 12. Purulence draining from incised fluctuant abscess. 13. Curved hemostat used to open incised site. 14. Monojet® syringe used to irrigate inside incision site.

only provide about 10 minutes of profound anesthesia. As with PDL injections, it is very painful when administered. (6) The needle should engage in the canal and for this to work, you must obtain resistance when injecting the anesthetic. (Figs. 8 & 9). SOFT TISSUE ABSCESS OF ENDODONTIC ORIGIN If your patient presents with a soft tissue swelling that is fluctuant, you should perform an incision and drainage (“I & D”). (Figs. 10-14). You should use a sharp scalpel and penetrate the “pointing” part of the abscess until you hit bone. A curved hemostat should be used to expand the incision site and help provide a way for the purulence to drain. For significant swellings, a drain should be 24 M AY 2020

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placed. This could be accomplished with a clean rubber dam cut in the form of the letter “T” with the top of the letter inserted into the incision site and sutured into place. ROOT CANAL INSTRUMENTATION By now you have diagnosed and identified the endo problem, anesthetized the patient and accessed the tooth. Next comes the canal instrumentation. It may be difficult, in the heat of the moment, but do make sure to locate and treat all the canals. This is much easier if magnification with enhanced illumination is incorporated. Dental loupes with a headlight or a dental microscope are exceptionally helpful, if not priceless. If endodontic treatment is not to be completed that day, it is very important to

completely instrument each canal. Anything less means leaving behind inflamed or infected pulp tissues. A pulpectomy by definition involves complete pulp extirpation and canal instrumentation.1 Furthermore, the canals should be medicated with calcium hydroxide between appointments. As you are in the midst of managing an emergency, it is extremely helpful to use an instrumentation system that is simple, efficient and easy to use. The trend in endodontic instrumentation has been to achieve the same or better clinical and biological outcomes, with fewer steps and instruments. Single file mechanized NiTi instrumentation is a relatively recent addition to endodontics. Thanks to its simplicity and efficiency, it is well suited for, amongst other things,

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emergency root canal treatments. An example is the WaveOne Gold reciprocating NiTi file. (Dentsply Sirona, Tulsa, OK) This file system has been shown to be safer, simpler and more efficient to use than many rotary NiTi systems.8 (Fig. 17). With respect to rotary NiTi files, there are newer systems that still require multiple files, but which work more efficiently and require slightly fewer NiTi files than traditional systems such as the ESX series of files (Brasseler USA Dental, Savannah, GA).

POST-OP MANAGEMENT OCCLUSION From a pain management perspective and if possible, it is recommended to reduce the occlusion of the involved tooth. The intention is to prevent post-op occlusal trauma to the tooth and periapical area that needs to be left alone to settle, so-to-speak. This is especially important in patients with parafunction habits who may be more likely to traumatize the problem tooth. (Fig. 18). In these times of COVID-19, you might not know when you’ll be able to see your patient again. Hence, I would also recommend you temporize the access with a permanent restoration. PAIN MANAGEMENT As a rule of thumb, if a patient presents with pre-op pain (except for pain to cold and hot), they are likely to experience post-op pain.7 In turn, you should prepare your patient to this and also provide them with analgesics suitable for their level of pain. For a healthy patient, these may range from 600mg of Ibuprofen every REF EREN C ES 1. Hargreaves KM, Berman LH. Cohen’s Pathways of the Pulp. 11th ed. St. Louis, MO: Elsevier;706, 2016. 2. Meng L. et al, Coronavirus Disease 2019 (COVID-19): Emerging and Future Challenges for Dental and Oral Medicine. J Dent Res 00(0), 2020. 3. Claffey E, Reader A, et al. Anesthetic efficacy of articaine for infe26 M AY 2020

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15, 16. Dental operating microscopes (left: Carl Zeiss, Toronto, ON and right: Global Surgical, St. Louis, MO) providing enhanced visualization during root canal treatment. 17. WaveOne Gold® NiTi reciprocating files. Available in four sizes. 18. Occlusal reduction performed with a “football” shaped diamond bur.

6 hours for mild pain, to 1 to 2 Tylenol 3 every 4 to 6 hours, for more severe pain. INFECTION MANAGEMENT: It is rare that post-op anibiotics will be indicated for endodontic emergencies, so long as the etiology is managed endodontically. That is, unless the patient presents with a space infection or systemic symptoms.9 For routine cases and patients, the antibiotic of choice is Amoxicillin (500mg, q8h). For patients with Penicillin allergies, Clindamycin is recommended (300mg, q6h). Both for a week.

rior alveolar nerve blocks in patients with irreversible pulpitis. J Endod 30 (8), 568, 2004 4. Malamed SF. Supplemental injection techniques. Handbook of Local Anesthesia. 5th ed. St. Louis: Mosby; 2004. 5. Moore PA, et al.: Periodontal ligament and intraosseous anesthetic injection techniques, J Am Dent

CONCLUSION One of the greatest challenges in clinical dentistry is managing endodontic emergencies. The coronavirus has only complicated this. So, when treatment is performed, it should be done efficiently and under profound pulpal anesthesia and with reduction or elimination of contaminated aerosols by using rubber dam isolation. And all this should be done while using the recommended personal protective equipment. Oral Health welcomes this original article. Disclosure: Dr. Haas reports no disclosures.

Assoc 142, 2011. 6. Hargreaves KM, Berman LH. Cohen’s Pathways of the Pulp. 11th ed. St. Louis, MO: Elsevier;706, 2016. 7. Hargreaves KM, Keiser K: New advances in the management of endodontic pain emergencies. J Calif Dent Assoc 32:409, 2004. 8. Abn,S, Kim H-C, Kim E, Kinematic Effects of Nickel-Titanium instru-

ments with reciprocating or continuous rotation motion: a systematic review of In Vitro studies. J Endod 42:1009, 2016. 9. Henry M, Reader A, Beck M: Effect of penicillin on postoperative endodontic pain and swelling in symptomatic necrotic teeth. J Endod 27:117, 2001.

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ENDODONTICS

Limited FOV CBVT in endodontics â&#x20AC;&#x201C; 3 years later and never looking back Geoffrey L. Sas, DDS, FRCD(C), Dip. ABE

n Endodontics, a clinical examination and diagnostic imaging are both essential components before making a pre-operative diagnosis. The process of selecting a treatment option specifically of whether to extract or retain a tooth can often be complex. Conventional 2-dimensional imaging is still the most popular imaging modality in endodontics. However, the potential of periapical imaging is somewhat limited. Diagnostic information from the radiograph can often be difficult to interpret when the background pattern is complex. Goldman and colleagues (Goldman, 1972) showed that the agreement between six examiners was only 47% when evaluating periapical lesions using two dimensional radiographs. In a follow up study, when the examiners re-evaluated the same films at various times, they were only in agreement with their previous interpretations 19-80% of the time. (Goldman, 1974). New imaging modalities have now become available in dentistry that can assist with some of the limitations of 2-dimensional imaging. In 2001, Cone Beam Volumetric Tomography (CBVT) was approved by the FDA for dental use. (Chogle, 2019) Numerous endodontic applications of CBVT technology have been described in the literature such as pre-operative assessment and treatment planning, assessment of internal and external resorption, pre-surgical assessment, dental anomalies, and treatment planning/assessment of traumatic injuries. For endodontic use, the small field of view (SFOV) imaging is the most accepted, as it is capable of providing images with sufficient special resolution with a lower radiation dose. With its accurate and high-quality 3-D representations of maxillofacial structures, CBVT technology offers tremendous improvements in diagnostic capabilities, eliminating surprises and minimizing the need for exploratory surgery. The result: more effective treatment and improved patient outcomes. Ball et al. in 2013 discussed the application and advantages of intraoperative CBVT in endodontics. The authors concluded that in cases of increased dif-

ficulty or intraoperative complications such as complex anatomy, dystrophic calcifications, root resorptions, perforations, and root fractures, it is prudent to consider the use of CBVT with its inherent diagnostic value and limited radiation exposure. (Ball, 2013) The benefits of the added diagnostic information provided by intraoperative CBVT images in select cases justify the risk associated with the limited level of radiation exposure. Ee in 2014 studied the relative value of preoperative periapical radiographs and CBVT scanning in the decision-making process in endodontic treatment planning. Thirty endodontic cases completed in a private endodontic practice were randomly selected to be included in this study. Each case was required to have a preoperative digital periapical radiograph and a CBVT scan. Three board-certified endodontists reviewed the 30 preoperative periapical radiographs. Two weeks later, the CBVT volumes were reviewed in random order by the same evaluators. The evaluators were asked to select a preliminary diagnosis and treatment plan based solely on their interpretation of the periapical and CBVT images. Diagnosis and treatment planning choices were then compared to determine if there was a change from the periapical radiograph to the CBVT scan. They concluded that preoperative CBVT imaging provides additional diagnostic information when compared with preoperative periapical radiographs, which may lead to treatment plan modifications in approximately 62% of the cases. (EE, 2014) Rodriguez et al. in 2016 wanted to determine the influence of CBVT imaging on clinical decision-making choices amongst different specialists (prosthodontists, endodontists, oral surgeons, and periodontists) in endodontic treatment planning. Similar to Ee, 30 Endodontic cases with varying degrees of complexity were selected. Each case included clinical photographs, digital periapical radiographs, and a small-volume CBVT scan. In the first evaluation, examiners were given all the information of each case, except the CBVT scan. Examiners were asked to select one of the proposed

Dr. Geoffrey Sas obtained his DDS from the University of Toronto in 2011 and his AEGD Certificate from the University of California, Los Angeles in 2012. In 2012 he enrolled in the endodontic graduate program at Nova Southeastern University and received his certificate in 2014. He received his diplomate status from the American Board of Endodontics in 2018. Currently, he is the president of the Ontario Society of Endodontics and the George Hare study club. He maintains a private practice limited to Endodontics and microsurgery in both Toronto and New York City . He can be reached at glsas@yhendo.com

28 M AY 2020

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ENDO DO NTICS

FOV CBCT in different phases of treatment. (AAE/AAOMR, 2016)

1 1A. Preoperative radiograph with a clinical diagnosis (AAE Guidelines) of Previous Treatment/Chronic Apical Abscess. B. CBVT Images showing the radiolucent entity, and potential additional anatomy. C. Final and 18-month recall showing complete healing. D. Clinical photo showing 3 mesial canals obturated.

treatment alternatives and assess the difficulty of making a decision. One month later, the examiners reviewed randomly the same 30 cases with the additional information from the CBVT data. The authors concluded that CBCT imaging has a substantial impact on endodontic decision making among specialists, particularly in highly complex cases. (Rodriguez, 2017). There is little doubt that the use of CBVT in endodontics overcomes many of the limitations of periapical radiography. The increased information provided by the CBVT should result in more accurate diagnosis and improved decision making for the management of complex endodontic problems. Patients will always be concerned about radiation; The effective radiation dose to patients when using limited FOV CBVT is higher than current 2-D radiography (Fayad, 2015). The benefit to the patient must therefore outweigh any potential risks of the additional

radiation exposure, especially in children. The value of CBVT for endodontic diagnosis and treatment planning should be determined on an individual basis to assure that the benefit: risk assessment supports the use of CBVT. Dental colleagues should utilize the referral to endodontists as the specialty uses the latest in diagnostic imaging and techniques thereby ensuring that patients benefit from their diagnostic and treatment planning expertise. In May 2015 an updated joint position statement of the American Association of Endodontists (AAE) and the American Academy of Oral and Maxillofacial Radiology (AAOMR) was published. The intent of the updated statement was to provide scientifically based guidance to clinicians regarding the use of CBVT in endodontic treatment and reflect new developments since the original 2010 statement. The next section of this article addresses some of the potential applications and recommendations for use of limited

PREOPERATIVE ANATOMY ASSESSMENT The success of endodontic treatment depends on the identification of all root canal systems so that they can be cleaned, shaped, and obturated. Recommendation #3 of the AAE/AAOMR position statement recommends CBVT for initial treatment of teeth with the potential for extra canals and suspected complex morphology, such as mandibular anterior teeth, and maxillary and mandibular premolars and molars, and dental anomalies. The superior ability of CBVT to accurately explore tooth anatomy and identify the prevalence of a second mesio-buccal canal (MB2) in maxillary molars when compared to the gold standard (clinical and histologic sectioning) has been well documented. (Santos Coelho, 2018). CBVT showed higher mean values of specificity and sensitivity when compared to intraoral radiographic assessments in the detection of the MB2 canal. (Michetti, 2010) The following is an example of using CBVT imaging for identification of complex tooth anatomy in a mandibular first molar. A patient presented with persistent pain on her first molar after initial root canal therapy had been performed 8 months prior by another endodontist. Her general dentist wanted a second opinion before condemning this tooth for extraction and replacement. The CBVT (Fig. 1) was suggestive of additional anatomy and could be a reason for the failed RCT. Probing was significant on the buccal aspect of the lower left first molar. Based on the findings of the CBVT scan, we decided to attempt orthograde retreatment. During the first appt, a middle mesial canal (MM) was found. All canals were cleaned/shaped, and medicated with Ca(OH)2 for one month. At the 2nd appt, the periodontal probing had improved, and all canals were obturated. The patient was completely asymptomatic 4 days after the first appt. A one-year recall PA shows the periapical radiolucency has healed. The first molar oralhealthgroup.com

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E N DODON T I CS

is asymptomatic, functional and the final crown had been cemented. Without the information from the CBVT, this tooth was likely headed for extraction and replacement which was premature in our opinion. Another example of a clinical case where CBVT in our opinion changed the direction is seen in fig. 2. A CBVT was taken mid treatment to identify the complex root anatomy. The axial scan clearly shows a radix root in the distolingual direction. Troughing for another distal canal close to the DB canal could have caused a perforation or unnecessary root removal. If the case was completed without cleaning and shaping the radix root, post treatment disease was likely. After the mid treatment limited FOV CBVT scan, the radix root was located, and the treatment was completed. The preoperative periapical image

30 M AY 2020

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2A. Preoperative Periapical and Bitewing showing no apparent complications. B. Axial and Saggital slices showing a Radix Disto-lingual canal. C. Final periapical image and 12-month recall showing complete healing.

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2020-04-22 5:27 PM

ENDO DO NTICS

did not allow for visualization of this complex root anatomy partly because the pulp chamber was calcified, and a fixed restoration was present. Clinical detection was also difficult without 3D imaging. Recommendation #12 according to the AAE/AAOMR Statement states that limited FOV CBVT is the imaging modality of choice in the localization and differentiation of external and internal resorptive defects and the determination of appropriate treatment and prognosis is. (AAE/AAOMR, 2016). A female patient presented with symptoms when chewing and brushing her teeth. Inflammatory root resorption was suspected and therefore a limited FOV CBVT image was taken to determine the treatment and prognosis. A class 3 invasive cervical resorptive defect was clearly seen on the MB root of her upper first molar. Treatment planning

concluded that if she wanted to save her tooth, initial root canal therapy followed by removal of the resorptive defect, and an associated restoration was needed. The patient accepted the endodontic treatment plan knowing the risks. Following root canal therapy, periodontal flap reflection and curettage, a topical application of 90% trichloracetic acid (TCA) was applied to the defect. The defect was then restored with a resin-ionomer restoration. Clinical images are shown (Fig. 3). A similar case is also shown in Fig. 4. The lower mandibular premolar was treatment planned after analyzing the CBVT images. Both the endodontist and the patient agreed that root canal therapy followed by a resin-ionomer restoration had a good prognosis. Root canal therapy was performed followed by surgery to remove the resorptive defect. After a flap was

raised, minor crown lengthening was performed, followed by application of TCA, and a resin-ionomer restoration (Heathersay protocol). The final peri-apical image is shown. The patient was sent back to the referring dentist for the final restoration. Another guideline according to the AAE/AAOMR position statement is “Limited FOV CBVT should be the imaging modality of choice when evaluating the nonhealing of previous endodontic treatment to help determine the need for further treatment, such as nonsurgical, surgical or extraction. If surgical endodontics is indicated, the position statement further reiterates the recommendation for a CBVT by stating ‘Limited FOV CBCT’ should be considered as the imaging modality of choice for presurgical treatment planning to localize root apex/apices and to evaluate the

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E N DODON T I CS

3A. CBVT Images showing the resorptive lesion. B. Clinical Image during surgery showing the repaired defect using Geristore. C. Final periapical image, and 1-year recall showing complete healing. D. 2.5 year recall CBVT Images showing complete healing. 4A. Pre-operative periapical radiograph. B. Clinical photo showing periodontal probing into the resorptive defect. C. CBCT Images showing the resorptive defect. D. Clinical photos during surgery showing the defect removed and after placing the restoration. E. Final periapical radiograph.

3 proximity to adjacent anatomical structures.â&#x20AC;? Fig. 5 shows how CBVT was indicated and how it ties in both of those position statements. The patient in fig. 5 presented with discomfort but a desire to keep her natural dentition. A CBVT was indicated to 32 M AY 2020

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treatment plan the molar in question. After an examination, a diagnosis of previous treatment/symptomatic apical periodontitis was made. CBVT for was used for planning and to evaluate her options. Amoxicillin was prescribed for one week. The CBVT shows a large lesion of endo

origin present around the distal apex. In our opinion, endodontic surgery was a more conservative option based on the existing crown, cast post and core. Orthograde re-treatment could have been completed but would have necessitated removal of considerable tooth structure.

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The patient elected for peri-apical surgery. The granulation tissue was removed, all three canals were retro prepped, and sealed with bio ceramic putty. Fig. 5c shows the 6-month recall which shows great healing. The patient was very happy with the result and she was able to keep her molar. CBVT technology was instrumental in treatment planning this case. CBVT Technology should no longer be considered an ‘emerging technology’; It is a powerful tool which every endodontist should use. Simply stated, it changes treatment plans, and allows for a more predictable outcome especially in difficult cases. CBVT Technology that is here to stay. Oral Health welcomes this original article.

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R E F E R E NCES 1. AAE/AAOMR. (2016). Use of Cone Beam Computed Tomography in Endodontics – 2015/2016 Update. 2. Ball, B. C. (2013). Intraoperative Endodontic Applications of Cone-Beam Computed Tomography. Journal of Endodontics, 548-556. 3. Chogle, Z. S. (2019). The Recommendation of Cone-beam Computed Tomography and Its Effect on Endodontic Diagnosis and Treatment Planning. Journal of Endodontics. 4. EE, F. J. (2014). Comparison of Endodontic Diagnosis and Treatment Planning Decisions Using Cone-beam Volumetric Tomography Versus Periapical Radiography. Journal of Endodontics, 910-916. 5. Fayad. (2015). Cone beam computed tomography: a new era in diagnosis and treatment planning. Clinical Practice, 39-46. 6. Goldman, P. A. (1972). Endodontic success – Who’s reading the radiograph? OOO, 432-437. 7. Goldman, P. A. (1974). Reliability of radiographic interpretations. OOO, 287-293. 8. Michetti, M., -9. (2010). Validation of cone beam computed tomography as a tool to explore root canal anatomy. Journal of Endodontics, 1187-1190. 9. Rodriguez, P. D.-S. (2017). Influence of Conebeam Computed Tomography on Endodontic Retreatment Strategies among General Dental Practitioners and Endodontists. Journal of Endodontics, 1433-1437. 10. Santos Coelho, L. S. (2018). Locating the second mesiobuccal canal in maxillary molars: challenges and solutions. Clinical Cosmetic and Ivestigational Dentistry, 195-202.

5 5A. Preoperative periapical image. B. CBCT slices for pre-surgical planning. C. Immediate postoperative periapical image. D. 6-month recall showing healing.

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ENDODONTICS

Endodontic microsurgery of an anatomically challenging zone using dynamic navigation: A case report P.A. Villa-Machado, DDS, Endodontist; K.S. Serota, DDS, MMSc; F.A. Restrepo-Restrepo, DDS, Endodontist

KEYWO R DS : ENDODONTIC MICROSURGERY, DYNAMIC NAVIGATION

INTRODUCTION nhanced magnification and visualization, innovations in instrumentation, new sealing materials and the incorporation of soft and hard tissue augmentation practices have brought Endodontic Microsurgery (EMS) from a last resort procedure to an integral part of endodontic retreatment.1,2 The retreatment of a failing root canal treatment is fraught with potential complications. The removal of cast posts (size and length can potentiate fracture)3 distinguishing bonded fibre posts from the surrounding dentin,4 removal of separated instruments5 negotiating blocked canals,6 circumventing ledging and a myriad of other factors can complicate removal of the residual bio-load and impede resolution of periradicular pathosis.7,8. Where possible, retreatment alone would be the treatment option of choice, however, where retreatment risk factors are high, EMS is the most viable option, far more so now than prior to the transition to microsurgical protocols. Contemporary EMS protocols provide for minimal flap size, small osteotomies and resections perpendicular to the long axis of the root. These minimally invasive practices reduce morbidity, accentuate more rapid healing, minimize the size of the retro-preparation and the number of dentinal tubuli exposed.9 Magnification and illumination have lessened the risk of damage to anatomic structures such as the IAN, maxillary sinus and the greater palatine nerve and artery. Given the inability to visualize the surgical site in three-dimensions, the possibility of procedural error remains, thus impacting on treatment options.10-13 Recently, Dynamic Navigation technology has been used in EMS to guide cutting instruments, including piezotomes, in real time, to perform

osteotomies and apicoectomies. Dynamic Navigation systems map the patient’s jaws to their cbCT scan by trace registering landmarks on teeth of the jaw to be treated. The system’s stereoscopic camera recognizes optical markers attached to the jaw to be treated and the instrument to be used and monitors the drill or saw position during the surgery. Unlike static navigation guides, Dynamic Navigation procedures are not constrained to a predetermined path, there is no risk of distortion as a complication of the guide fabrication, and the inability to work in restricted areas of the mouth due to the bulk of the guide is obviated. Dynamic navigation enables adjustment of the osteotomy pathway and the angle of the root section during the EMS procedure. The clinician follows the surgical instrument’s movement in three-dimensions on the computer monitor and assesses the surgical site through the microscope oculars. This case report presents the use of Dynamic Navigation to avoid damage to the Schneiderian membrane of the maxillary sinus while performing EMS in an anatomically challenging space. CASE REPORT A 50-year-old male patient presented with moderate pain associated with a previously treated maxillary right second premolar (tooth #1.5). The medical history was non-contributory. The tooth had been endodontically treated and restored with a cast post/core and full crown. The patient’s scan (cbCT) revealed two separate roots, an intact buccal plate and an apical lesion associated with the palatal root (Fig 1). The tooth was moderately sensitive to vertical percussion, periodontal probe depths and mobility were within normal limits. The diagnosis was symptomatic apical periodontitis

*Corresponding author: Prof. Paula Andrea Villa Machado, Laboratory of Immunodetection and Bioanalysis, Faculty of Dentistry, University of Antioquia. Calle 70 N° 52-21, Medellín, Colombia. Phone number: (574) 219673 5 Fax: (574) 263 123 0. e-mail address: paula.villa@udea.edu.co, paulavillam@gmail.com. Kenneth S. Serota has been active in online education since 1998, he is the founder of the Endodontic forum ROOTS and the interdisciplinary Facebook forum NEXUS. Dr. Serota is a clinical instructor in the University of Toronto postdoctoral endodontics department. He is the social media and marketing director for Navident Dynamic Navigation. Dr. Felipe Restrepo is an Associate Professor at the Universidad de Antioquia teaching their postgraduate level students in endodontics and also Director of the Dental Emergencies Diploma. Dr. Restrepo has authored scientific articles in peer-reviewed journals. He can be reached at felipe.restrepo@udea.edu.co

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associated with a previous root canal procedure. After consultation, the patient chose to have EMS treatment done with Dynamic Navigation. The proximity of the palatal root apex to the sinus floor raised the issue of an existing sinus perforation or the risk of iatrogenic creation. Dynamic Navigation enabled real-time feedback of the position of the instrument tip in a z axis as it accessed the palatal root apex and the floor of the sinus. Lidocaine 2% with 1:80,000 epinephrine (New Stetic, Guarne, Ant. Colombia) was used to achieve profound local anesthesia and a full thickness mucoperiosteal flap with a vertical releasing incision was elevated. (Fig 2a). Three landmarks (up to 6 can be used) were marked on teeth displayed in the patient’s scan in a non-colinear array. A Head Tracker (optical marker) was secured to establish jaw position, a tracer tag attached to a tracer tool and a stentless trace registration of the maxilla done by creating a cloud of points around the landmarked teeth thus accurately mapping the avatar maxilla on the cbCT. An accuracy check was performed to verify the trace registration, a drill tag (optical marker) was secured to the Piezotome® Cube handpiece (Acteon group, France) by an adapter, the LC2 saw secured to the handpiece and the saw tip calibrated. The Dynamic Navigation software algorithms enable the micron tracker (stereoscopic camera) to identify the avatar saw tip as it cuts the periphery and depth of the cortical window (Figs 2b, 2c). The position of the saw at the periphery of the palatal root resection can be precisely tracked thus preventing a sinus communication (Figs 3a, 3b). The retro-preparations were done using a E30RD ultrasonic tip (USA – NSK-Nakanishi International). EndoSequence BC RRM Fast Set Putty (Brasseler, Savannah, GA) was used as the retro-sealing material (Fig 3C). Radiographs were taken to confirm the density and position of the retroseals. The post-surgical cbCT confirms the precision of the saw cuts resulting in accurate resection of both roots without complications ensuant from an iatrogenic tear of the sinus membrane (Fig 4).

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1. Pre-surgical cbCT. A. Axial view. B. Coronal view. C. Sagittal view of buccal root. D. Sagittal view of palatal root. 2. Surgical procedure. A. A full thickness mucoperiosteal flap was raised exposing the overlying cortical bone of tooth #1.5. B. The periphery of the cortical window is shown. The efficacy and accuracy of Dynamic Navigation enables a minimally invasive resection of the lid due to the real-time feedback from the monitor. C. The micron tracker identifies the tag attached to the Piezotome handpiece. The calibrated avatar saw tip is visualized on the cbCT, the periphery of the cortical window outlined, the bone lid removed and the apices resected. The saw position can be oriented perpendicular to the long axis, the lingual aspect of the root and the proximity to the sinus demonstrated. 3. Preparation of the root end. A. The resection of the palatal root is performed while observing its progress on the computer monitor. B. Buccal and palatal canals were retroprepared. C. Apical cavities were filled with EndoSequence BC RRM Fast Set Putty (Brasseler, Savannah GA). 4. Post-surgical cbCT. A. Axial view showing the retroseals in place. B. 3D reconstruction of the area. C. Sagittal view of palatal root showing the angle of the resection and the retroseal in place. D. Coronal view of the buccal and palatal roots showing the angle of the resection and the retroseals.

DISCUSSION Dynamic Navigation has been shown to be more accurate than freehand and static navigation in surgical implant placement.14 Its effectiveness has been demonstrated for the removal of foreign objects from the maxilla and mandible, repositioning of the IAN and removal of pathology with minimal hard and soft tissue damage.15-18 Piezosurgery is a relatively new surgical technique. Its major advantages include; precision, ease of curvilinear osteotomy, less 38 M AY 2020

trauma to soft tissue, preservation of neurological and vascular structures, reduced hemorrhage, minimal thermal damage to the bone, and improved healing. Piezoelectric bone surgery has been demonstrated to mitigate complications during maxillary osteotomy procedures, such as oroantral communication.19-23 Vercellotti et al. introduced the piezoelectric bony window osteotomy as a simplified technique for sinus elevation24. Due to the cessation of the surgical action of the piezoelectric scalpel when it comes in contact with nonmineralized tissue, there is a reduced risk of iatrogenics25. In conjunction with Dynamic Navigation, Piezosurgery allows for the creation of a cortical

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2020-04-22 5:44 PM

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window which accurately approximates the pathology about the root apices. CONCLUSION Dynamic Navigation is an exciting and promising adjunct for enhancing positive EMS outcomes in contrast to the REF EREN C ES 1. Huang S, Chen NN, Yu VSH, Lim HA, Lui JN. Long-term Success and Survival of Endodontic Microsurgery. J Endodon 2020 Feb;46(2):149-157. 2. Kim S, Kratchman S. Modern endodontic surgery concepts and practice: a review. J Endodon. July 2006;32(7):601-23. 3. Truschnegg A, Rugani P, et al. Long-term Follow-up for Apical Microsurgery of Teeth with Core and Post restorations. J Endodon February 2020;46(2):178-183.

40 M AY 2020

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efficacy of static navigation guides. The real-time feedback feature of Dynamic Navigation technology mitigates risk in areas close to anatomic structures. Selective and controlled osseous dissection is enhanced. The ability to alter the surgical pathway provides for an improved

4. Anderson GC, Perdiago J, Hodges JS, Bowles WR. Efficiency and effectiveness of fiber post removal using 3 techniques. Quintessence Int October 2007;38(8):663-70. 5. Souter NJ, Messer HH. Complications Associated with Fractured File Removal Using an Ultrasonic Technique. J Endodon July 2005;31(6):450-2. 6. Lambrianidis T. Ledging and blockage of root canals during canal preparation: causes, recognition, prevention, management, and

margin of accuracy and degree of safety. Its use in other aspects of EMS are being evaluated. Oral Health welcomes this original article. Photographs: Figures 1, 2, 3 Brian Waters. Figures 4-11 Sejaan Arora.

outcomes. Endo Topics February 2009;15(1):56-74. 7. Villa-Machado PA, Botero-RamĂrez X, TobĂłn-Arroyave SI. Retrospective follow-up assessment of prognostic variables associated with the outcome of periradicular surgery. Int Endodon J. 2013 Nov;46(11):1063-76. 8. Tabassum S, Khan FR. Failure of Endodontic Treatment: The usual suspects. Eur J Dent January-March 2016;10(1):144-147 9. von Arx T. Apical surgery: A review of current techniques and

outcome. Saudi Dent J January 2011;23(1):9-15. 10. Nino-Barrera JL, Ardila E, et al. Assessment of the relationship between the maxillary sinus floor and the upper posterior root tips: Clinical considerations.. J Investig Clin Dent May 2018;9(2):e12307.

Remaining references can be viewed on our website:

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THE LESSONS THAT I DIDN’T LEARN AT SCHOOL

never thought the day would come where I would be writing for Oral Health, but I guess there’s a first time for everything. My name is Hunter Soll, daughter of co-chairman of the editorial board of Oral Health, Dr. Jordan Soll. There are many differences between me and my father, one of them being that I’ll never have DDS on the end of my name. Four years ago, I was accepted to Queen’s University to join their Class of 2020. However, on the bottom of my admission email, there was no fine print that said, “Time at Queen’s may be cut short due to a pandemic”. Instead of spending the last 4 years at Queen’s, it’s really been 3.75. I didn’t get to spend the final 3 weeks with my friends going out and relishing the last moments of our time together, instead knowing that my last class really was my last class. I quickly packed my bags to hurry out of there, and subsequently found out that my convocation has since been delayed indefinitely. No longer am I part of the Class of 2020, but rather, I’m now known as part of the ‘Class of COVID-19’. As awful as all of this may sound, I’ve taken this entire experience as a learning opportunity. You know what they say; when life gives you lemons, add some club soda and vodka and you got yourself a cocktail! I know that when the world begins to return to the way we remember it, I will take away the following lessons; Lesson #1 - Our Actions Impact Others: My classes were cancelled because Queen’s was scared of having large lectures become a breeding ground for the spread of Covid-19, but it goes so much farther than that. We are all connected one way or another, and something that may affect one person can have an effect on another person. Regardless if it is

practicing social distancing, or something else, remember that your actions have consequences. Lesson #2 - We Are All Equal: Truth be told, I, like many of my peers, thought that COVID-19 wasn’t going to come to Canada, and it certainly wasn’t going to affect me. However, (and this may be my Generation Z mindset talking) when Tom Hanks and Rita Wilson were diagnosed and the NBA cancelled its season all in the span of an hour, I realized that we are all equal. Regardless of our financial situation, race, gender, religion or status, this disease has treated us all equally. Maybe we should treat one another equally as well. Lesson #3 - Take a Chill Pill: I understand that it is incredibly difficult to relax, especially during a global pandemic, but one good thing about being holed up inside of your house, is that you can finally just relax and slow down. Too often, we are going like the Energizer bunny. Now, we have nowhere to go, and there’s something kind of beautiful about just relaxing and giving yourself time to breathe. Lesson #4 - Give Gratitude: As hard as it might be for some people to stay inside 24/7, realize how lucky you are to have a home to be quarantined in. Sure, your hands might be getting red and rough from the countless handwashing, but that means you are lucky enough to have running water in your home. When it is so easy to find the negative in a situation, make sure you can find the positive and be grateful.(see life giving you lemons). Whether you’re at the end of your career or just starting out, a dentist or a lawyer, these lessons are all something that we can take and put towards our professional and personal lives going forward. Stay healthy, be safe, and until we can go outside again, I’ll send you the link to my graduation ceremony on Zoom. G

Hunter Soll

Dr. Jordan Soll CO-CHAIRMAN OF THE EDITORIAL BOARD OF ORAL HEALTH

Hunter Soll is graduating from Queen’s University with a BA(Hon.) in Sociology, and will be attending Ryerson University in Fall 2020 in the Master of Professional Communication program. She is a Gold Duke of Edinburgh Award recipient and a second degree black belt. Hunter is a Pop Culture and Lifestyle Writer for mytherapistsays.ca. Dr. Jordan Soll is a Toronto based general practioner and Co chairman of the editorial board of Oral Health Journal.

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IS THIS REALLY THE BEST TIME TO BUY A PRACTICE? A

BSOLUTELY!!! And here is why. If your ultimate goal is to own your own practice, then do not pass on a good office because of the times we are currently in. An economic crisis can be the best possible time to invest in yourself! As an associate, this could be the moment you buy yourself a job because no one knows what life will be like once the doors re-open. Every recession creates opportunities. And inaction does not mean safety in uncertain times. Rather than simply hope things will get better, you should act to improve your situation and position yourself for growth when things recover. If you are an associate, your income has and will be controlled by the principal you work for. If you work in an office with the principal, there is a very high chance your schedule is going to be impacted particuarly because the principal will be in the negative due to the clinic being closed. Therefore, a principal may choose to work longer hours

Jackie Joachim is Chief Operating Officer of ROI Corporation. Please contact her at Jackie.joachim@ roicorp.com or 1-888-764-4145.

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to make up for this. You cannot blame someone for choosing to work more or take the better quality patients when they have owned the practice during this financially critical period. Is it not better to be the owner of a closed office when the doors finally open rather than an associate waiting for the return of consistent hours? Buyers are reluctant to spend money to make acquisitions during an economic downturn. However, downturns can be an ideal time to invest in your own practice. As an associate, how long will it take for you to personally return to work? How long will it take you to return to your same level of billings prior to COVID-19? The countryâ&#x20AC;&#x2122;s key lending rate has now fallen from 1.75% at the start of the month to its current rate of 0.25%. The last time the overnight rate fell so much in the span of a month was in 1992. Therefore, prime rate as of today (March 31, 2020) is 2.45% and will most likely decrease by end of year. There has never been a better time to borrow. The sale will not close until the doors for dentistry re-open. Again, with the closures, revenue is not lost but deferred. By default, there will be a demand for visits. During this time as you prepare to take over the practice, you can engage the team to brainstorm and generate new ideas that could help you when

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the doors re-open. After all, the employees of an established practice are on the frontline and have a lot of insight into patient and practice needs. Yes, there will be stricter protocols required for infection control. That will not change regardless if you are an owner or currently an associate. While our situation today is different from the market crash of 2008, it is worth noting that Warren Buffett, in a 2008 Berkshire Hathaway shareholder meeting, said that the market might go up, the market might go down, the economy might fluctuate, but there will always be intelligent things to do. What an empowering message!! He went on to further say, “In the 20th Century alone, we dealt with two great wars (one of which we initially appeared to be losing); a dozen or so panics and recessions; virulent inflation that led to a 21½% prime rate in 1980; and a Great Depression of the 1930s, when unemployment ranged between 15% and 25% for many years.” While COVID-19 is something we have never seen, the fact is that globally, we will overcome it just as we did these other significant crises. Buying an office now gives you the opportunity of time. Usually, when people are purchasing an office, they do not have enough hours in the day to plan a successful transition. A personal marketing plan rarely is made, staff training to ensure the smooth transition does not happen and you, as a

History has proven that during challenging times that all the great fortunes were made. The most successful self-made people did not sit home in fear because of a financial crisis. new owner, do not have the time to develop critical business skills such as financial management, effective communication. If you buy an office that does not close until dentistry is open for business again, you have the benefit of this time to make serious and achievable plans. History has proven that during challenging times, all the great fortunes were made. The most successful self-made people did not sit home in fear because of a financial crisis. Ultimately, during tough times, it’s important to keep a positive outlook rather than focus on a bleak picture. It takes courage to invest in times of uncertainty, but if you do it wisely, you’ll see positive results down the road. The reality is that people will still need to see their dentist. Healthcare has proven its ability to manage during and post financial crises. G

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SPRUCE GROVE, AB

WESTWIND VISION

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estwind Dental is situated on the edge of the fast growing family community of Spruce Grove, Alberta. Dr. Steven Aneca and Dr. Adriaan Mik wanted to create a practice that was comfortable yet still maintained an ease of everyday functions for both patients and staff. The layout allows for smaller pockets of open ops in order to support efficiency, while still maintaining the feel of a smaller private clinic in an 8 operatory dental clinic. The clinic has supporting dental related conveniences such as plumbed medical gas and a lab that houses the advanced technological vision for milling and 3D printing. Careful curation of durable finishes like polished concrete floors, custom plaster wall features and quartz countertops were incorporated to create a clinic that is also durable to the everyday wear of a commercial space. It was important to the vision of the clinic to incorporate other sensory comforts to the clinic such as heated floors, 4K fireplaces, adjusted color temperature lighting within support areas, automated window coverings to reduce glare, and zoned heating and ventilation. The clinic also incorporated additional IT cabling in order to allow for future provisions for any technology innovations. The reception desk uniquely incorporates live edge wood slabs to balance the stone and plaster with the warmth of natural wood. The practice has a comfortable kidâ&#x20AC;&#x2122;s area with games, both digital and tactile, complete with durable laminate wainscoting in order to have the waiting experience be comfortable for patients of all ages. Westwind Dental is a contemporary new dental clinic inspired loosely by the comfort of hospitality.G

Interior Designer: Jennifer Buchanan Interior Design General Contractor: Seagate Contract Management Dental Equipment Supplier: Henry Schein Edmonton

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COVID-19:

Maximizing Government Benefits

ith COVID-19 shutting down many dental practices across the country, the government has introduced new benefits to help businesses weather this storm. Here is an overview of what’s available for dentists and some ways to optimize the benefits for you and your team. Canada Emergency Wage Subsidy (CEWS) – This benefit provides a subsidy of 75% of wages paid, up to $847 per week from March 15, 2020 to June 6, 2020. Canada Emergency Response Benefit (CERB) – This benefit provides individuals with $2,000 per month for up to 4 months who have been without work and pay for 14 consecutive days. Canada Emergency Business Account (CEBA) – This benefit provides businesses who have payroll between $20,000 to $1,500,000 with an interest-free loan of up to $40,000 until December 31, 2022 when it converts to an interest-bearing loan. $10,000 of the loan is forgivable if repaid by December 31, 2022.

Helping staff while minimizing cost While the government discourages employers from abusing the benefits, it is possible for employees to have their wages fully funded by the government. Keep in mind that optimizing is a mathematical exercise but changing an employee’s wages can have legal consequences; speak to your employment lawyer before implementing any employment changes. To do so, you need to separate employees based on their pre-crisis wages as follows: 1. $0 to $1,000 per week 2. $1,001 to $1,130 per week 3. $1,130 or more per week

Employees with $0 to $1,000 in pre-crisis weekly wages Employees in this category can receive up to $750 per week in government benefits. This comes from a combination of CERB ($500 per week) and CEWS (up to $250 per week). The CERB allows an individual to receive up to $1,000 per month or $250 per week, therefore it’s possible for an employee to combine both the CERB and CEWS. Going over

This article was prepared by David Chong Yen*, CPA, CA, CFP, Louise Wong*, CPA, CA, TEP, Basil Nicastri*, CPA, CA and Eugene Chu, CPA, CA of DCY Professional Corporation Chartered Professional Accountants who are tax specialists* and have been advising dentists for decades. Additional information can be obtained by phone (416) 510-8888, fax (416) 510-2699, or e-mail david@dcy.ca / louise@dcy.ca / eugene@dcy.ca . Visit our website at www.dcy.ca. This article is intended to present tax saving and planning ideas, and is not intended to replace professional advice.

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the $1000 per month/$250 weekly wage however means an employee would have to repay the CERB. As an example, Mary is currently receiving the CERB, prior to COVID-19 she was making $800 per week. As an employer, you decide you want to help Mary out, so you rehire her. You have two options: 1. Pay her $800 per week. Mary receives $800, you receive $600 in CEWS from the government, and you pay $200 difference out of pocket. Mary ends up with $300 more in her pocket compared to just the CERB but the employer ends up having to pay $200. 2. Pay her $250 per week. This is the maximum Mary can receive before she must repay her CERB. In this case, Mary keeps her $500 per week CERB payment and she gets $250 per week from you which is covered by the CEWS. In the end, Mary receives $250 more per week compared to just the CERB, but does not cost you anything. For employees in this category pay them 75% of their pre-crisis wages up to a maximum of $250.

Employees with $1,000 to $1,130 in pre-crisis weekly wages Employees in this category would be better off forgoing the CERB. With the CEWS they can receive between $750 to $847 per week in government benefits. This is based on 75% of their pre-crisis weekly pay. An employee making $1,100 weekly could be paid $825 per week without costing the employer any money. For employees in this category pay them 75% of their pre-crisis wages. You can pay them more, it will just come out of your pocket.

Employees with $1,130 or more in pre-crisis weekly wages Employees in this category can receive the maximum $847 per week. While it seems easy enough to just pay your staff $847 per week instead of their normal wages, you may wish to exercise caution here and compare everyone’s salary as a whole. CRA can challenge your claim where you and your family members are getting more than $847 per week, but all other staff get exactly $847 per week. For employees in this category pay them $847 per week but be mindful of what you are paying yourself and family members.

Getting the most out of the $40,000 interest-free loan It’s important to remember that the CEBA was created to help businesses facing immediate cash flow problems. The funds were meant for paying rent, personal protection equipment, utilities, salaries to staff and other necessary business expenses. Using the $40,000 to issue dividends to yourself and family members or to purchase investments is not what the government intended and may result in interest and penalties. This is not to say you can’t pay dividends or salaries to yourself and family members and/or pursue investment opportunities, but that you should have a plan and records in place to do so. By maintaining records to show where the $40,000 is being utilized, you can then use any excess cash to pursue investments and/or paying yourself and family members. Your records should include: • Copy of your bank statement showing your bank balance prior to receiving the $40,000 loan so that you can differentiate your cash versus the government’s. • A list of expenses you intend to use the $40,000 loan for. Use this list as the starting point for a budget so you know how much you need to spend in the coming weeks or months. • Copies of cheques and invoices that were paid using the $40,000 loan. • Copies of investment transactions and cheques or invoices for non-essential expenses. These expenses should not exceed your bank balance prior to receiving the $40,000. Another important benefit of the CEBA is that $10,000 is forgivable. In order to receive the full $10,000 benefit you need to have a balance of $40,000 outstanding as of December 31, 2020. You can then proceed to repay $30,000 between January 1, 2021 to December 31, 2022 and the remaining $10,000 will be forgiven. As an example, if you borrow $40,000 and have excess cash and decide to repay $30,000 on November 30, 2020 leaving you with a $10,000 balance as of December 31, 2020, you will only be eligible for $2,500 (25% of $10,000) of loan forgiveness. This is one of the rare situations where paying your bills early can cost you money. There’s no free lunch in this world, when COVID-19 is in our rear-view mirror, expect some unfavourable tax changes in the future. Until then, take the time to use the government benefits to put you and your team in the best position possible to weather the storm. G

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Impact of the Current COVID-19 Pandemic on Dental Practice Valuations and Sales

ever has the statement that we live in unprecedented times been truer. As of the writing of this article, none of us fully understands how this pandemic will play out. But even in times of unprecedented crisis, experience and basic principles can often help us draw reasonable conclusions about how businesses will likely be affected.

What is going to happen to dental practices in the short run? In March, regulators and health authorities recommended that dental offices immediately stop seeing patients, except for emergency treatment. The resulting office closures led to unprecedented revenue declines across the sector. The key thing to keep in mind, is that unlike many other businesses, much of this is a deferral of revenue, not the loss of revenue. This is very different than many businesses. The revenue for the Uber ride someone did not take, or the meal they did not buy at a restaurant is lost forever. But COVID-19 does not reverse tooth decay or

make impacted wisdom teeth go away. That restoration will still need to be done, and those wisdom teeth will still need to be extracted. There will be lost hygiene revenue, and depending upon how the eventual recovery goes, revenue for some elective procedures may be lost. But unlike many businesses, that deferred revenue is building up a back log that will help the recovery in the dental industry far more than many others. In addition, dentists have been able to shed most, but not all, costs. The four costs which generally account for the vast majority of dental practice expenses are wages (25%-30%), rent (6%-9%), supplies (6%-10%) and lab (3% to 8%). Most offices immediately laid off staff. Supplies and lab costs are not incurred until patients are back. So, with the exception of rent, most offices pared costs to the point that their economic survival is not threatened.Â In addition, unlike many small businesses, most practice owners have sufficient assets to withstand business interruptions for longer periods, especially

Bill Henderson (left) is President of Tier Three Brokerage Ltd, one of Canadaâ&#x20AC;&#x2122;s leading dental practice brokerages. He has an extensive business background including senior executive positions at Procter & Gamble, AIM Trimark and was a board member for the Investment Funds Institute of Canada. Dr. Bernard Dolansky (right) is a Past President of the Ottawa Dental Society, ODA, CDA, and the Dentistry Canada Fund. He is currently the Senior National Partner at Tier Three where he continues to assist dentists with transition planning; evaluations: practice purchases and sales; Bill and Bernie write and lecture about practice valuations and transitions across Canada.

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What will dental practice recovery look like, following the shut downs?

with the government support programs that have been implemented.

What about practices with high levels of outstanding debt? For the most part, banks are working closely with the dental offices that have significant debt. Of the many types of small businesses that banks have loaned money to, dental practices will remain among the most secure loans the banks have. As noted above, in almost all cases, the survival of a dental practice is not in question. This has been a timing issue, not an existential one. And banks are smart enough to know this. In most cases, banks have been prepared to defer principal repayment and make other arrangements to keep practices going. The banks have a very strong economic incentive to help a dental practice weather the storm. Only those practices that get through this crisis will be able to eventually repay the loan. So, the banks have an entirely rational, economic imperative to help practices get through this. Just look at the facts. In most cases, 75% or more of the value of a dental practice is goodwill. That goodwill becomes virtually worthless if the dentist and dental team aren’t there to treat patients. And even the 25% that may be tangible assets can’t be sold at close to that value, in the absence of ongoing practice operations. So, in almost all cases, the best way for a bank to protect itself is to ensure continued operation of the dental practice – and that won’t happen if they push the practice into bankruptcy.

As previously discussed, much of what has happened in the dental industry is a deferral of revenue, not a loss of it. So, when the advisories are lifted and practices return to normal patient treatment, there could be a surge in business at many practices. We do not yet know if that surge in business will build slowly or quickly. Much will depend on the decisions that public health authorities and dental regulators will make on the manner in which dental offices can return to work. But we do know that those restorations will still need to be done, and those wisdom teeth will still need to be extracted. In some recovery scenarios, we think the only limitation on the magnitude of the revenue increases will be the availability of staff. Certainly, most staff that were laid off in a practice will be more than eager to make up for lost time and wages. But before the pandemic hit us, the number one issue we were hearing from practice owners was the challenge of getting enough, good staff. Prudent practice owners have been making advance preparations to ensure they will have adequate staffing to deal with the substantial backlog. You should too.

We are now in a recession. How will this impact dental practices? History has a lot to teach us in this regard. Readers will remember the major recession we went through as recently as 2008/2009. By many measures, it was the worst economic decline since the Great Depression. How did it impact dental practices? For most practices, it had only modest, if any, negative impact on revenue and earnings. There were individual exceptions, but for the most part, dentistry is remarkably resilient in the face of economic declines. Indeed, that is often cited by the large institutional and private equity investors, who are backing the companies consolidating dental offices across Canada, as a primary motivator in investing in dental practices. That isn’t going to change. History teaches us that a recession will have far less impact on the average dental office than the vast majority of other businesses, small and large. While the exact impact will be determined by the magnitude and duration of the recession plus regional factors, we and, more importantly, many buyers remain confident that recessionary impacts on dental practices are likely to be moderate, and an eventual return to normal levels of revenue and profitability will ultimately be where things end up. The only question ishow long will it take?

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Prudent practice owners have been making advance preparations to ensure they will have adequate staffing to deal with the substantial backlog. You should too. What will be the impact on dental practice selling prices? Once again, history provides us some great guidance, for when we emerge from practice closures. First, a key thing to keep in mind is that prior to the COVID-19 pandemic, existing supply and demand forces had already driven practice values to unprecedented heights. We were in a strong “sellers’ market” in most places across Canada. The key drivers of this – a significant oversupply of dentists making patients the scarcest resource in dentistry, the excellent economics of most dental practices, banks offering great financing terms on practice loans, and an unlimited supply of investment capital funding practice consolidators, have not changed. Second, history teaches that those intractable forces of supply and demand are likely to get stronger. During and after the 2008/2009 recession, what happened to dental practice selling prices? They went up! Often considerably. That may sound counter intuitive to some, but not if you look at the factors driving supply and demand – the ultimate determinate of the price of everything. The devastating drops in stock markets in 2008 meant that many practice owners, who had been planning on retiring, could no longer afford to. That resulted in a reduction in the supply of practices for sale. Then, like now, government responded to the recession by cutting interest rates to stimulate economic growth. Lower borrowing costs drove demand up then, and will again. With a reduction in supply, and an increase in demand, prices responded the way they always do when those forces are at work. They went up and laid the foundation of the sellers’ market that ran non-stop throughout the past decade. And, what of the corporate practice consolidators? They all rely to some degree on institutional investors and private equity. In tough economic times, professional money managers look for safe harbours. Dental practices are high cash return businesses, that have shown better ability to withstand recessions than most industries. That makes them far safer harbours than most alternatives for investment capital.

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While the corporate consolidators are not usually the “high bidder” on individual practices, they will continue to provide a solid floor to practice values.

With inevitable declines in revenue and earnings in 2020, won’t that result in a lower appraised value for my practice? A basic principle in valuing a business is to remove the impact of one-time events that purchasers are not going to factor into their assessment of future earnings potential. The revenue declines that practices experienced due to office closures in March, April and May 2020 are just that kind of “one time” event. It is straightforward to adjust for this in a practice valuation. The most common approach will be to substitute monthly revenue from 2019 for the months in 2020 that are affected by COVID-19 related declines, with appropriate consideration being given to whether monthly revenue trends prior to the arrival of the pandemic were positive or negative. The longer-term unknown is whether earnings will be impacted once everyone can return to work. Past recessions indicated little to no lasting impact. If that is the case this time around, valuations need not come down.

Are there any other risks to worry about? Sadly, there will always be those that will try to take advantage of the fear, uncertainty and doubt that we all experience in a crisis. Just a week into this crisis, we had already begun to hear stories of buyers who were trying to panic practice owners into selling now, at prices below fair market rates, or with unreasonable conditions that hugely favoured the buyer. Practice owners need to take comfort in the fact that, despite everything going on, the fundamental laws of economics, led by supply and demand, have not been repealed, or even deferred. The one thing we know about all crises, is that they end. And that the prospects for practice values remain strong. The key is to seek out experienced advisors you can count on, not yielding to buyers whose real interest is their own gain. In conclusion, no one can deny the incredible challenges dental practice owners have faced over the past months, and the sacrifices they have made. As we work through the impact of the COVID-19 pandemic, patients’ needs should remain your focus. As you focus on that, you can do so knowing that history and the basic laws of economics, suggest that your practice value remains strong, and when the time comes for you to sell, a strong market awaits. G

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hat does it mean to be an influencer? It used to be that someone would pay you thousands of dollars to pose with pretty purses to influence others to desire the merchandise you were posing with. Nice gig if you can get it, but for most of us in dentistry, it’s not what we are seeking. We want to be known for our knowledge and skills and how we can help the world, more often than for anything else. Plus, that is the influencer of old. Now there is a new influencer in town; the credible influencer. These credible and talented professionals are changing the world by selflessly and freely sharing their knowledge online through social media. Influencer marketing is different from the traditional, commercial marketing we have been

employing. Not only is it a different approach, it is more effective than anything that we have ever had in our arsenal. All you need in order to use influencer marketing is a means to convey your knowledge, a social media profile, and a little courage. I say courage because influencer marketing is not for the faint of heart - you are putting yourself out there for the world to judge whether your knowledge is worthy of consumption. Scary? Yes. Worthwhile? Definitely. We all have little voices of doubt in our heads asking us if we are frauds in how our patients and the public perceive us. Are we really worthy of the accolades that we get? Are we worthy of the pedestal that we are pushed onto? Influencer marketing will reveal what you are made of and will help you

Dr. Angela Mulrooney turned a run-down clinic into a cutting edge practice that was referred to by colleagues for full-mouth reconstruction, I.V. sedation, and sleep apnea therapy. In doing so, she more than doubled her hourly production while working 50% fewer hours at 28 years of age. After sustaining a career ending injury, she decided to turn tragedy into opportunity by sharing her credibility and production-boosting secrets through practice management and social media marketing to help talented colleagues realize their full potential clinically and entrepreneurially.

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to see your worthiness. If you have something that the world needs, if you put it out there and it is consumed, with people wanting more, then the world is telling you that you are worthy. It is effective because it is different than any other carefully crafted marketing campaign you have ever used, where you are conveyed perfectly on a day that you had a great photographer or videographer to capture a moment in time. The old way of perfect marketing campaigns with the perfect message is gone. Now people seek authenticity. They want to know that you are credible and trustworthy. They also want to know the person behind the brand - what makes them tick, whether they are as smart as they seem, and whether they are consistent over a period of time. No perfect commercial marketing campaign can do that for you. But… influencer marketing can. Social media is the ideal milieu for influencer marketing for several reasons. It is easy to use - unlike our websites that require massive training to execute changes well, social media can be updated easily. It is cost effective - you don’t necessarily need someone to do those updates for you. It is accessible - anyone can find you if you are putting yourself out there.

Sharing knowledge about what you do is scary because there is always fear that knowledge will be stolen. It is one of the greatest roadblocks to talented professionals stepping into the spotlight with influencer marketing. Because of these reasons, you have an opportunity to have your social media as up to date with you as your last post. There is no excuse for falling behind with your marketing when it is as easy as point, shoot, upload and caption. So why are more professionals not leveraging social media for their brands in a way that allows them to be purveyors of knowledge? It comes back to the fear of this form of marketing. When you use your social media in a personal way, no one’s

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going to call you out for posting cute photos of your puppy on your feed. When you use your social media in a professional way, they may call you out if you express your knowledge - or lack thereof - on a topic. Let’s take LinkedIn for example. LinkedIn is full of highly educated, successful individuals and thought leaders. Who would want to expose their potential lack of knowledge on a platform like that? Not many. That is why the opportunity exists for you with influencer marketing. The average and even above average professional is not willing to expose themselves to criticism of their knowledge on any public platform. Here is why you should though. You can be the most talented professional in the world, but if no one knows that you exist, then what does it really matter how talented you are? This especially rings true if you have a talent that people need to access. Hiding your head in the sand and keeping your knowledge to yourself or only exposing it to your small group of patients who already know you, is doing the world a disservice. I would call it selfish. When you have invested in training that not many people know about which makes your care a scarce commodity, it is only fair to let more people know that it exists, if you believe you can truly help people with your skills. If you do believe you have the ability and an obligation to help the world with your skills, the next step is getting your knowledge out there. How can you get yourself out there showing what you know? Start by figuring out what it is that patients get from your care. Let’s work through a specific example: sleep apnea. You can hang your shiny certificate out on social media and tell the world you are qualified to help them. You can list the diseases that your care can help prevent. You can explain the process. You can show the options for appliances. You can even take photos of the appliance in someone’s mouth. However, few will get what you actually do. Instead, start thinking from your client’s perspective. The easiest way to do that is to talk to the clients who have benefitted from your care. Ask how your care changed their life. Did they go from dragging themselves through life to being full of vim and vigor? Did they go from being overweight and sluggish to being a healthy weight and wanting to move? Did they go from being average at work to being a super star because they can finally concentrate and be creative? Anything we do to purvey our

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People want to know the person behind the brand. They don’t just want to know that you are smart and talented. They don’t just want to know what is in it for them. They also want to know that the person delivering the care is a relatable, flawed human being like them. knowledge can’t be like a lecture to our potential clients, where we spout how smart we are while talking above our audience’s head. Instead, we need to figure out what is in it for our clients because clients are self-centred when making buying decisions - even when it comes to buying decisions about healthcare. When they are shelling out time and cash for treatment, they want to know there will be some tangible changes in their lives when all is said and done. When you can convey your knowledge in a way that shows them what they get out of it rather than what you can do for them, you change the game for yourself. Sharing knowledge about what you do is scary because there is always fear that knowledge will be stolen. It is one of the greatest roadblocks to talented professionals stepping into the spotlight with influencer marketing. When you can step into the spotlight and share your knowledge, you are seen as the expert. If your colleague beats you to it, they are seen as the expert. Truthfully, there is always a risk that someone will copy your ideas or try to take credit for the knowledge you are purveying. So, the fear of knowledge being stolen is valid. But, think about those who are industry disruptors. Let’s take Tesla for example. They innovated the automotive industry and were so far ahead of their competition and seemed untouchable. It was shocking when they decided to reveal

their secrets and publicly release their designs to the world. The world saw them as knowing even more than before because of their fearlessness. I encourage you to be the same way. If you can be the Tesla of your industry, fearlessly sharing your knowledge secrets with the world, you will be seen as the go-to person for that knowledge. Whether that go-to position is just in your local area, your city, your province, or beyond, by being someone who contributes your knowledge to the world, you will be perceived as the expert. Even better, the people who need you will be able to find you. Your knowledge combined with who you are is what really wins when marketing. Again, people want to know the person behind the brand. They don’t just want to know that you are smart and talented. They don’t just want to know what is in it for them. They also want to know that the person delivering the care is a relatable, flawed human being like them. Influencer marketing allows you to get that part across if you let your true self come through. Have those moments where you aren’t perfectly coiffed or dressed to the nines. Show those moments where you didn’t look perfect, but it was a good moment to capture a part of your life that shows what you do in a real way. Combine the real you, with your knowledge, and credentials, and you will be able to help more of the patients who need you than ever before. G

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“I’m a dentist and entrepreneur. I spent 18 years building my practices, and at one point I was the payroll clerk, recruiter, bookkeeper, IT consultant, lease negotiator and more. I partnered with dentalcorp to leverage their support and expertise so I can focus on growing my practices the way I want: patient-centric and forward-thinking.” —Dr. Amit Puri, Toothworks, Partner since 2019

Get back to doing what you love. Visit dentalcorp.ca to learn more.

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Dental Marketplace Contact: Karen Shaw | 416-510-6770 | 437-991-7187 | karen@newcom.ca fax: 416-510-5140 | toll free CDA & USA: 1-888-639-2669

OPPORTUN ITIES IN TH E DEN TISTRY PROF ESSION

P RO F ESS I O N AL S E RV I C ES

A boutique law firm servicing dental professionals since 1974

Alglobe

Construction Company

20 years construction experience • Dental office construction and design + cabinet making. • Provide turn key operation to dental office. • Reliable construction timing, • Good following up service after construction. Call: Stanley • New dental location and lease negotiation. Tel: (416) 321-3313 • Save time, save money. www.alglobe.com

CA R E E R S GP DENTIST AVAILABLE 19 years Experienced GP dentist available to work in Toronto and GTA. Monday,Wednesday and Saturday. All types of dentistry including all endo, surgical exo and impactions. Please contact sidhumehboob@hotmail.com

EQUI P M E NT SARNIA, ON E4D, scanner, milling unit and furnace for sale. Very lightly used over its 4 year life. Not being used by associates is reason for sale. Great opportunity to acquire at fraction of new cost. Best offer. Contact Dr Tim Pringle 519 339 6619.

PRACT I C ES & OFFI C ES WHY LOSE 10% TO A BROKER? NO PRODUCTION GUARANTEES! Looking to sell your practice for full market value? We welcome the owner staying on too. Confidentiality is guaranteed. E-mail: gtadentist@yahoo.com

• Dental Practice Sales and Purchases • Incorporation of dentistry professional corpoHoward Kutner rations • Estate planning for dentists • Associate, employment, partnership and cost sharing agreements • Lease and real estate transactions. Tel: (905) 479-2524 50 Acadia Ave., Suite 307 Markham, Ontario L3R 0B3 www.kutnerlaw.ca Michael Kutner

Dental Practice Advisory Services • Practice Purchase Consulting • Financial Planning • Professional Corporation • Review of Dental Practice Tax and Investment Strategies Appraisal Reports Victor Staniewski CA victor@fgsaccountants.com 416-222-3221

Fedder, Gurau & Staniewski CHARTERED PROFESSIONAL ACCOUNTANTS

ASSO C I AT ES H I P S ALBERTA Highly productive Dental Practices seeking Full Time General Dentists, Orthodontists and Pediatric Dentists in major cities in Alberta, including Grande Prairie, Fort McMurray, Calgary and Edmonton. This is an exciting opportunity for dentists interested in above average remuneration and expanding clinical experience. Mentorship is provided, and opportunities for partnership and fixed salary will be offered to the right candidate. General Dentist candidates must have experience in working with patients of all ages and must be proficient in performing complex dental procedures including cosmetic dentistry, implants, sedation, endodontics and surgery. Qualified applicants with strong communication skills and in search of a long-term career opportunity in a cutting edge practice are encouraged to submit a resume today to albertadentalopportunities@gmail.com

oralhealthgroup.com

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60 M AY 2020

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WHO WILL BUY YOUR PRACTICE? Over 45 years of experience speaks for something. We know and understand the business of buying and selling dental practices.

Discretion, Privacy, Practice Preservation Call 1.844.ROI.2020

Subscribe to our New Listing Service at roicorp.com

ACROSS CANADA, we have evaluated practices for over 15 years. Our evaluations are readily accepted by bankers, lawyers, accountants, purchasers, sellers and the courts.

EXPERIENCED PROFESSIONAL INDEPENDENT NATIONAL

As part of the evaluation, we will provide valuable professional advice on goodwill enhancement/protection techniques and current tax planning. Having been practicing Chartered Accountants with a national client base restricted to dentists, we are very familiar with these matters. For more information, please contact Ron MacKenzie in confidence. Articles on practice evaluation matters are available without charge.

MACKENZIE & COMPANY Vancouver (604) 685-9227 Edmonton (780) 424-9294 Toronto (905) 270-7454

(Practice restricted to dentists)

e-mail: mackenz@telus.net â&#x20AC;˘ cell: 604.312.3780

www.mackenziecompany.com oralhealthgroup.com

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HEALTHY Stay INFORMED Recover STRONG Stay

When this crisis ends, will you be in a strong position to recover quickly? During the dental shutdown, it is time to take action â&#x20AC;&#x201C; not shut down. This includes financial planning and regular communication with your advisors, your team and especially your patients! PPS is aware of market developments and we have created a complimentary cash flow model that illustrates the financial impact on your practice over the next 12 months. Pre COVID

12 months incl. shutdown

12 months after re-opening

Professional Billings

$1,000,000

$600,000

Your Estimate Here

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$450,000

$212,000

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EXAMPLE

% Change

-53%

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David Lind

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david.lind@ppsales.com (905)-334-1794

colin.ross@ppsales.com (416)-999-2607

gerry.crandles@ppsales.com (416)-452-9882

mike.suffield@ppsales.ca (604)-764-6066

linda.oconnor@ppsales.ca (778)-879-3800

nicky.saini@ppsales.com (647)-502-9906

Whether you are selling now or well into the future, we can help you make your best decisions. Contact PPS for a Market Consultation or visit our website for more details.

1.888.777.8825 www.ppsales.com

B R O K E R AG E

PRACTICE VALUATION | PRACTICE BROKERAGE | BUYER REPRESENTATION | NEGOTIATIONS

62 M AY 2020

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ASSO C I AT ES H I P S BURLINGTON, ON EXCITING OPPORTUNITY FOR EXPERIENCED DENTIST!!! Established and thriving Burlington practice looking for the right ‘fit’ with a part-time moving to full-time associate. Must be available to commit to 2 days/ evenings and alternate Saturdays. If you are DRIVEN, PASSIONATE ABOUT DENTISTRY and interested in growing and establishing a consistent patient load and are committed, we would love to hear from you! Please reply to 1stdentalteam@gmail.com

CORNWALL, ON FULL-TIME ASSOCIATE DENTIST We are looking for a full time, team oriented associate dentist to join our practice. The office is modern and spacious, with a small town friendly atmosphere and an outstanding team. We are a full-service dental practice focusing on general dentistry, cosmetic services, endodontics, implant placement and restoration, orthodontics and sedation dentistry. Cornwall is located along the beautiful St Lawrence River, nestled between Montreal Quebec and Ottawa the Nation’s Capital offering all the charm and amenities. Candidates must have accredited DDS/ DMD program or completion of NDEB Equivalency Exam. Certified with NDEB. Licensed and in good standing with ODA. Please forward resume to: kim@smilesonseventh.com

LONDON, ON PART TIME ASSOCIATE REQUIRED FOR BUSY, WELL-ESTABLISHED OFFICE Looking for a part time associate for Mondays 8-5 and Wednesdays 1-5 in a busy general practice clinic in the London area. Candidate must have at least 1-year experience. The ideal candidate should be proficient in all aspects, particularly oral surgery and endodontics. Please send your resume to: info@525dental.com

PERMANENT OPPORTUNITY IN A WELL ESTABLISHED ORTHODONTIC PRACTICE This is a two (2) days per week position. The right candidate will enjoy working with a great team of professional and support staff, while enjoying all that beautiful Sarnia-Lambton region has to offer. If you are passionate about building strong patient relationships while providing them with exceptional care and are looking for an opportunity to work alongside and learn from some of the industry’s leading clinicians, then this is an opportunity for you. This position comes with the opportunity to grow and work at our other Ontario locations. Candidate must have graduated from an accredited orthodontic program and passed the Canadian National Board Exams (licensure in 2020 is acceptable). No experience necessary – grad students welcome to apply. Position available immediately. Starting per diem rate: $2,000 Please submit your CV and cover letter if interested in the opportunity. Candidates must be legally eligible to work in Canada. We thank all applicants, but only suitable applicants will be contacted. Job applicants with a disability who require a reasonable accommodation for any part of the application or hiring process can contact our HR team at HR@ritebite.ca. Reasonable accommodations will be determined on a case-by-case basis and your request will be responded to as soon as possible.

GTA-TORONTO, ON

KITCHENER, ON

Multiple offices in GTA looking for associates, weekdays and alternating Saturday. Please email: henrywong_dds@hotmail.com

Well established modern practice is seeking an ENDODONTIST for 1 day a month. Our practice has a strong patient base, experienced and long-term staff, and a friendly work environment. We provide an experienced Endo assistant, all the armamentarium and global microscope. Please reply with your resume or CV to monica@dentistryinfo.com

BELLEVILLE , ON

WHITEHORSE, YT

Busy non-corporate family practice with sole owner and over 7200 active recall patients seeks a full time associate. Work schedule can accommodate up to 4 days per week. Owner works 4 days per week. No weekends required. Remuneration 42.5% of billings. Strong communication skills an absolute must. Clinical experience an asset. Newly renovated clinic with great staff and work environment. Immediate start available if suitable. Email: toothdoc911@gmail.com

Full time associate required. We enjoy a modern clinic and our excellent team is focussed on patient centered care. Come and join us and experience a northern lifestyle second to none. Tel: 867-633-4401 Fax: 867-633-4402 E-mail: office@murrayadental.ca

Seeking associate dentist to add to our expanding office located in Bradford. Tuesday 8am to 5pm (maybe extended). Fridays 8am to 4pm. Saturdays 9am to 4pm. Must be easy going and well versed clinically. Send resume to mightymolars@live.ca

BRADFORD, ON

GATINEAU, QC Full time associate needed for extremely busy modern practice in large shopping mall in the heart of Gatineau. Just minutes from Ottawa. New dentist will have a full schedule and will be taking over existing patient base with over 1500 patients and 100+ new patients a month. Email: Gatineaudental@yahoo.ca

TORONTO, ON Busy downtown family dental clinic is looking for a F/T or P/T General Dentist and Periodontist. Please send resume to Davidkourosh@hotmail.com

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ASSO C I AT ES H I P S MID AND DOWNTOWN GTA LOCATIONS FULL-TIME ORAL AND MAXILLOFACIAL ASSOCIATE This fast paced, full-scope oral surgery practice has an immediate need for a full-time associate. May lead to possible partnership opportunity. This high-volume multi-doctor practice with mid- and downtown GTA locations has a wellestablished referral base and potential hospital availability. Onsite CBCT/digital X-rays. The position requires a BoardCertified or Board-Eligible oral and maxillofacial surgeon who has ambition! Email: admin@metropolitanoms.com

KAMLOOPS, BC Dental Associate Needed in Beautiful British Columbia. We are looking for a motivated dentist to join our busy family dental practice in Kamloops, BC. We are a paperless, digital office with a busy recall system in place. Kamloops is home to world renowned skiing, golf, fishing, and mountain biking. Our practice is team orientated. The position is full time and is available for July 2 2020. New Graduates welcome. Please call 250-398-0532 or email vitoratos@shaw.ca

STONEY CREEK/BRANTFORD, ON Looking for a highly motivated dentist. PT/ FT skilled in most aspects of dentistry for a busy, modern practice with an established patient load. Excellent remuneration. Please reply to pwdentist3@gmail.com

PETERBOROUGH, ON

ASSOCIATE WANTED IN WELL ESTABLISHED OFFICE Looking for a part time associate, leading to full time in a busy well established preventative/conservative patient focused dental office. Looking for someone to care for our long standing loyal patients in a friendly family dental clinic. Experience Preferred. Send resumes to: dentistryinpeterborough@gmail.com

REXDALE ON (Kipling and Steeles) Family practice looking for a p/t associate for Saturdays. More days to be offered to the right candidate. Friendly and good communication skills a must. Familiar with all aspects of dentistry. Please send resume to amdentalinfo@gmail.com 64 M AY 2020

THE PAS, MB

SARNIA, ON

Awesome opportunity for full/part time associate or locum. Principal wanting to take some much needed time off. Come and practice stress free dentistry in a state of the art, modern clinic. Be as busy as you want to be. License, travel, accommodations and even a car for you to travel around in all provided! Just show up and start working!

Established family practice with loyal patients, located in the downtown core. Looking for an associate dentist 2-3 days per week to start, with the potential to grow. No evenings or weekends. The ideal candidate is enthusiastic and caring with good communication skills and would enjoy working in a team setting. Please email resume to eltantydentistry@hotmail.com

Contact dentris2012@yahoo.ca or (204) 978-1158 for more details.

BRAMPTON, ON Great opportunity to Associate for a well established Brampton Group Practice. Call Kathy at 905-457-3606 to set up a visit, if interested.

MILTON, BRAMPTON, MISSISSAUGA & VAUGHAN

OSHAWA, ON Part time Associate Dentist needed for 2 days per week, possibly more, to take over for retired dentist. Busy established general dentist clinic. We are looking for a motivated and experienced dentist to join our team of professionals. English proficiency is a must. Apply to: oshawadentist1@gmail.com No phone calls please.

BURLINGTON, ON DENTAL ASSOCIATE POSITION

Associates needed for our busy dental practices. Our locations are surrounded by thousands of newly built homes. We have in-house specialists servicing our patients. Mentorship program available for new grads. Please email dentist@thedentalteam.ca

Modern state of that art dental office with a loyal patient base seeking associate dentist Tuesday-Friday. No evenings or weekends. Excellent systems in place to facilitate comprehensive treatment planning. Incredible opportunity for the right candidate. A commitment to continuing education and quality of care is essential.

CALGARY, AB

Please reply in confidence to: BurlingtonAssociate2020@gmail.com

ASSOCIATE REQUIRED FOR A BUSY CALGARY DENTAL OFFICE We are currently seeking either a full or part time general dentist to complete our team. Our office has recently moved to a new store front location in south Calgary. We are a growth oriented practice that puts emphasis on personal and professional development as well as providing an exceptional patient experience. The successful candidate will be experienced in all areas of general dentistry. Please leave a detailed voice message about yourself at 403-836-3235. No resumes. Only the most qualified candidates will be contacted.

GTA & SURROUNDING AREAS, ON Associate opportunities available across the GTA and surrounding areas including Scarborough, Mississauga, Brantford, Hamilton, Barrie, Dundas, Brampton, Etobicoke, Oakville, Waterloo, and Owen Sound. E-mail: yourdentaldream@gmail.com

GUELPH, ON Central Guelph Dentistry is looking for an experienced DDS to replace retiring previous owner. Two days a week. No weekends. Candidate with conservative dentistry approach would be a great fit. Please apply at drksasan@yahoo.com

oralhealthgroup.com

| oralhealth

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The Oral Health Group of publications offer classified advertising sections in each and every issue. We carry more classified ad pages than all other Canadian dental magazines combined. I can help with your dental marketplace needs

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AD INDEX 3M Oral Care ��7 ABELDent �� 35 Air Techniques �� 25 Canadian Dental Services �� 18 dentalcorp �� 44, 58 DiaDent Group International �� 21 Garrison Dental Solutions �� 41 Henry Schein ��5 iFinance Dental �� 31 MKR Dental Cabinets �� 36 Oral Science �� 20 Planmeca �� 39 PTIFA – Pacific Training Institute for Facial Aesthetics �� 30 Sable Dental Industries �� 34 SciCan ��13, OBC Septodont �� IFC Takara Belmont �� 27 University of Alberta Faculty of Medicine & Dentistry �� 40 VOCO Canada ��IBC waterpik �� 33

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TH E L AST WOR D ON TEC H N OLO GY

Changing the way we see caries – literally

GreenMark Biomedical uses non-invasive nanotechnology to rethink how dental professionals will diagnose and treat carious lesions Lou Shuman, DMD, CAGS, CEO and Founder of Cellerant Consulting

ypically the purview of science fiction writers and medical researchers, nanotechnology isn’t something dental professionals are asked to think about very often, let alone incorporate into their daily clinical practice. As more people learn about what GreenMark Biomedical makes possible, that will certainly change. GreenMark is a healthcare startup specializing in targeted biopolymer particle technology. The company is aiming to transform the dental experience by enabling dentists to accurately assess when to treat carious lesions and make painless, natural repair possible. Caries remains the world’s most prevalent chronic disease and affects over 95% of Americans over their lifetime. GreenMark is leveraging starch nanoparticles to identify and diagnose active pre-cavities at an early stage. Its diagnostic product – LumiCare™ Caries Detection Rinse, currently 510(k) pending – is intended for use in routine dental exams: The patient rinses first with the diagnostic solution and then with plain water. All that remains after the water rinse are the particles that have penetrated the tiny porosities in the enamel and attached themselves temporarily to the active subsurface lesions. The particles contain molecules that fluoresce or light up under exposure from a standard blue curing light. Within seconds, the dentist receives a direct visual diagnosis because the illuminated areas indicate areas of porosity. The starch particles are completely biocompatible and resorbable, making them ideal for use in the oral cavity. They break down in the presence of amylase which is a naturally occurring enzyme in human saliva. So, by the time the patient leaves the office the particles are completely degraded and there is no residue. “We know visual and tactile exams using the explorer miss lesions or can cause cavitation. X-rays cannot catch lesions until they’re well advanced – by that time it’s too late for anything but drill and fill. But if you can detect caries in the incipient stage, you have the opportunity to treat noninvasively,” said Steven Bloembergen, PhD, GreenMark’s founder and CEO. “Active carious lesions are characterized by surface porosity, while inactive ones are non-porous and arrested. At present there are no diagnostic techniques or devices capable of differentiating between active and inactive lesions on the market. Dental professionals tell us that it’s a complete guess.”

Once the areas of early decay are detected, the dental team can use minimally invasive products and practices to treat the disease while preserving healthy tooth structure. This is an excellent way to build patient trust, avoid needles and drills where possible and for a practice to demonstrate it actively promotes modern dentistry. “This technology will allow dentists to better evaluate the effect of noninvasive treatments,” Steven continued, “So, we think this is truly a disruptive technology that has the potential of changing the way things are done in the field of caries management.” Based on the same platform technology, GreenMark is actively developing CrystLCare™ Restorative Gel, which contains targeted mineral-loaded starch particles to non-invasively fill early sub-surface porosities. “Calcium and phosphate, the key minerals that are depleted from teeth during the process of decay, can be bonded very effectively inside the small sub-micron starch particles. Since the targeted starch particles adhere to the internal surfaces of carious lesions, we have the potential to deliver the building blocks of enamel directly to the site of active disease. The minerals are released when the starch degrades, triggering recrystallization of the tooth subsurface by drawing on large amounts of naturally occurring calcium and phosphate from the saliva in a process known as “crystal nucleation,” shared Wendy Bloembergen, MD, MS, GreenMark’s Vice President of Clinical Affairs. “While this application is still in preliminary research, our team has been very excited by the initial test results.” This is a company I’m excited to follow as I see its potential to bring the promises of early caries detection and minimally invasive treatment – goals our industry has talked about for years – to fruition. It is a new reality. It is a gamechanger that soon will be available to integrate into your practice. For more information, go to greenmark.bio.

Contact me with your feedback on this new feature at: amy@newcom.ca and let’s start talking. 66 M AY 2020

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