CJ) CJ) m r m :::0 ili TRITON ® ALL-IN-ONE IRRIGATION SOLUTION yoursimplifytimeIt'stoirrigationprotocol. See the studies at BrasselerUSA.com/Triton _09.22_EPB_5557 PROMOTING EXCELLENCE IN ENDODONTICS Building confidence and improving repeatability in your endodontic practice Dr. Mark Anthony Limosani Corporate profile Endo Practice Partners Practice profile MicroSurgical Endodontics Company spotlight CareCredit — Financing Simplified Fall 2022 Vol 15 No 3 endopracticeus.com FAQ Special Section n 4 CE Credits Available in This effectiveStreamliningIssue*irrigation
Dr. Allen Ali Nasseh
Simpler for you. Better for your patients.™ Say Hello CleanFlow™IntroducingCleanFlowto™theGentleWave®ProcedurewithTechnology To learn more, scan here or visit sonendo.com/cleanflow CleanFlow™ facilitates single-handed cleaning and disinfection of the root canal system from outside the tooth. © 2022 Sonendo, Inc. All rights reserved. SONENDO, the SONENDO logo, SAVING TEETH. IMPROVING LIVES., GENTLEWAVE, the GENTLEWAVE logo, CLEANFLOW and SIMPLER FOR YOU. BETTER FOR YOUR PATIENTS. are trademarks of Sonendo, Inc. Patented: sonendo.com/intellectualproperty. 22SON117 MM-1622 Rev 01
This adage — originated by English author Thomas Fuller and popularized by the late broadcaster Vin Scully — ought to serve as a clinical mantra for endo dontists. It sounds the warning of complacency. More importantly, it beckons us to engage in lifelong learning at the service of our patients. This fall issue of Endodontic Practice US presents some of the many exciting clinical advances in instrumentation, imaging, and disinfection.
INTRODUCTION
There is no shortage of competing files, CBCT machines, and irrigant-delivery vehicles. So, while endodontists’ adaptability to new trends is a boon, they face a challenge in vetting the many technologic options before them. Continuing educa tion by review of available evidence is one approach to navigate the maze. Discus sion with colleagues represents another.
Editorial Advisors
Louis E. Rossman, DMD
CE Quality Assurance Board
Gregori M. Kurtzman, DDS, MAGD, FPFA, FACD, FADI, DICOI, DADIA
Lisa Moler (Publisher)
Michael Tagger, DMD, MS
Joshua Moshonov, DMD
Fall 2022 n Volume 15 Number 3
Marcela Fridland, DDS
To answer that question, we first have to challenge its premise. Without exhaus tive posttreatment recalls of patients, many endodontists may be overestimating their own success. The endodontic triad of shaping, cleaning, and filling has value when contextualized to biologic principles and outcomes-based research. Reported success rates for nonsurgical and microsurgical endodontic treatment widely range from 70% to over 95% across both short- and long-term outcomes studies. This vari ation in reported success should not discourage us from trusting the anvil of research upon which our profession has been forged. Rather, it should prompt discussions of case selection, factors underlying modes of endodontic failure, and the value-add of new technologic adjuncts to treatment outcomes.
Stephen F. Schwartz, DDS, MS
Fred Stewart Feld, DMD
1endopracticeus.com Volume 15 Number 3
Dennis G. Brave, DDS
Martin Trope, BDS, DMD
The financial considerations of incorporating new technologies in a clinical practice are not negligible. In these challenging economic times, endodontists as small business owners are beholden to their staff, associates, and families to maintain practice solvency. However, investments in new clinical devices can be highlighted to patients who are increasingly reliant on websites and online reviews to optimize their care. And in many markets, they are willing to pay the premium associated with cutting-edge technology.
Eshwar Arasu, DMD, MSD, is a private practice endodontist in Nashville, Tennessee. Dr. Arasu obtained his dental degree from the Harvard School of Dental Medicine and completed his postdoctoral endodontic training through the residency program at Virginia Commonwealth University. He was awarded a Master of Science in Dentistry for his thesis on the volumetric analysis of surgically treated endodontic lesions via cone beam computed tomography. Dr. Arasu is a Diplomate of the American Board of Endodontics. He may be reached online at wwww.cendotn.com.
Syngcuk Kim, DDS, PhD
© MedMark, LLC 2022. All rights reserved. The publisher’s written consent must be obtained before any part of this publication may be reproduced in any form whatsoever, including photocopies and information retrieval systems. While every care has been taken in the preparation of this magazine, the publisher cannot be held responsible for the accuracy of the information printed herein, or in any consequence arising from it. The views expressed herein are those of the author(s) and not necessarily the opinion of either Endodontic Practice US or the publisher.
Gary B. Carr, DDS
David L. Pitts, DDS, MDSD
“Good is not good when better is expected.”
The onus is on endodontists to evaluate the merits of new technologies and adopt them when appropriate. However, there is inertia to this adoption. For endodontic newcomers and owners of fledgling practices, costs may manifest as time away to undergo training or marginal squeeze due to increases in overhead. For seasoned cli nicians, these very issues can surface as a nagging question: Why should I introduce change and expense to my practice when I already have efficient treatment success?
Robert Fleisher, DMD
Arnaldo Castellucci, MD, DDS
David C. Brown, BDS, MDS, MSD
Gordon J. Christensen, DDS, MSD, PhD
Gerald N. Glickman, DDS, MS
E Steve Senia, DDS, MS, BS
Luiz R. Fava, DDS
Peter Velvart, DMD
L. Stephen Buchanan, DDS, FICD, FACD
Rick Walton, DMD, MS
For those who practice in an endodontic group, comparing notes on cases and techniques can be as illuminating as they were in residency. Clinicians in a solo practice need not be isolated from educational engagement — study groups, end odontic forums, and annual meetings are effective avenues to continued learning. Lastly, endodontists should be emboldened to educate their referring doctors while marketing their practices. Assembling presentations compel endodontists to self-as sess whether their practices meet standards of care and exceed their patients’ expectations for comfortable, modern treatment.
Stephen Cohen, MS, DDS, FACD, FICD
Bradford N. Edgren, DDS, MS, FACD
Yosef Nahmias, DDS, MS
John West, DDS, MSD
Gregori M. Kurtzman, DDS, MAGD, FPFA, FACD, DICOI
Kenneth A. Koch, DMD
Justin D. Moody, DDS, DABOI, DICOI
ISSN number 2372-6245
Lou Shuman, DMD, CAGS
Jeffrey W Hutter, DMD, MEd
Ken Serota, DDS, MMSc
Mali Schantz-Feld, MA, CDE (Managing Editor)
Richard Mounce, DDS
Samuel O. Dorn, DDS
Josef Dovgan, DDS, MS
COVER
STORY
Cover Nasseh of Brasseler challenging with a new
discusses approaching zero loss of structural integrity during RCT ................................................ 24 FAQ SPECIAL SECTION Brasseler USA® 28 Sonendo® .................................... 29 US Endo Partners ................ 30 108PRACTICE PROFILE
simplify the irrigation process
Dr. L. Stephen Buchanan
minimally endodonticinvasivecase
2Endodontic Practice US Volume 15 Number 3 TABLE OF CONTENTS
USA. PUBLISHER’S PERSPECTIVE Calculated risks add up to greatness Lisa Moler, Founder/CEO, MedMark Media............................... 6 CORPORATE PROFILE Endo Practice Partners The sole specialty partnership organization (SPO) in the industry ............................................. 14 COMPANY SPOTLIGHT CareCredit — Financing Simplified ......................................................... 16 CASE REPORT managementEndodontic of
Dr. Allen Ali Nasseh his
courtesy
Dr. Hugo Sousa Dias of of a
MicroSurgical Endodontics
image of Dr.
file system
practice, endodontic education, and innovation
contemplates
a case with complex root canal ..............................................................anatomy 18 TECHNIQUE Anatomy
Streamlining effective irrigation
Dr. Allen Ali Nasseh discusses how to
illustrates retreatment
anatomy
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ENDOSPECTIVE Evolution or revolution in endodontic thought
Dr. Mark Anthony Limosani discusses a new endodontic file system 38
Drs. Avi Shemesh, Korektor-Rubinstein,MarinaIddo Levy, Aurel Dadoun, Roman Grushyn, Alin Yaya, Shir Keshales-Shultz, Meital Abadi, and Avi Levin look into how to improve teledentistry outcomes 31
PRACTICE MANAGEMENT The elephant in your life
CONTINUING EDUCATION
..........................................
Dental infections: help avoid resistanceantimicrobial—part1
PRODUCT PROFILE
Building confidence and repeatabilityimprovingin your endodontic practice
CONTINUING EDUCATION
BIO-C® Sealer ION+
TABLE OF CONTENTS
PRODUCT PROFILE Zarc4Endo creates the first multi-alloy file system
Dr. José Aranguren, endodontist, and cofounder of Zarc4Endo –Madrid, Spain, discusses the new revolutionary ZARC BlueShaper® file system 54
Wiyanna K. Bruck, PharmD, and Jessica Price start their discussion on the judicious use of antibiotics in the dental practice..............................................42
........................................
Dr. Eric Herbranson discusses traditional theories and embracing change 50
Dr. Albert (Ace) Goerig offers practice perspectives that you’ll never forget 56
...............................................
Connect. Be Seen. Grow. Succeed. | www.medmarkmedia.com READ the latest industry news and business WATCH DocTalk Dental video interviews with KOLs LEARN through live and archived webinars RECEIVE news and event updates in your inbox by registering for our eNewsletter CONNECT with us on social media www.endopracticeus.com *Paid subscribers can earn 4 continuing education credits per issue by passing the 2 CE article quizzes online at https://endopracticeus.com/category/continuing-education/
4Endodontic Practice US Volume 15 Number 3
BIO-C® Sealer ION+ is a ready-touse bioceramic root canal sealer 48
Endodontic diagnoses and teledentistryspecialistsdentistsperformedplantreatmentformulationsbygeneralandendodonticwiththemethod
RESEARCH
.................................
You Your Patient
At HighFive, we’re experts at taming those time-devouring tasks that come with running a successful Endodontic practice. So if you’re ready to get back to saving smiles and doing what you love, let’s chat. We’ll handle the rest. Don’t let your business consume your practice.
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One of the most interesting parts of being a publisher is that I get to meet people and read articles by people who take calculated risks. In the dental business, that usu ally entails devising new techniques or products. Sometimes it seems that everything that could be invented has already been invented. Who would have thought that implants could have a success rate of up to 98% or that sleep-disordered breathing could be treated at a dental practice? Remember when braces were just metal wires, brackets, and bands? Now we can chose from lingual braces, 3D-printed brackets, clear aligners, and many other ways to create perfect smiles in less time than ever before. Endodontics also has come a long way too — lasers, files of different shapes, sizes, and materials, and cleaning and disinfection instrumentation that leads to less pain and positive outcomes. All thanks to dentists, scientists, and nonclinical people who saw a problem that needed not just a solution, but their solution.
To your best success, Lisa MedMarkFounder/PublisherMolerMedia
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6Endodontic Practice US Volume 15 Number 3 PUBLISHER’S PERSPECTIVE
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In the fall issue, our innovative authors have provided us with interesting and educational content. In our Cover Story, Dr. Allen Ali Nasseh writes about how clinicians can eliminate expensive gadgets and complicated initial and final irriga tion protocols with the Brasseler USA® Triton All-in-One Irrigation Solution. In our CE, Dr. Mark Anthony Limosani explores a new endodontic file system, the ExactTaperH DC™ file. Read his article on how this file provides more conservative shap ing protocols and preserves more tooth structure. Dr. Hugo Sousa Dias manages challenging anatomy with MANI® GPR files for desobturation and the JIZAI rotary endodontic system. Read his case study of treating a patient with files that he reports are more flexible, more resistant to fracture, and effective in the shaping of root canals. In our Special Section, we shine a spotlight on Brasseler USA, GentleWave® by Sonendo®, and US Endo Partners, companies that are focused on improving the way endodontists practice.
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Each of us has our own idea of greatness. While some want to stand in the spotlight, others want to aim the spot light. It’s all a matter of perspective and how you choose to see the light. On the news and social media, we see people who have achieved success. Copycats abound — whether it’s wearing the same styles or seeking the same lifestyle. But what really is success? After so many years in the publish ing business, I have seen many people, both doctors and nonclinical, achieve success. But the ones who achieve greatness have something in common. They don’t do what everyone else is doing. They find their passion, think outside of the box, and take calculated risks to reach their goals.
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not afraid of greatness. Some are born great, some achieve greatness, and others have great ness thrust upon them.” – William Shakespeare
Whatever profession you chose, and whatever path you take, make sure that you follow your passion. Work hard and build a trusted team to help reach your goals. While your dreams are becoming reality, there are sure to be some nightmares, even during the day. But the things you lose sleep over can bring you satisfaction beyond your wildest dreams. We all have greatness in us. We just have to have the courage to discover it and share it.
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To share a bit of endodontic history, it was here in our practice where the very first case of hydraulic condensation using bioc eramic obturation was performed in North America, and where BC Putty (Brasseler USA®), the very first bioceramic putty, was conceived and prototyped to be used with the novel surgical and nonsurgical Lid-Techniques. Today hydraulic cement usage
8Endodontic Practice US Volume 15 Number 3 PRACTICE PROFILE
MicroSurgical Endodontics
Dr. Allen Ali Nasseh contemplates his practice, endodontic education, and innovation
the past 25 years, my endodontic practice, MicroSurgical Endodontics (MSEndo.com), has been a small, boutique dental practice in the heart of Boston’s Copley Square. Over these years, and as we expanded from a solo practice to a multispecialty group practice, our mission of providing quality endodontic care in a warm, caring atmosphere has slowly expanded to providing world-class endodontic education and medical device innovations to our colleagues around the world. This transition took place soon after I began to lead Real World® Endo (realworldendo.com) 10 years ago. At that point my responsibil ities doubled as a leader and manager of an endodontic practice while simultaneously leading and managing the full-time duties of an independent, long-established endodontic education and innovation company, Real World® Endo. From its inception and founding by Drs. Koch and Brave in 1999, Real World Endo’s goal has been to develop techniques and technolo gies while educating our dental colleagues on improving their efficiency of the care they render.
Dr. Allen Ali Nasseh at his practice MicroSurgical Endodontics in Boston
and bioceramic materials usage for various facets of endo — spanning from obturation, repair, and surgery — have revolutionized our field and have changed the way we practice.
EP
For
More recent innovations in the area of irrigation, using all-in-one irri gation solutions, thinner gauge nee dles, activation of these solutions, all-encompassing negative and positive pressure systems, handpieces with exotic built-in motions and apex locations, 3D imaging, digital dentistry, and many other great technological advances are here already. And many more developments in the near future are moving the field forward.
While our clinical practice caters to Boston’s many elite legal and financial firms in the downtown area, we also focus on the providing affordable care to Boston’s student and general population. As the owner of this practice, I’ve now completed over 28,000 root canal proce dures and apicoectomies in my 30-year career; but despite this large number and after so many cases, I still consider myself a student in this field. I learn and grow every day as I practice or even when I assume my Real World Endo duties. I owe this to the people I work with — both on the practice side and the educational side at Real World Endo. My colleagues, coworkers, staff, and large faculty of speakers embody the true spirit of profes sionalism, conscientiousness, care, and empathy. Furthermore, using both my clinical skills with my hands while thinking cre atively to solve clinical challenges for my colleagues through development of novel techniques and technology is satisfying to me. The work is at times time endless and arduous at best. But the rewards of seeing satisfied patients leave the operatory or getting messages of gratitude from colleagues worldwide who are thankful for the products and techniques we’ve developed for them is endlessly fulfilling.
There has never been greater interest in endodontics as a field. The future is indeed bright. But the most important thing we try to abide by in our practice, which happens to be the core mission of Real World Endo — is a relentless dedication to simplicity and efficiency of care. This is why in the words of our cofounder, Dr. Anne Koch, we “don’t worship at the altar of tech nology.” Instead, we try to minimize the tools we need and focus on the important concepts of care in a patient-centered practice model. I’m grateful for being part of this profession and look forward to being an integral part of many upcoming innovations in our field in the years to come.
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The root canal anatomy can be intricate with many curves, fins, and anastomoses. And while the coronal pulp chamber and the coronal root have many dentinal tubules that can act as potential sites of microbial penetration, these spaces constitute
Beyond the volume, the delivery of the solutions into the root canal is also important. Positive pressure irrigation is when the solution is pushed through the syringe with the use of a nee dle deep in the root canal. Needles with different tip designs distribute the irrigants differently. Currently, close-ended, sidevented needles are the safest needles for use as they reduce the risk of irrigation extrusion from inside the canal. However, while these needles have to be taken deep in the canal in order to be effective, it’s important to use the thinnest needle available and to make sure it’s not binding in the canal during irrigation. In order to help reduce the odds of accidental extrusion, negative pressure systems were recently developed where the vacuum force is moved at the apex with the aid of a thin needle/cannula, and the irrigation solution is deposited coronally in the access opening. This method helps reduce the odds of solution extru sion dramatically. The downside of negative pressure, however, is the ergonomics of the system and the chance of the small suc tion needle getting blocked prematurely.
Dr. Allen Ali Nasseh treating a patient
Allen Ali Nasseh, DDS, MMSc, received his dental degree from Northwestern University Dental School in Chicago, Illinois, in 1994 and completed his postdoctoral endodontic training at Harvard School of Dental Medicine in 1997, where he also received a Masters in Medical Sciences (MMSc) degree in the area of bone physiology. He has been a clinical instructor and lecturer in the postdoctoral endodontic program at Harvard School of Dental Medicine since 1994 and the Alumni Editor of Harvard Dental Bulletin. Dr. Nasseh is the endodontic advisor to several educational groups and study clubs and is endodontic editor to several peer-reviewed journals and periodicals. He has published numerous articles and lectures extensively nationally and internationally in surgical and nonsurgical endodontic topics. Dr. Nasseh is in solo private practice (MSEndo.com) in downtown Boston, Massachusetts.
Disclosure: Dr. Nasseh is the President and Chief Executive Officer for the endodontic education company Real World Endo® (RealWorldEndo.com).
xperienced endodontists have asserted that the cleaning component of the endodontic triad of cleaning, shaping, and obturation is the most important determinant of clinical success in root canal therapy. However, we tend to spend more time and effort evaluating the latest instrumentation method or finding ways to enhance the final look of our radiographs by incorporating more radiopaque cements into our clinical arma mentarium instead of focusing on improving our irrigation pro tocol and, by proxy, our outcomes.
Streamlining effective irrigation
Dr. Allen Ali Nasseh discusses how to simplify the irrigation process
10Endodontic Practice US Volume 15 Number 3 COVER STORY
a very small volume. The root canal has a volume of 20-40 ml1 with an average of about 0.025 cc. To give you a sense of scale, this volume is equal to the volume of about half a drop of water. Therefore, each cubic centimeter (cc or ml) of irrigation solu tion will displace 20 to 40 root canal volumes. This is important considering the fact that volume is an important component of effective irrigation. However, we don’t know exactly how much volume replacement is enough for effectively cleaning and whether the chemistry of chemicals used can catalyze this event. We do know that heat increases the kinetic energy of the solution and will therefore catalyze the rate of reaction.2,3
E
To make things worse, when we finally decide to focus on irrigation, we find that we are either facing a complicated irri gation protocol shared by many experts on the field or are told that we need expensive, laser-based or sound-based devices that promise to facilitate the irrigation process only if we would be willing to spend large sums, forcing us to either increase our fees or face a greater overhead. So, how can we simplify our irrigation protocol without expensive gadgets and complicated initial and final irrigation protocols?
Before we do set out to simplify our irrigation protocol, it would be worthwhile to review the important concepts that apply to effective irrigation, what chemicals are commonly used, and the objective for their use. Once we have a better grasp of these concepts, we can decide if a simpler solution that addresses our needs is clinically available without exorbitant costs. I’ll briefly discuss some of the physical and chemical parameters in irriga tion process and irrigation solutions and potential interactions between the reagents commonly used.
Physical parameters and limitations
2. Gently dissolve the inorganic tissues inside the root canal space (spear layer, dentinal chips, and calcifications).
Chemical parameters and limitations
Generally, the sodium hypochlorite solution and EDTA solu tions are used intermittently throughout the chem-mechanical process by using them back and forth with additional protocols of EDTA at the end to remove the smear layer. This separation has been due to an additional chemical limitation when using NaOCI in teeth. We know that sodium hypochlorite is not only buffered by EDTA, but also buffered and neutralized very quickly upon contact with dentin and dentinal chips. Therefore, the use of EDTA interchangeably throughout the process has been theorized to help dissolve the dentinal chips and therefore help reduce the rate of NaOCI deactivation. But since they cannot be mixed together, they are used in different syringes inter changeably. Lubricants enter the scene as well as per operator’s discretion.
Figure 1: Positive pressure using thick needles does not allow the needle to go deep in the canal. Furthermore, it can lock the needle in the thinner portions of the canal, causing a hypochlorite extrusion
3. Disinfect surfaces left behind by destroying all forms of established biofilms inside the root canal.
One challenge, however, is the fact that NaOCI and EDTA cannot be mixed together as they neutralize and hydrolyze each other within a few minutes after mixing.4 This is why operators have to use two separate syringes for each solution, and if chlorhexi dine (CHX) is used in addition, then an additional water rinse is required in between NaOCI and CHX to avoid a toxic precipitate.
COVER STORY
Figure 2: This is why the thinnest available needles (Size 31 gauge) should be used to allow deeper insertion without needle binding, allowing the solution to flow back up coronally instead of apically Figure 3: Brasseler Triton All-in-One irrigation Solution
To date, this has been achieved with the help of a concen tration of sodium hypochlorite solution that ranges from 1% to 6% NaOCI (lower concentrations for disinfection only and higher concentrations for additional tissue dissolution). In addition, we’ve used a 17% EDTA solution (17%) to remove the loose inorganic components inside the root canal. Additional lubri cants like RC-Prep® (Premier®, Plymouth Meeting, Massachusetts) and also surfactants to reduce surface tension and aid in solution penetration inside dentinal tubules have also been used by some for additional benefits but have not been considered essential to the irrigation process.
11endopracticeus.com
As you can see, these chemical interactions and buffering limitations have created a long and labor-intensive process of using multiple syringes with multiple needles throughout the process with complicated order of operations at the end of the procedure with the main goal of dissolving the dentinal chips with EDTA followed by dissolution of the organic tissue and
1. Dissolve the organic tissue from inside the root canal (pulp, organic portion of dentinal chips, collagen, smear layer, etc.).
To simplify the process of root canal irrigation to its bare essentials, most irrigation solutions are solutions based on either acids, bases, disinfectants, and/or lubricants. The main goal of irrigation is the removal of the macro debris generated during instrumentation and use the aforementioned chemicals in order to achieve the three main objectives of irrigation:
While the use of these three basic solutions in alternate syringes has become second nature to most of us, over the past decade chemists from a couple of companies have been working to develop a series of chelating chemicals that can withstand the harsh and corrosive reaction between NaOCI with EDTA by focusing on replacing the EDTA component of irrigation with a series of substitute chelating agents that are less neutralizing to NaOCI. It’s important to note that this scientific effort was made to replace EDTA rather than NaOCI in this process, since NaOCI is considered the gold standard irrigant in the endodon tic therapy, primarily due to its simultaneous action on organic tissue dissolution while being an effective disinfectant. As a result, instead of reinventing the wheel by developing a new dis infectant and a new organic solvent, which would have required prospective long-term studies to validate their efficacy, NaOCI was used as the base for a new solution that contains a mix of 11 different gentle chelators, which exhibit resistance to NaOCI and do not buffer NaOCI as quickly as EDTA.
disinfection by NaOCI. So, are we forced to work through this multiple syringe system and accept this complexity?
The operator can make a decision about how much solution is needed for each case and proceed to draw for use. Each bottle yields a total of 480 ml of solution, which at 6 ml/cc per case (average use by any given clinician), would allow for about 80
2. Basrani B, Haapasalo M. Update on endodontic irrigating solutions. Endod Topics. 2012;27:74-102.
3. Haapasalo M, Shen Y, Wang, Z, Gao Y. Irrigation in endodontics. Br Dent J. 2014;16(6): 299-303.
Average Tip+Syringe Cost per Procedure $3.84 $2.97 $3.84 $1.26
Solutions Used 3 2 2 1
Furthermore, by maintaining 4% sodium hypochlorite as the main active ingredient in Triton, we can apply through precedent the existing body of literature and long-term clinical experience about the efficacy of this solution for disinfection. All the addi tional benefits and its potential synergy will be a bonus to the 1.REFERENCESclinician.Cardoso
A better solution?
FGDR, Martinho FC, Ferreira NS, et al. Correlation Between Volume of Root Canal, Cultivable Bacteria, Bacterial Complexes and Endotoxins in Primary Infection. Braz Dent J. 2019;30(2):117-122.
Syringes Used 3 2 3 1
cases. The unmixed solution in the bottle has a shelf life of 1 year on the bench top and 2 years in the refrigerator. In my practice, I have found that Triton is actually more cost-effective versus my old protocol using multiple solutions, syringes, and needles. Aside from the material costs, Triton has simplified my procedural setup and increased my clinical efficiency saving me valuable chair time.
12Endodontic Practice US Volume 15 Number 3 COVER STORY
EP
While the future of this product is bright, and it may be shown to improve the irrigation/disinfection process, one thing is certain — that the move from multiple syringes and complicated irrigation protocol to a much simpler irrigation protocol, where a single syringe is used from the beginning to the end of the pro cedure without any sequencing needs, can allow a much more efficient irrigation protocol for most clinicians.
Tips Used 3 2 3 1
Water Rinse Required Yes Recommended Yes No
A number of independent scientific studies have been per formed by various universities around the world, and the studies are on the publication path at the time of writing this article. The results of these studies show excellent disinfection qualities as expected from a NaOCI based solutions. Further synergistic effect is possible as simultaneous application of chelation during disinfection can potentially have a catalytic effect on both pro cesses. This and other results have to be seen. Being a hypochlorite solution, Triton should be kept inside the tooth, and the same care with NaOCI irrigation should be applied here.
4. Zehnder M. Root canal irrigants. J Endod. 2016;32(5):389-398.
Irrigation Solution Cost per Procedure $1.10 $0.85 $2.38 $1.87
Furthermore, a number of saponification agents and lubri cants were also added to the mix so that the final cocktail of solutions can address all three requirements of irrigation and potentially more all in one solution. The resulting irrigation solu tion is Triton™ (Brasseler USA, Savannah, Georgia). The delivery of the irrigants in a Triton bottle is possible through a unique bottle with a dual barrel delivery system, where 8% NaOCI is mixed 1:1 with a solution of chelating agents, lubricants, surfac tants, and detergents. As a result, the final solution drawn into the syringe is a 4% solution of NaOCI with all the additional ingredients in it. Triton solution is stable for 3 to 5 hours after mixing/drawing from the bottle beyond which the NaOCI con centration is considered too low for its intended use. Therefore, Triton is drawn/mixed to use per patient and is stable for 3 to 5 hours after being drawn from the bottle.
Table 1: Procedural Step and Irrigation Cost Comparison*NaOCI+EDTA+CHXNaOCI+EDTA
Total Irrigation Cost per Procedure $5.03 $3.82 $6.22 $3.15
2:1 Solutions Triton
‡
✓ More effective at smear layer removal vs. NaOCl with EDTA
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BY YOUR SIDE
After retiring from the preeminent end odontic group practice in Nashville with three locations and eight doctors, Dr. Terryl Propper cofounded the specialty partner ship organization, EPP.
We seek those practices that want to be best in class, pro gressive, and realize the strength that comes from being part of a larger group. Many practices don’t have the time, bandwidth, or resources to support their vision. EPP provides technology, financial guidance, operational expertise, marketing, recruiting associates and staff, HR, and business support to position our equity partners to move from success to exponential success.
How does EPP stand out in the market? We provide value to our affiliates by personalizing a strategic growth plan, by fully integrating all our affiliates, and by deliver ing on what we promise. EPP is not in competition to be the largest or fastest growing. Success speaks for itself. Fuel your success by partnering with Endo Practice Partners. When you’re ready, we’d love to talk to you. Email us at terryl.propper@EPPendo.com. This information was provided by Endo Practice Partners (EPP).
The sole specialty partnership organization (SPO) in the industry
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EPP cheesin’ for a quick photo at this year’s Southern Endo Study Group Meeting! (left to right) Alex Nolte, Jake Williams, Maddie Vandiver, Tucker Moore, and Sam Hutcheson
Cofounded
Endo Practice Partners (EPP)
EPP was founded on sound business principles: to operate with purpose, maintain ethical practices, operate with integrity and compassion, and maintain our affiliates’ autonomy and brand. As a nationwide partnership of endodontic practices focused on patient care, clinical quality, and growth, EPP sup ports what matters most for patient care and quality of care.
Big smiles from EPP during the welcome reception at the inaugural Canals on Canal Conference in New Orleans, which Endodontic Practice Partners was proud to help kick-off
and led by a female endodontist, EPP understands the changing market and the advan tage an affiliation brings to a traditional practice. The market is in a state of flux, constantly changing and evolving. Call it what you might –– SPO, ESO, DSO, SSO –– all the endodontic-focused companies in this competitive market provide similar services but with different strategies, cul tures, approaches, goals, and management teams. Founded in 2019 and funded in the summer of 2020, Endodontic Practice Partners (EPP) has experienced exponential growth and creates a value proposition for affiliated practices. EPP is rich in expertise and the management team replete in their respective fields: clinical, operations, M&A, marketing, and finance.
14Endodontic Practice US Volume 15 Number 3 CORPORATE PROFILE
“As a past president of the AAE, many of my colleagues have asked me how I cofounded a company that consolidates practices and moves away from the traditional private practice model. I can answer that in one sentence — because I under stand the changing market and the advantages the paradigm shift brings to a traditional practice, being part of a larger entity provides leverage, resources, best practices, and opportunities otherwise not attainable.”
simple. Accepting CareCredit to help more patients get care is easier than ever because there are so many ways to learn about and apply for the CareCredit credit card. If your practice management software has CareCredit integrated, you can access the payment calculator, help patients see if they prequalify, and apply within the software (at their request),* saving your team time and helping improve efficiency. Or you can use your cus tom link to have patients learn about CareCredit and apply pri vately from their home computer or on their smart device while in the practice. It’s financing simplified, and here’s how it works:
It’s
2. Have patients scan your custom link QR code with their smart device to learn about CareCredit, see if they pre qualify (without impacting their credit bureau score), and apply for the CareCredit credit card privately. You can also use provided custom link digital assets to enable patients to see if they prequalify and apply before their
*Exceptmycustomlink.forproviders
September
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is Office Manager Appreciation Month.
16Endodontic Practice US Volume 15 Number 3 COMPANY SPOTLIGHT
If you have yet to accept the CareCredit credit card, join a network of more than 260,000 provider and health-focused retail locations by calling 800-300-3046 Option 5.
Youappointment.nolongerneed to share the details about CareCredit, assist with the application, or communicate credit decisions — which may save your team some valuable time. And your patients no longer need to share sensitive information for the application. It’s that easy and convenient — for patients and for your team.
If you accept CareCredit and would like to get your custom link and more valuable resources that make financial conversa tions easier, call 800-859-9975, or visit www.carecredit.com/
1. Place a CareCredit practice display that features your custom link QR code in your reception area and through out your practice to let all patients know you accept CareCredit. This can be especially helpful for the 12.7plus million current CareCredit cardholders who may already have a way to pay for care.
CareCredit — Financing Simplified
in California who are prohibited under state law from submitting applications on behalf of patients for certain healthcare loans or lines of credit, including the CareCredit credit card.
We recently got our CareCredit custom link and QR code, and it has made sharing financing as a way to get treatment so much easier for the team and patients. We let patients know we accept the CareCredit credit card. Many already have CareCredit, but for those who don’t, all they do is scan our custom link QR code to see their esti mated monthly payment with financing, see if they prequalify for the CareCredit credit card, and apply — all on their smartphone.”
— Dr. Emmanuel Ngoh, Augusta Endodontic Center
Visit https://omam.carecreditvirtual.com
for ideas on how to celebrate your #AwesomeOM. And all #AwesomeOMs are invited to the same site for a special experience just for them!
You proactively recommend the CareCredit credit card to patients. Have patients scan your custom link QR code where they can privately see if they prequalify, apply and pay with CareCredit.
#1: #2: It’s financing simplified.
learn
To more scan this QR code. yet to add the CareCredit credit card as a financing solution call 800-300-3046 (option 5).
If you’ve
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It takes two steps to help patients get care
The ideal root canal preparation is one where the original canal morphology is maintained during the biomechanical prepara tion along with the development of flaring from coronal to the apical portion and preserving the apical foramen.5 However, the ideal root canal preparation may not be always possible due to the complexity of the root canal anatomy.6
18Endodontic Practice US Volume 15 Number 3 CASE REPORT
Dr. Dias is also the Director of the Endodontic Master Program at Foramen Dental Education – Porto, Portugal, since 2015. In 2019, he started a new teaching project, Side By Side Custom Endodontic Made Programs for individualized training in endodontics. He is a founder and active member of the Portuguese Group For Endodontic Study, organizing study club sessions in different parts of Portugal. Dr. Dias is a board member of the Portuguese Endodontic Society and a member of European Society Endodontology. He is an invited professor of Endodontic Post-Graduation Programs at University of Lisbon – School of Dentistry, CESPU University, and University of Porto – School of Dentistry. He is a member of the Clinical Masters Network and has published clinical reports in Roots Magazine, Clinical Masters Magazine and Saude Oral Magazine.
JIZAI (MANI, Tochigi, Japan) is a NiTi rotary file system made of a proprietary heat-treated NiTi alloy with shape memory characteristics. JIZAI has an off-center quasi-rectangular cross section with a radial land on one of the short sides. The manufac turer claims that the radial land reduces screw-in forces, and that the off-centered design provides wide spaces for debris removal.
Disclosure: Dr. Dias is a key opinion leader for KaVo Kerr (2013-2017); MANI, Inc. (since 2017); Septodont (since 2018); and Karl Kaps GMBH & Co. KG (since 2021).
Dr. Hugo Sousa Dias illustrates retreatment of a case with complex root canal anatomy
It is well established that the success and predictability of root canal treatment to prevent or cure apical periodontitis is dependent upon accurate diagnosis and performing each stage of treatment to a high standard.1 The endodontic treatment fail ure is usually associated with insufficient disinfection of the root canal system (RCS), unfilled or inadequate root canal obturation, and defective coronal restoration.2 Endodontic retreatment is the primary therapeutic option in these cases and initially involves removal of the obturation material to allow thorough cleaning, disinfection, and Instrumentationshaping.3during retreatment procedures can lead to changes in dentin volume and transportation of root canals. Transportation can result in ledging, zipping, and perforation, particularly in the apical third, and weakens the tooth structure.4
Endodontic management of challenging anatomy with a new file system — about a retreatment in upper first premolar type VI Vertucci
One of the main factors related to these failures is that the lack of thorough knowledge of the morphological and anatom ical variations of RCS can result in failure to identify all root canals or can result in the use of inadequate instrumentation, leading to endodontic treatment failure.9 Therefore, the first step in achieving a successful endodontic outcome is an exact evalu ation of the RCS and its anatomical variations.10
Introduction
This case report discusses the endodontic retreatment of a first upper premolar type VI Vertucci with MANI® GPR files for desobturation and JIZAI rotary endodontic system (MANI, Tochigi, Japan) for the shaping protocol.
Different root and root canal configuration types can be found in any group of teeth. Therefore, a thorough knowledge of their most common anatomic morphologies and variations may help clinicians detect those deviations during root canal therapy, enhancing the chance for successful treatment.7 Several studies have reported that maxillary premolars have a highly variable internal canal configuration. According to Martins, et al.,8 the prevalence of upper first premolars with one root is between 36.4%-83.2%, and the prevalence of type VI Vertucci (two sep arate canals leave the pulp chamber, merge in the body of the root, and redivide prior to the apex to exit as two distinct canals) is between 0.2%-12.3%.
Hugo Sousa Dias, DDS, received his Doctor of Dentistry in 2008 from the Universidade Fernando Pessoa – Porto, Portugal. In 2015, he completed his postgraduate program in endodontics at University of Lisbon – School of Dentistry, Portugal. He lectures and leads hands-on courses worldwide. He is the founder of Hugo Sousa Dias & Friends webinar sessions. His areas of special interest follow: pulp canal obliterations, guided endodontics, separated instruments retrieval, instrumentation and obturation, retreatments, MTA and other bioceramics, apical microsurgery, and regenerative endodontics. Dr. Dias is in private practice limited to endodontics in Porto, Portugal.
MANI GPR (MANI, Inc. Utsunomiya, Japan) is a fourinstrument system consisting of two stainless steel instruments to work in the straight segment of the canal (1S [70/0.04)] and 2S [50/0.04]), and two nickel-titanium instruments for the curved canal segment (3N [40/0.04] and 4N [30/0.04]).
Figures 1 and 2A: 1. A final diagnosis of previously treated tooth with symptomatic apical periodontitis was confirmed. 2A. After administrating local anesthesia, access cavity preparation was performed with BR-154 round bur
radiolucency in an endodontically treated tooth (No. 14). A final diagnosis of previously treated tooth with symptomatic apical periodontitis was confirmed, and the root canal retreatment was advised (Figure 1).
Case report
A 42-year-old female patient was referred to the clinic with severe pain in the upper right first premolar teeth from a local dentist. The patient gave a history of pain for 3 months that aggravates when chewing and while sleeping and relieves after taking the medications. No significant medical history was observed.
The intraoral examination revealed a provisional restoration in tooth No 14. Pain on percussion was observed for tooth No.14. A intraoral periapi cal radiograph (IOPA) was advised to draw the final diagnosis and treatment plan. The IOPA revealed a periapical
Figure 4: For coronal flaring JIZAI was used
Figures 2B: After administrating local anesthesia, access cavity preparation was performed with BR-154 round bur
Figure 5: After copious irrigation with 5.25% of NaOCl, JIZAI was used with the 25.04 up to the WL in both root canals
CASE REPORT
Figure 3: 3N (40/0.04) instrument was used up to 2 mm short of the obtura tion material
19endopracticeus.com Volume 15 Number 3
After administrating local anesthesia (2% lignocaine 1:200000 epinephrine), access cavity preparation was per formed with BR-154 round bur (MANI, Tochigi, Japan) (Figures 2A and 2B). The pulp chamber was irrigated by following the standardized irrigation regimen of 5.25% of NaOCl. The desob
For curved canals, a size 25 .04 taper instrument followed by a size 25 .06 taper instrument is used sequentially in a single length technique to the full working length. One study has reported that JIZAI exhibits flexibility and cyclic fatigue resistance comparable to HyFlex EDM® (Coltene-Whaledent, Allstätten, Switzerland), another contemporary single-length NiTi rotary system manu factured using electro-discharge machining followed by thermal treatment. The manufacturer recommends that JIZAI instruments can be operated at a maximum rotational speed of 500 rpm.11
The final irrigation protocol was done with 5.25% of sodium hypochlorite, 17% ethylenediaminetetraacetic acid and physio logical saline with Endo1 (passive ultrasonic irrigation) (Wood pecker) (Figure 7).
Due to the complexity of internal root canal anatomy, the development of new instruments, which are more flexible, more
Figures 8 to 10: Hydraulic condensation technique performed using CeraSeal (bioceramic sealer)
Figures 6 and 7: 6. Shaping protocol was finished with 25.06. 7. Final irrigation protocol was done with 5.25% of NaOCl, 17% EDTA, and physiological saline with Endo 1
20Endodontic Practice US Volume 15 Number 3 CASE REPORT
Figure 10
For coronal flaring JIZAI (MANI, Tochigi, Japan) 25.06 was used (Figure 4). After copious irrigation with 5.25% of sodium hypochlorite, it was used with the 25.04 up to the WL in both root canals (Figure 5), and the shaping protocol was finished with 25.06 (Figure 6).
glidepath was done with JIZAI GLIDER (13.04) (MANI, Tochigi, Japan), according to company parameters (300 rpm, 1 Ncms). The shaping protocol was done with JIZAI (MANI, Tochigi, Japan) rotary files with a modification in the suggested protocol.
turation was done with MANI GPR (MANI, Tochigi, Japan); gutta percha was removed using the 2S (50/0.04) instrument in con tinuous rotation at 1000 rpm and 2 Ncm in the coronal part. Then the 3N (40/0.04) instrument was used up to 2 mm short of the obturation material (Figure 3). Next, the patency of the root canals was determined using No. 8, No. 10, and No. 12 D-Finder files (MANI, Tochigi, Japan), and the work ing length (WL) was confirmed using a Elec tronic Apex Locator (Morita TriAuto ZX2, J. Morita,MechanicalJapan).
Figure 11: Pulp chamber was sealed with Ionoseal®
The hydraulic condensation technique was performed using bioceramic sealer (CeraSeal, MetaBiomed) with 25.04 master cones (Figures 8 to 10). The pulp chamber was sealed with Ionoseal® (VOCO, Germany) (Figure 11), and a temporary resto ration was made. The patient was referred to her dentist for the permanent coronal restoration.
Discussion
The postoperative instructions were given to the patient and recalled after 3 months for evaluation.
Ongoing development in instrumentation techniques is making endodontics easier, and operators can now achieve the desired canal shape more quickly. Furthermore, with various root
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Several novel thermomechanical process ing and manufacturing technologies have been developed to optimize the microstructure of NiTi alloys to improve flexibility and fatigue resistance of endodontic instruments.13 Other recent devel opments in file design include an off-centered cross section. The principle of this design is to minimize the engagement between the file and the dentin of the canal wall, therefore decreasing the load on the file. Such a cross section also allows space for debris to accumulate between the flutes of the file, and it is driven in a coronal direction. It is anticipated that such a design will enhance cleaning of the root canal system due to efficient debris removal. The off-centered cross-sectional design also allows greater flexibility in the file. This is achieved as this file design creates a larger envelope of motion and will cut a larger preparation compared to a file with a conventional cross-sectional design. Therefore, a greater tapered preparation can be created with a file that has a smaller centered mass, which will mean the file is more flexible.1
According to Nakatsukasa, et al.,11 JIZAI (MANI, Tochigi, Japan) showed better centering ability. It also exhibited flexibility and cyclic fatigue resistance similar to EDM, maintaining a canal curvature, and generated smaller torque and screw-in force than other files. Accurate knowledge of root canal morphology and its anatomical variations are essential for successful root canal treatment.6 Teeth with straight root canals are very rare to observe in endodontics as most of the teeth tend to exhibit some sort of curvature and multiple planes of deviations along the course of the root canal length.15 The endodontic complications — e.g., the ledge formations, canal blockages, root canals perforations, and apical transportations — are usually observed with the improper handling of the instruments or improper techniques of instrumentations in these clinical cases.16
13. Azim AA, Griggs JA, Huang GT. The Tennessee study: factors affecting treatment outcome and healing time following nonsurgical root canal treatment. Int Endod J. 49(1)6-16.
8. Martins JNR, Marques D, Silva EJNL, Caramês J, Versiani MA. Prevalence Studies on Root Canal Anatomy Using Cone-beam Computed Tomographic Imaging: A System atic Review. J Endod. 2019;45(4):1-15.
12. Gutmann JL, Gao Y. Alteration in the inherent metallic and surface properties of nick el-titanium root canal instruments to enhance performance, durability and safety: a focused review. Int Endod J. 45(2):113-128
CASE REPORT
18. Kimura S, Ebihara A, Maki K, et al. Effect of optimum torque reverse motion on torque and force generation during root canal instrumentation with crown-down and sin gle-length techniques. J Endod. 2020;46(2):232-237.
20. Zupanc J, Vahdat-Pajouh N, Schäfer E. New thermomechanically treated NiTi alloys — a review. Int Endod J. 2018;51(10):1088-1103.
resistant to fracture, and effective in the shaping of root canals, is extremely important. It has been reported that the maintenance of the original canal shape and lack of canal aberrations are associated with the preservation of tooth structure and higher clinical success rates.12
Figure 12: Scan this code with your mobile phone to view a clinical video
4. Ganesh A, Venkateshbabu N, John A, Deenadhayalan G, Kandaswamy D. A compara tive assessment of fracture resistance of endodontically treated and re-treated teeth: an in vitro study. J Conserv Dent. 2014;17(1):61-64.
canal preparation systems now available, canals that may once have been deemed too difficult to negotiate and prepare are now more manageable. The appropriate root canal instrumentation tech niques need to be selected based on the root canal anatomy, calcifications, and economic factors.
5. Peters OA. Current challenges and concepts in the preparation of root canal systems: A review. J Endod. 2004;30(8):559-567.
6. Estrela C, Bueno MR, Sousa-Neto MD, Pécora JD. Method for determination of root curvature radius using cone-beam computed tomography images. Braz Dent J. 2008;19(2):114-118.
17. Kyaw Moe MM, Jo HJ, Ha JH, Kim SK. Root canal shaping effect of instruments with offset mass of rotation in the mandibular first molar: a micro-computed tomographic study, J Endod. 2018;44(5):822-827.
14. Estrela C, Bueno MR, Couto GS, et al. Study of root canal anatomy in human perma nent teeth in a subpopulation of Brazil’s center region using cone-beam computed tomography - Part 1. Braz Dent J. 2015;26(5):530-536
19. Shen Y, Zhou HM, Zheng YF, Peng B, Haapasalo M. Current challenges and con cepts of the thermomechanical treatment of nickel-titanium instruments. J Endod. 2013;39(2):163-172.
9. Vertucci FJ. Root canal anatomy of the human permanent teeth. Oral Surg Oral Med Oral Pathol. 1984;58(5):589-599.
Conclusion
1.REFERENCESTomson PL, Simon SR. Contemporary cleaning and shaping of the root canal system. Prim Dent J. 2016;5(2):46-53.
2. Rödig T, Reicherts P, Konietschke F, et al. Efficacy of reciprocating and rotary NiTi instruments for retreatment of curved root canals assessed by micro-CT. Int Endod J. 2014;47(10):942-948.
11. Nakatsukasa T, Ebihara A, Kimura S, et al. Comparative evaluation of mechanical prop erties and shaping performance of heat-treated nickel titanium rotary instruments used in the single-length technique. Dent Mater J. 2021;40(3):743-749
This clinical case is well managed; and with the use of ade quate instruments, the root canal anatomy can be respected, and all mechanical and biological goals can be accomplished.
15. Ruddle C. Cleaning and shaping the root canal system. In: Cohen S, Burns RC, (eds.) Pathways of the Pulp. 8th ed. Mosby; 2002.
10. de Pablo OV, Estevez R, Péix Sánchez M, Heilborn C, Cohenca N. Root anatomy and canal configuration of the permanent mandibular first molar: a systematic review. J Endod. 2010;36(12):1919-1931.
The JIZAI rotary instrumentation has shown an efficient and time-saving biomechanical prepara tion in this clinical case and thus is indicated for safe and efficient biomechanical preparations in curved and constricted root canal systems.
16. Patnana AK, Kanchan T. Endodontic management of curved canals with ProTaper Next: A case series. Contemp Clin Dent. 2018;9(suppl 1):S168-S172.
Many technological advancements have been made to pre serve the original canal curvature and to prevent inadvertent instrument fracture, including changes to the cross-sectional design,17 motion,18 and metallic property.19 In particular, heat treatment changes the phase transformation temperature of the NiTi alloy, which results in the growth of soft and ductile phases — i.e., the martensite phase and R-phase, thereby enhancing the fracture resistance and flexibility.20
3. Stabholz A, Friedman S. Endodontic retreatment: case selection and technique — part 2: treatment planning for retreatment. J Endod. 1988;14(12):607-614.
7. Karabucak B, Bunes A, Chehoud C, Kohli MR, Setzer F. Prevalence of apical periodon titis in endodontically treated premolars and molars with untreated canal: a conebeam computed tomography study. J Endod. 2016;42(4):538-541.
22Endodontic Practice US Volume 15 Number 3
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Mentioning
Figures 1A-1C: 1A. Preoperative radiograph of a 1996 mandibular molar case with its mesial root deeply fluted on its furcal side. 1B. Immediate postoperative radio graph showing 20-.06 canal shapes cut with a single GT Rotary File (Dentsply/ Tulsa Dental) having a maximum flute diameter limitation of 1.0 mm. Anti-curvature (“brushing motion”) shaping is not necessary or helpful when files with conserva tive MFD limitations are used. 1C. Distally angled postoperative radiograph reveals remarkable three-dimensional obturation results despite conservative canal shapes. The uninstrumented but obturated lateral canal forms — the mid-mesial isthmus with branching lateral canal and the retrofilled DL canal — are proxies for irrigation efficacy, ergo the “Thrill of the Fill”
A. B. C. A. B. C.
What does MIE even mean? Regarding any specific RCT case — in my opinion — MIE means whatever the treating DDS says it is! If you weren’t holding the file, you aren’t the MIE shot caller. This is the number one thing to keep in mind when getting small — if the case fails because the convenience form of a Ninja access prep was inadequate, did we really preserve tooth structure? Also, within the skill level of a given DDS doing RCT, MIE will mean different things in different cases. When calcified canals elude us, when interocclusal distances are small, and even when patients are being jerks, if it’s necessary to cut a bit bigger access cavity to get the case done successfully, that is yours to decide and work through.
24Endodontic Practice US Volume 15 Number 3 TECHNIQUE
Figures 2A-2C: 2A. Preoperative 2D and 3D radiography of this upper second molar revealed carious penetration into its calcified pulp chamber, tortuous radicular anatomy, but only three canals. The MB root and its canal had an abrupt and severe distopalatal bend in its cervical third, with its apical half severely bent in the opposite direction. The DB canal had a 450 bend 3 mm above its orifice but little curvature in its apical half. The palatal root was relatively straight. 2B. The immediate postoperative radiography shows the 900 cervical kink in the MB canal lessened to 450 after cutting a 15-.05 miniKUT EZP Rotary Negotiating File (PlanB Dental) to length. Because this canal gauged (binds at length) with a No. 15 K-File, complete instrumentation of this dilacerated MB canal was accomplished with just the single miniKUT File. 2C. Mesial X-ray view showing lateral canals filled in the apical thirds of the MB and palatal canals — evidence of PulpSucker (PlanB Dental) irrigating efficacy in spite of the minimal canal enlargement
Disclosure: Dr. Buchanan is a stockholder of Sonendo®; he is the inventor and owner of the IP associated with the closed-system, negative pressure, positive outflow irrigation (PulpSucker) device described in this article, and he is PlanB Dental’s Clinical Director.
Anatomy of a minimally invasive endodontic case
the term “minimally invasive endodon tics” (MIE) invites a wide a range of emotional responses and definitions from endodontic specialists worldwide. “Ninja” access cavity preparations have bedeviled us as we’ve struggled to work through their compromised convenience form. We’ve lost heart muscle in frustration with the challenges of irrigating and cone fitting 15-.03 root canal shapes. Yet MIE is here to stay. Why? Because preserving our patient’s tooth structure during RCT is a virtuous objective as well as being the best argument against replacement of teeth with implants rather than saving them with RCT.
L. Stephen Buchanan, DDS, FICD, FACD, Dipl. ABE, has been lecturing and teaching hands-on endodontic continuing education courses for over 30 years, both in his state-of-the-art training facility in Santa Barbara, California, as well as in dental schools and at meetings around the world. He currently serves as a part-time faculty member in the endodontic departments at the University of the Pacific’s Arthur Dugoni School of Dentistry and the University of California at Los Angeles as well as being the Endodontic Advisory Board Member to the Academy of General Dentistry. Dr. Buchanan is nationally and internationally known for his 50-plus endodontic procedural articles as well as his expertise in the research and development of new endodontic technology, instruments, and techniques. He is a Diplomate of the American Board of Endodontists, a Fellow of the International and American College of Dentists. Dr. Buchanan also maintains a private practice limited to Endodontics in Santa Barbara, California.
Don’t forget that at any time during the procedure, if it’s not working, stop, refine the entry path of the access line angle,
Dr. L. Stephen Buchanan discusses approaching zero loss of structural integrity during RCT
While MIE may be a relatively new trend to many endodon tists, it isn’t new to endodontics. The case shown in Figure 1 was treated shortly after the advent of rotary shaping files, demon strating the shape of things to come in both conceptual and procedural terms. An interesting sidenote is that all three of the canals in Figure 1 were single-file shapes, cut with rotary rather than reciprocating motion. The case in Figure 2 shows the results of the following 20-plus years of MIE development— a case with dilacerated canal curvatures completely negotiated and shaped with a single rotary file in each canal.
How do we irrigate MIE canal preparations? There are sev eral high-tech irrigation methods that can do the job, including multisonic irrigation (GentleWave® by Sonendo®, Laguna Hills,
Figure 5: Early PulpSucker staging gear applied through 1 mm individual MIE access openings. Because PulpSucker irrigation vacuum draws solutions out the ends of the irrigating cannulas, there is a “Forward Effect” 5 mm ahead of the cannula ends, minimizing the need for apical canal enlargement
26Endodontic Practice US Volume 15 Number 3
Figure 4: Cordless endodontic handpiece with the smallest head size in endo and an integrated apex locator (PlanB Dental). When used for rotary nego tiation, apical progress is completely controlled by the apex locator so that within a microsecond of reaching the apical terminus, the file stops, slightly bound in the canal, simplifying the accurate adjustment of file stops to ref erence points. At this point during treatment, most or all pulp tissue in the primary canal has been extirpated, length has been determined, and because coronal enlargement has also been completed, canal lengths remain consis tent. In canals with small terminal openings, it is literally time to fit a GP cone and start irrigating as soon as the first EXP File cuts to length
and continue on. This is experienced most often during cone fitting because it requires a larger access opening to cement GP cones in all the canals at once than it does to instrument and irrigate them.
When powered by a cordless endodontic handpiece contain ing an integrated apex locator (Figure 4), rotary negotiation with miniKUT EZP files can easily save 10-30 minutes of treatment time in a difficult molar.
One of the coolest aspects of minimally invasive endodontic concepts is that as soon as clinicians accept the reality that tiny canal shapes can be adequately cleaned with irrigants, the num ber of instruments needed to complete instrumentation drops to one or two files per canal — including negotiation — without the need for overpriced rotary or reciprocation NiTi files.
TECHNIQUE
The case in Figure 2 was completely negotiated with mini KUT EZP 15-.05 rotary negotiating files (PlanB Dental, Goletta, California) despite the dramatic canal curvatures encountered. This was a beautiful demonstration of the efficacy of rotary negotiation because after I determined that I was unable to reach the DB terminus using No. 06, No. 08, and No. 10 SS K-Files by hand, the miniKUT 15-.05 EZP rotary file cut to length in two passes! That is so counterintuitive considering our common belief that hand files are more facile than rotary files when mak ing our way to length the first time. The fact of the matter is that with the right file tip geometry (Figure 3), rotary files are able to bump and bounce past canal impediments that stainless steel hand files will engage in every time.
Figure 3: The 15-.05 miniKUT EZP (Easy Pass) Rotary File by PlanB Dental. The cupped square cross-sectional geometry provides the strength to resist breakage during rotary negotiation procedures, while the perfectly radiused file tip and soft transitional angles prevent ledging. Negotiation with rotary files, because of their helical flute paths, pull cut debris coronally, completely obviating the need for patency file use to clear the apical thirds of root canals. Conversely, reciprocating files cut dentin and push the debris apically, creat ing more opportunities for apical blockage
TECHNIQUE
4. Enlarging the coronal halves of canals beyond 0.8 mm to 1.0 mm does not improve irrigation efficacy at all.
3. The ideal MIE access path is often through pre-existing decay and restorations where little or no further tooth structure needs to be cut to accomplish the RCT. While I prefer to treat molars through a mesially tipped access cavity preparation, I will do the more conservative but difficult thing by operating through the distal of a tooth when it has been destroyed by caries.
EP
Keep in in mind the following thoughts:
Connect. Be Seen. Grow. Succeed. | www.medmarkmedia.com 3 REASONS TO SUBSCRIBE • 16 CE credits available per year • 1 subscription, 2 formats – print and digital • 4 high-quality, clinically focused issues per year 3 SIMPLE WAYS TO SUBSCRIBE • Visit www.endopracticeus.com • Email subscriptions@medmarkmedia.com • Call 1-866-579-9496 Endodontic Practice US 1 year $149 / 1 year digital only $79 Summer2022 Vol15 No2 endopracticeus.comImplants n CBCT4CECreditsAvailableinThisIssue—recognizingBlueprintforthefuture NorthernColoradoEndodontics PROMOTING EXCELLENCE IN ENDODONTICS Buildingconfidenceandimprovingrepeatabilityinyourendodonticpractice Dr.MarkAnthonyLimosani Corporateprofile EndoPracticePartners Practiceprofile MicroSurgicalEndodontics Companyspotlight CareCredit—FinancingSimplified Fall2022 Vol15 No3 endopracticeus.comFAQSpecialSection n 4CECreditsAvailableinThisIssue effectiveStreamliningirrigation Dr.AllenAliNasseh
2. Access openings as small as 1 mm in diameter are large enough to provide adequate convenience form as long as they are angled such that files do not bend to enter canal orifices. When operating at this level, it is very helpful
27endopracticeus.com Volume 15 Number 3
With that said, how do we approach zero loss of structural integrity during RCT?
1. We do not clean canals with files; we use files to cut the shape in root canals needed to adequately clean and fill them in three dimensions. That’s it. Corollary to No. 1: When canals present with adequate shape, don’t cut any dentin. Just irrigate the snot out of the RCS, and stuff it. These opportunities are most commonly seen in young patients with pulpitic teeth with recently completed root formation.
to use dynamic guidance systems like X-Guide® (X-Nav Technologies).
When Dr. Herbert Schilder wrote that canals should have continually tapering root canal shapes, he was addressing clinicians during an era of rigid stainless steel files and plug gers, and we needed those larger coronal shapes to accomplish our clinical objectives in the apical third. Today most of these issues are moot — we now have hyperflexible files, irrigating cannulas, carriers, and electric heat pluggers — so it is sense less to continue to advocate cutting more dentin for no clinical advantage. Yet many endodontists have not received the memo and still associate big access cavities and boofy coronal canal shapes as the “Look” of well-done RCT when they are actually just mementos of no longer relevant endodontic history.
California) and YSGG laser cavitation (WaterLase® by Biolase®, Foothill Ranch, California). Those methods are fun and effective for high-tech early adopters but require a capital investment of $40K to $80K, plus per/case fees, plus maintenance fees, plus the cost of rapid obsolescence. Low-tech methods such as con tinuous irrigation with a conventional syringe and a safe-ended cannula can be just as effective if given enough time to defini tively irrigate multicannular teeth — one canal at a time. Better yet, using a negative-pressure, multicannular irrigation device, e.g, PulpSucker (PlanB Dental), means you can have a cappuc cino while it runs by itself after staging is completed (Figure 5).
5. Enlarging the coronal halves of canals beyond 0.8 mm to 1.0 mm does not improve obturation results either.
*The cases were all treated by the author.
How do they differ from bioceramics?
bioceramics (BC Temp contains calcium silicates releases cal cium and hydroxyl ions and BC Liner releases calcium, phos phate and fluoride ions).
To learn more, please visit BrasselerUSA.com, or contact Brasseler at 800-841-4522.
• BC Liner is a multi-functional, light curable patented RMGI that is optimized for use with BC Sealer/RRM. It extremely strong and has excellent wear characteristics. It can be placed over the top of unset BC RRM after repair of a per foration, resorptive defect, or pulp-capping procedure. The blue version is most often utilized as an orifice barrier, and for this application, a bonding agent is not needed.
Bioactives are generally categorized as any product that elicits a positive biological response. In dentistry, the response is typically in the form of a release of beneficial calcium, phos phate, or fluoride ions. Bioactives can include non-bioceramic components as they are defined by what they do and not by their composition.
QFASPECIALSECTION
28Endodontic Practice US Volume 15 Number 3 SPECIAL SECTION
What are bioactives?
How can clinicians use Brasseler’s line of bio active materials?
What are hybrid bioactive materials?
Brasseler
• BC RRM Paste™ is slightly thicker than BC Sealer and can be syringed into a site for perforation repair or pulp cap ping. BC Paste should be used for difficult to reach repair procedures, where you would normally utilize the MAP system with MTA.
• BC RRM Putty/Fast Set Putty™ is used for all repair proce dures where you would like to condense the material and where you need strong resistance to washout. It is ideal as pulp cap and retro filling.
Bioceramics are defined by both their composition and what they are designed to do. Bioceramics are inorganic, ceramic material (refractory polycrystalline compounds). Brasseler’s bio ceramics are pure calcium silicate, calcium phosphate-based bioceramics that are designed to set hard in the presence of the moisture naturally present in dentin. According to these definitions, products consisting of metals and/or resins are not pure bioceramics. Many recently introduced sealers that claim to be “bioceramics” don’t meet this definition as they contain non-bioceramic components in order to try to circumvent the BC Sealer patents. They are also void of calcium phosphate and contain lower levels of calcium silicates.
Brasseler USA ®
USA’s complete line of bioactive materials can cover all of your endodontic material needs while provid ing you with the best healing and handling characteristics. We want you to understand how our thoughtfully developed materials can benefit your patients.
• The BC Sealer™ and BC Sealer HiFlow™ are used for obtu ration (ortho or retrograde as a root-end filling capped with a plug of putty). HiFlow is optimized for warm condensa tion methods, and BC Sealer is optimized for cold hydraulic condensation.
Hybrid bioactive materials include BC Liner™ and BC Temp™. These materials contain some components that are not defined as bioceramics. The non-bioceramic components of these products were incorporated to overcome the inherent challenges of pure premixed bioceramics. BC Temp includes components that prevent the material from setting hard, which allows it to be easily removed (intra-canal dressing). BC Liner includes components that allow for light curing and for optimal strength and wear characteristics. Both of these materials are bioactive and highly compatible with Brasseler’s pure premixed
• BC Temp is an intracanal dressing that gradually releases hydroxyl and calcium ions maintaining a steady ph and it is easily delivered and removed.
Michael Tulkki, DDS, MS, shares his experiences
®
Has GentleWave® improved your clinical outcomes?
What concerns do you have, if any?
has not resulted in any adverse results over the past 5 years of clinical care utilizing the procedural guidelines.
Has GentleWave contributed to increased production?
From a business standpoint, the GentleWave procedure has improved clinical efficiency in indirect ways. Our armamen tarium has decreased with far less instrumentation than previ ously, which decreases certain supply costs. We have far less follow-up pain issues that can take considerable time address ing postoperatively. We have decreased our surgical endodon tic therapy by addressing more anatomy with the GentleWave system. This allows us to have more time to spend on initial or retreatment root canal therapy, which has a better reimburse ment in our area.
To learn more about GentleWave® System, scan here, or visit Sonendo.com/Technology.
Dr. Michael Tulkki
In our practice all teeth are evaluated with a cone beam scan during our diagnostic evaluation. This allows us to evaluate the etiology and potential prognosis for root canal therapy. With this information, we can visualize both the internal anatomical complexities as well as the surrounding hard and soft tissue that correlates with our planned procedure. The overall safety of our procedure has improved with pre-op evaluation and treatment with the GentleWave procedure. The GentleWave procedure
®
GentleWave by Sonendo
29endopracticeus.com Volume 15 Number 3 SPECIAL SECTION SECTIONSPECIALFAQ
The GentleWave procedure has changed the way I discuss clinical outcomes with patients. Traditional endodontic therapy has clinical limitations that can affect overall prognosis. Teeth that present with long, thin, curved roots and difficult anatom ical situations — e.g., C-shaped canals, lateral canals, and isthmuses — can be very difficult to achieve predictable results with traditional instrumentation and irrigation protocols. The GentleWave procedure changes our prognosis by allowing for multisonic cleaning of these anatomical challenges in a conser vative treatment approach that protects the natural anatomy of the tooth. Without question, the ability to treat these challenges in a new way improves clinical outcome.
What is US Endo Partners?
“It’s business as usual — but it’s business in a better way.” — John Haycock, Fayette Endodontics, Partner and Believer since 2021
But we’re not just looking to create wealth for our Partners — we seek to create value. Part of that value is fostering mean ingful opportunities for our doctors and their teams to grow as people; we believe wholeheartedly that better people make better leaders, which make better practices, and that better practices help more patients get out of pain.
“Partnering with US Endo was not an exit strategy. It was a growth strategy.” — Scott Doyle, DDS, MS, Metropolitan Endodontics, Partner and Believer since 2021
QFASPECIALSECTION
30Endodontic Practice US Volume 15 Number 3 SPECIAL SECTION
We’ve hand-selected a support team from the best-of-thebest in their respective fields. They collaborate with the busi ness side of your practice in areas from marketing and human resources to billing and compliance, so you can keep your eyes on what matters most. In short, we do what we do best, so you and your team can do what you do best.
We believe that the success we generate from our aligned pursuit of excellence should be rewarded. Our Partners have a stake in the company’s proven financial success and are Class A shareholders in our company, which means you invest in your partners, and they invest in you. Moreover, as a practicing endodontist, your work continues to produce for you at the same time as your investment does. This allows our Partners to realize the benefits of retirement while they’re still building — and benefiting from — their careers.
The Endo Files Podcast — Deep dives and unexpected conversations with the top names in Endo. Scan to listen!
US Endo looks for opportunities to support you and your team, and to amplify your practice — not to fix things that aren’t broken. Most importantly, our business model leaves the clin ical side of your business untouched; you’ll continue to have freedom to treat patients the way you always have, and the time and energy you need to focus your attention on exceptional outcomes. US Endo respects what you’ve worked years to build and honors that by keeping your team whole and preserving your practice name, brand identity, and culture.
Simply put, our Partners are what set us apart. Not only are they successful clinicians operating successful practices, but they also care deeply about where the specialty is going. We are also driven by our heartfelt Vision, Mission, and Core Val ues as they provide clarity, alignment, and unity of purpose that define our thriving culture.
“There’s a sort of magic to this group. We have support and the opportunity to grow — and to do it as a collective, instead of as individuals.” — Brett E. Gilbert, DDS, King Endodontics, Partner and Believer since 2020
Beyond financial, what are the other benefits to partnering with US Endo?
What makes US Endo different from other SDSOs?
What do I have to change when I partner with US Endo?
“It’s a beautiful thing to see hundreds of the best endodon tists in the country committed to the same vision and values — all in the patient’s best interest. — Olivia Cook, DMD, Highland Endodontics, Partner and Believer since 2020
US Endo Partners is a national network of growth-minded clinicians who collaborate to create better outcomes for our patients, partners, and teams, and to advance the endodontic specialty. By sharing best practices and key learnings, chal lenging each other to push past comfort zones, and encour aging our peers to think bigger, we achieve a higher level of success — while feeling invigorated, connected, and content in our careers and at home. Founded in 2018, we were the nation’s first Specialty Dental Service Organization exclusively for endodontists — and we were recently the nation’s first end odontic SDSO to enjoy a successful equity event.
US Endo Partners
31endopracticeus.com Volume 15 Number 3 RESEARCH
As life expectancy increases and with advances in medical system technology and procedures, burdens on the healthcare system increase as well. Telemedicine is a broad term comprising a number of technologies, from digital X-rays to over-the-phone consultations, videoconferencing, and remote surgery.1 In other words, telemedicine is simply the use of telecommunications technology to deliver medical care or services, thereby making medical care more accessible, convenient, and affordable. Tele medicine makes it easier for patients and individuals to access medical care. Rather than spending many hours or days traveling to a healthcare center, medical advice and consultation can be
Alin Yaya, DMD, MSc, and Meital Abadi, DMD, are General Practitioners, Israel Defense Forces (IDF), Medical Corps, Tel Hashomer, Israel, and in the “Bina” Program, Faculty of Dental Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.
Drs. Avi Shemesh, Marina Korektor-Rubinstein, Iddo Levy, Aurel Dadoun, Roman Grushyn, Alin Yaya, Shir Keshales-Shultz, Meital Abadi, and Avi Levin look into how to improve teledentistry outcomes
Avi Levin, DMD, is from the Department of Endodontics, Israel Defense Forces (IDF), Medical Corps, Tel Hashomer, Israel, and is in the “Bina” Program, Faculty of Dental Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.
Shir Keshales-Shultz, DMD, is from the Department of Periodontics, Israel Defense Forces (IDF), Medical Corps, Tel Hashomer, Israel, and is in the “Bina” Program, Faculty of Dental Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.
The study included 187 patients who required endodontic specialist (ES) consultation. The study consisted of three phases: General practitioners (GP) in the clinic (GPIC), ES by teleden tistry (EST), and ES in the clinic (ESIC). In each phase, pulp and periapical diagnoses and treatment plans were determined. The results were summarized, and differences among the three examination methods were evaluated. Data was analyzed in SPSS-24 using the Chi-square test. The p-value was set at 0.05.
Continuing education for GPs will lead to better and more successful teledentistry, as it could reduce the number of refer rals to specialists, reduce the waiting time for appointments, and minimalize the in-person interaction between patients and den tists/dental clinic staff, which is crucial during this COVID-19 pandemic.
Results
Disclosure: None of the writers of this article has financial interests or financial benefits stemming from the publication of this article and/or of teledentistry providers.
ObjectivesAbstract
Complete agreement on pulp evaluations was found between ESIC and GPIC and between ESIC and EST. Partial agreement on periapical diagnoses and treatment plans was found (an agree ment of 55% on periapical diagnoses and 73% on treatment plans determined by GPIC and ESIC and an agreement of 68% on periapical diagnoses and 80% on treatment plans determined by EST and ESIC).
The purpose of the present study was to assess pulp and root canal diagnoses and treatment plan formulations performed by endodontic specialists (ES) and general practitioners (GP) in the clinic and by teledentistry.
Conclusions
Avi Shemesh, DMD, was born and raised in Israel. In 2005, he received his dental degree from Tel Aviv University, The Maurice and Gabriela Goldschleger School of Dental Medicine. After graduating from dental school, he practiced general dentistry in the Medical Corps, Israel Defense Forces. In 2011, he started his Endodontic Residency in the Department of Endodontics in the residency center of the Medical Corps in the Sheba TelHashomer Hospital. From 2015 to 2021, Dr. Shemesh served in different specialist duties in the Medical Corps. Now Dr. Shemesh’s rank is lieutenant colonel, and he is the Chief Dental Surgeon in the Medical Corps, Israel Defense Forces. He also is in the “Bina” Program, Faculty of Dental Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.
Iddo Levy, DMD, Aurel Dadoun, DMD, and Roman Grushyn, DMD, are General Practitioners, Israel Defense Forces (IDF), Medical Corps, Tel Hashomer, Israel.
Materials and methods
Introduction
Endodontic diagnoses and treatment plan formulations performed by general dentists and endodontic specialists with the teledentistry method
Marina Korektor-Rubinstein, DMD, is from the Department of Prosthodontics, Israel Defense Forces (IDF), Medical Corps, Tel Hashomer, Israel.
Normal Apical Tissue
Other:Opentype:Resorption,PerforationVRFApex
All patients with teeth with existing root canal treatment who were referred for endodontic consultation to decide whether endodontic involvement was necessary were eligible for inclu sion in the study. Patients who were referred for endodontic consultation for other purposes were excluded from the study.
Pulp Diagnosis
IDDate:__Number: ______________ Chief complaint
Subjective Findings Objective Findings Radiographic Findings
A total of four general practitioners with 3-4 years’ experi ence and two endodontic specialists with 5 years’ experience participated in the study. The diagnoses and treatment plans in each phase were summarized, and disagreements among the three examination phases were evaluated.
Root
Patient name: _____________
Bone loss:
PDL:Roots:Crown:Continuous Absent
m
Significant___________________________: edical histo y
– degree of mobility (Miller's Classification): 0 1 2 3
Periapical radiographic findings:
32Endodontic Practice US Volume 15 Number 3 RESEARCH
First phase — examination by a GP in the clinic (GPIC): The GPIC phase included pulp and periapical diagnosis and treat ment plan formulation performed by a GP via clinical and radio graphical examination in the clinic according to a structured questionnaire (Figure 1).
Second phase — teledentistry “store-and-forward method” by an ES (EST): The EST phase included pulp and periapical diag nosis and treatment plan formulation performed by an ES using the periapical radiograph and questionnaire findings from the first phase, which were sent electronically from a GP.
Learning objectives
obtained more locally, freeing up time and increasing the ease of receiving care.2
In 1994, telemedicine was first used as a subspecialist field in a military project of the United States Army (U.S. Army’s Total Dental Access Project), aiming to improve patient care and dental education and to effectuate communication among dentists, dental lab oratories, and dental specialists. Teleconsul tation through teledentistry can take place by either “real-time consultation” or the “store-and-forward method.”5 Real-time con sultation involves a videoconference in which dental specialists and their patients commu nicate with one another from different loca tions. The store-and-forward method involves the exchange of clinical information, static images, and radiographical data collected and stored by dental general practitioners, who forward them to dental specialists, who determine consultation and treatment plans.3,6
The study was approved by the Ethics Committee on October 18, 2018 (number of approval–5269). The study included teeth from 187 patients from military bases (average age of 19 years old) who required endodontic specialist (ES) consultation.
Third phase — examination by an ES in clinic (ESIC): The ESIC phase involved pulp and periapical diagnosis and treatment plan formulation performed by an ES via clinical and radiographic examination in the clinic. The third phase was performed 2 weeks or more after the second phase by the same endodontist.
Other findings:
Figure 1: Endodontic questionnaire
Extraoral examination: Intraoral PeriodontalNoneReactionSinusSwelling:TenderPercussion:Evaluationexamination:ofclinicalcrown:NoYestopalpation:NoYesAbsentPresenttract:AbsentPresenttothermaltest:ShortProlongedstatus
Chronic Apical Abscess Condending Osteitis
Teledentistry is a term that combines the terms telecommunications and dentistry. It involves the delivery of clinical data and images through different technologies for dental consultation and treatment plan formu lation at a distance.3 The term “teledentistry” was first used in 1997, when Cook defined it as “… the practice of using videoconferencing technologies to diagnose and provide advice about treatment over a distance.”4
History of the tooth:
Tooth number: ____
Periapical Diagnosis DiagnosisDifferential Treatment Plan
Data was analyzed using SPSS-24 (IBM SPSS Inc., Chicago, Illinois). In order to examine the existence of variance between
r
Asymptomatic Apical SymptomaticPeriodontitis
Other:FollowExtractionApicalRetreatmentRootTreatmentCanalCanalSurgeryup
Apical Periodontitis
Allergy/used medicines:
Materials and methods
The purpose of the present study was to compare pulp and periapical diagnosis and treatment plan formulation by endodontists and general practitioners performed in the clinic and by teledentistry and to evaluate the efficacy and accuracy of teledentistry.
Periapical area: Normal Apical radiolucency
Normal Pulp Pulp
PreviouslyPreviouslyPulpitisAsymptomaticReversibleNecrosisPulpitisIrreversibleTreatedInitiatedTherapy
The study included three phases of examination for each patient:
| Half the leakage, Half the Cost OptimalAnti-microbialbiocompatibility Excellent sealing ability Unique stability Calcium silicate-based CeraSeal provides an optimal biocompatible environment to periapical and root canal tissues. No shrinkage or expansion, with next generation sealing abilities. To learn more about this product, scan here ClinicalCeraSealReviewArticle3015 Advance Lane, Colmar, PA america@metabiomed-inc.commetabiomedamericas.com18915267.282.5893
GP in clinic/ ES in the clinic 187 (100%)103 (55%)135 (73%)
Expected outcomes
GP in the clinic compared to ES in the clinic
Criteria
Table 4: Cases of disagreement on periapical diagnoses determined by ES examination by teledentistry compared to ES examination in the clinic
Incorrect estimation of the vertical root fracture4 (7%)
Endodontic follow-up Extraction 1 (2%)
Endodontic retreatment Endodontic follow-up 18 (35%)
Results
Incorrect estimation of the periapical lesion19 (23%)
Number of cases
34Endodontic Practice US Volume 15 Number 3 RESEARCH
Total number of cases 60
the groups, a chi-square tests were used. The p-value was set at 0.05.
We expected agreement between the ESIC and EST groups in both pulpal and periapical diagnoses and suggested the highest rate of differences in diagnoses will be found in comparing ESIC and GPIC groups due to variations in examination technique and lack of clinical experience.
Incorrect estimation of the periapical lesion20 (33%)
• Among 84 (45%) cases of disagreement on periapical diagnoses, most cases (70%) of disagreement were due to incorrect estimation of symptoms (Table 2).
ES by teledentistry compared to ES in the clinic
• Among 60 (32%) cases of disagree ment on periapical diagnoses, most cases of disagreement were due to incorrect estimation of symptoms (53%) and incorrect estimation of periapical lesions (33%) (Table 4).
Table 1: Cases of agreement on pulp and periapical diagnoses and treatment plans among three examination methods
Total 52
ES by teledentistry/ ES in clinic 187 (100%)127 (68%)149 (80%)
Incorrect estimation of the symptoms 59 (70%)
Incorrect estimation of sinus tract 4 (5%)
Table 3: Cases of disagreement on treatment plans determined by GP examination in the clinic compared to ES examination in the clinic
Extraction
diagnosisPulp diagnosisPeriapical planTreatment
Endodontic retreatment 25 (48%)
• Among 52 (27%) cases of disagreement on treatment plans, most cases (83%) of disagreement were about the necessity of endodontic involvement (Table 3).
Discussion
Endodontic retreatment Extraction 2 (4%)
Number of cases
Criteria
Table 2: Cases of disagreement on periapical diagnoses determined by GP examination in the clinic compared to ES examination in the clinic
In situations such as this, teledentistry can provide an inno vative solution to continue dental practice during the current pandemic and beyond.9 In this research, the validity of diagnoses
Total number of cases 84
Incorrect estimation of the symptoms 32 (53%)
The difference between the methods was significant (p < 0.05).
Incorrect estimation of the vertical root fracture2 (2%)
The use of teledentistry for specialist consultations, diagno ses, and treatment planning will enable more affordable and convenient decision-making. The COVID-19 pandemic created challenges in dentistry across the globe.7 Examination and den tal treatment involve interaction with the patient, consisting of inspection, diagnosis, and intervention. As a result, during the current pandemic, most routine dental procedures worldwide were suspended, and only emergency dental procedures and surgeries were being performed.7,8
ES examination in the clinic GP examination in the clinicNumber of cases
• Among 38 (20%) cases of disagree ment on treatment plans, most cases (72%) of disagreement were about the necessity of endodontic retreat ment (Table 5).
Table 1 summarizes the agreement on pulp and periapical diagnoses and treatment plans among the three examination methods. Complete agreement on pulp diagnoses was found between ESIC and GPIC and between ESIC and EST, while par tial agreement on periapical diagnoses and treatment plans was observed (Table 1).
Endodontic retreatment 6 (11%)
Endodontic follow-up
Incorrect estimation of sinus tract 4 (7%)
methodExamination
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Different diagnostic evaluations and treat ment plans between GPs and ESs were previously studied in different dentistry fields: Tamse, et al., 2011 reported that only 33.8% of vertical root fractures were diagnosed by GPs;10 Shemesh, et al., 2018, found that 37% of external invasive root resorptions were not diagnosed by GPs;11 Al-Haj Ali, et al., 2020, demonstrated insufficient knowledge on the emergency management of complicated crown fractures of immature permanent teeth,12 and Alkhalifah, et al., 2017, revealed large differences in treatment planning approaches for cracked teeth between GPs and specialists.13 In our study, the disagreement percentages, which are similar to those of the preceding studies, indicate the inaccuracy of clinical and radiographic evaluations by GPs.Moreover, the present study revealed different evaluations of diagnoses and treatment plans between ESIC and EST. EST diag noses and treatment plan formulations were based on GPs’ eval uations of the results of clinical and radiographical examinations. Incorrect estimations of symptoms, incorrect intraoral clinical examination methods, and incorrect radiographical periapical lesion evaluations by GPs might lead to incorrect diagnoses and treatment plan formulations by ESs. Bogari, et al., 2019, revealed differences in examination and diagnostic methods among gen eral dental practitioners in endodontic treatment and reported that only 55.5% thought that percussion was a reliable method of diagnosis, which can lead to misdiagnosis and an incorrect treatment plan.14 The different evaluation of radiographs by the same dentist that was described by Goldman, et al., 1972, might also explain the difference between ESIC and EST.15
12. Al-Haj Ali, Algarawi SA, Alrubaian AM, Alasqah AI. Knowledge of General Dental Practitioners and Specialists about Emergency Management of Traumatic Dental Inju ries in Qassim, Saudi Arabia. Int J Pediatr. 2020;2020:6059346.
Conclusions
6. Bhambal A, Saxena S, Balsaraf S. Teledentistry: potentials unexplored! J Int Oral Health. 2010;2(3):1-6.
15. Goldman M, Pearson AH, Darzenta N. Endodontic success — who’s reading the radiograph. Oral Surg Oral Med Oral Pathol. 1972;33(3):432-437.
Endodontic follow-up
Total 38
Continuing endodontic education for general practitioners for accurate estimation of symptoms and clinical findings will lead to better and more successful teledentistry and could reduce the number of referrals to specialists, reduce the waiting time for appointments, and minimalize the in-person interaction between patients and dentists/dental clinic staff, which is crucial during this COVID-19 pandemic.
1. There is a low percentage of agreement on diagnoses and treatment plans determined by general practitioners and endodontists using teledentistry compared to diagnoses and treatment plans determined by endodontists in the clinic.
10. Tamse A, Fuss Z, Lustig J, Kaplavi J. An Evaluation of Endodontically Treated Vertically Fractured Teeth. J Endod. 1999;25(7):506-508.
Table 5: Cases of disagreement on treatment plans determined by ES examination by teledentistry compared to ES examination in the clinic ES examination by teledentistry ES examination in the clinicResult
Endodontic retreatment 15 (39%)
EP
Highlights
ST. Physician liability issues and telemedicine: Part 3 of 3. Ear Nose Throat J. 2016;95(1):12-14.
Acknowledgments
8. Rocca MA, Kudryk VL , Pajak JC, Morris T. The evolution of a teledentistry system within the Department of Defense. Proc AMIA Symp. 1999;921-924.
11. Shemesh A, Levin A, Ben Itzhak, et al. External invasive resorption: Possible coexisting factors and demographic and clinical characteristics. Aust Endod J. 2018;45(2):141-145.
2. Yan Velsen L, Wildevuur S, Flierman I, et al. Trust in telemedicine portals for rehabili tation care: an exploratory focus group study with patients and healthcare profession als. BMC Med Inform Decis Mak. 2016;16:11.
4. Fricton J, Chen H. Using Teledentistry to Improve Access to Dental Care for the Underserved. Dent Clin North Am. 2009;53(3):537-548.
Endodontic retreatment
Endodontic retreatment
13. Akhalifah S, Sharma ON, AJ Moule. Treatment of cracked teeth. J Endod. 2017;43(9):1579-1586.
1.REFERENCESKmucha
2. Continuing endodontic education for general practi tioners will improve the accuracy of diagnoses and treat ment plans by teledentistry.
36Endodontic Practice US Volume 15 Number 3 RESEARCH
7. Ghai S. Teledentistry during COVID-19 pandemic. Diabetes Metab Syndr. 2020;14(5): 933-935.
3. Teledentistry can serve as a crucial tool during the COVID-19 pandemic and can reduce the waiting time for appointments and minimalize the interaction between patients and dental clinic staff.
14. Bogari DF, Alzebiani NA, Mansouri RM, et al. The knowledge and attitude of general dental practitioners toward the proper standards of care while managing endodontic patients in Saudi Arabia. Saudi Endod J. 2019; 9(1):40-50.
9. Alabdullah JH, Daniel SJ. A systematic review on the validity of teledentistry. Telemed J E Health. 2018;24(8):639-648.
5. Reddy KV. Using teledentistry for providing the specialist access to rural Indians. Indian J Dent Res. 2011;22(2):189.
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
3. Jampani ND, Nutalapati R, Dontula BS, Boyapati R. Applications of teledentistry: A literature review and update. J Int Soc Prev Community Dent. 2011;1(2):37-44.
Endodontic follow-up 13 (33%)
and treatment plans by ESIC, EST, and GPIC was compared, and complete agreement on pulp diagnoses was found among the three methods. However, partial agreement on periapical diag noses and treatment plans was found between GPIC and ESIC and between ESIC and EST.
16. Balto HA, Al-Madi EM. A comparison of retreatment decisions among general dental practitioners and endodontists. J Dent Educ. 2004;68(8):872-879.
Balto, et al., 2004, compared retreatment decisions between general dental practitioners and endodontists. Similar to our results, he found significantly different decisions between these two groups regarding retreatment cases.16
Extraction 10 (28%)
LEARNING
CURVE? TOTRANSITIONASAFEYET CONSERVATIVE WAY TO DO ENDO 1 2 3 4 5 YAY GULP NOOO SIGH PHEW
EXACTTaperH DC™ files variable taper design and controlled memory ensure flexibility closely following the anatomy of the canal, reducing the risk of ledging, transportation, and perforation. A maximum flute diameter of .8 ensures you’ll conserve maximum pericervical dentin while reducing the potential for over-preparation.
1145 Towbin Avenue Lakewood, New Jersey 08701 www.sswhitedental.com SCAN ME to Try Yourselffor
Better Patient Outcomes Improved Efficiency Faster Practice Growth Dental®
Predictable results …No learning curve required.
Mark Anthony Limosani, DMD, MS, FRCD(c), received his DMD degree from the University of Montreal in 2007. He attended the specialty program in endodontics at Nova Southeastern University where he also received his master’s degree in dental science. He is a Fellow of the Royal College of Dentists of Canada and a Diplomate of the American Board of Endodontics. He is currently on staff at Miami Children’s Hospital and teaches at the AEGD residency program at Community Smiles. Dr. Limosani has lectured locally and internationally on dental traumatology, restoration of endodontically treated teeth, restoratively minded endodontics, diagnosis and treatment planning, and cone beam computed tomography (CBCT) use in endodontics.
Disclosure: Dr. Limosani has received lecture honorarium from SS White Dental® for courses on endodontics.
2 CREDITSCE
Another component that plays into the ExactTaperH DC Sys tem’s ability to fulfill on its promise of greater dentin conservation resides in the variable taper design combined with a restricted maximum flute diameter. Previous file designs involved a con stant taper from D1 to D16, thus removing more tooth structure in the coronal one-third of the canal space. The ExactTaperH DC System allows for the most tapered portion of the instrument to be concentrated in the apical one-third of the file. The taper of the
Expected outcomes
View two case reports, one instru mented in a conservative manner and one where too much pericervical dentin was removed.
• Recognize the importance of adopting dentin conserva tion principles with a protocol that creates space for irri gant exchange while also providing resistance form in the apical one-third allowing for obturation control.
• Realize the importance of being mindful of preserving as much pericervical dentin as possible.
Educational aims and objectives
Endodontic Practice US subscribers can answer the CE ques tions by taking the quiz online at endopracticeus.com to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can:
Building confidence and improving repeatability in your endodontic practice
This self-instructional course for dentists aims to explore a new endodontic file system, the ExactTaperH DC™ file that aims at providing more conservative shaping protocols to practitioners interested in preserving more tooth structure during root canal therapy.
Dr. Mark Anthony Limosani discusses a new endodontic file system
38Endodontic Practice US Volume 15 Number 3 CONTINUING EDUCATION
E
ndodontic therapy’s primary purpose is to optimize oral health by preserving the natural dentition by treating an ail ing pulp dentin complex. Most practitioners are mindful of the fact that the longevity of their work depends on the patient’s ability to manage oral hostilities such as caries, periodontal dis ease, and occlusal disharmony, just to name a few. The practi tioner’s primary objective in attempting to preserve the natural dentition that has succumbed to pulpal disease is to extirpate inflamed and infected tissue from the root canal system, thus decreasing the biological burden to a level that no longer trig gers an immune response. Care must be taken subsequently to restore the damaged dentin-enamel complex to a level where predictable masticatory function can resume without discomfort or clinical manifestations of disease. The main procedural chal lenge one encounters is striking a balance between achieving all biological goals aforementioned without weakening the tooth from a structural perspective. This article’s purpose is to bring to light a new endodontic file system, the ExactTaperH DC™ file (SS White Dental®, Lakewood, New Jersey) that aims at providing more conservative shaping protocols to practitioners interested in preserving more tooth structure during root canal therapy.Clark and Khademi outlined the hierarchy of tooth needs emphasizing the importance of being mindful of preserving as much pericervical dentin as possible at the expense of tooth structure that offers less structural support.1 Access design and shaping principles aimed at fulfilling this goal will often leverage carious or previously restored areas of the tooth in order to facil itate instrumentation while also minimizing mechanical com promise. The ExactTaperH DC System allows the practitioner to adopt dentin conservation principles with a protocol that creates space for irrigant exchange while also providing resistance form in the apical one-third allowing for obturation control.
Several elements have been put into practice to allow for the creation of this series of files that allow for the principles of dentin preservation to come to life. First, the heat-treated nature of the nickel-titanium instruments has allowed for a significant increase in flexibility thus providing more resistance to cyclic fatigue. Second, the heat-treated nature of the files has allowed them to maintain shape memory, which allows for them to be precurved prior to their insertion into the canal space. These fea tures have become critical when performing root canal therapy on patients with limited openings where traditional instruments would be a much greater risk of separating during the procedure, creating a whole host of issues for the practitioner.
• Identify some characteristics of the ExactTaperH DC file that can provide more conservative shaping protocols.
39endopracticeus.com Volume 15 Number 3 CONTINUING EDUCATION
Figures 1 and 2: 1. Bitewing radiograph of a 42-year-old female patient diagnosed with symptomatic irreversible pulpitis and normal apical tissues. 2. The periapical radio graph of tooth No. 31
file then diminishes in the midroot and coronal aspect allowing for increased flexibility and preservation of root structure. Such properties decrease the possibility of unintended alteration of the internal anatomy of the tooth, sometimes leading to complications such as apical transportation, ledging, or strip perforation. The maximum flute diameter is defined as the cutting area of the file with the widest width. Tradi tional file designs presented a MFD of 1.2 mm compared to the ExactTaperH DC’s significantly more conservative 0.8 mm. This decrease in shape becomes all the more crucial when dealing with teeth with longer roots and/or a more delicate slender body.
was disinfected using the GentleWave® system along with the CleanFlow™ handpiece (Sonendo®, Laguna Hills, California). Radiopaque findings consistent with impacted teeth Nos.
The periapical radiograph of tooth No. 31 revealed roots that appeared to be longer than most as well as proximity of the apices to the M and D roots (Figure 2). Endodontic access was performed through the ceramic restoration using a round SS White Dental® Great White® Gold Bur as well as a coarse grit chamfer diamond to enter the pulp chamber. A hyperemic pulp was noted. Note the conservative nature of the access design aimed at minimizing removal of valuable tooth structure (Figure 3).
Figure 3: Endodontic access through the ceramic restoration. Note the con servative nature of the access design aimed at minimizing removal of valuable tooth structure
A 42-year-old female patient presented to the office with a constant throbbing sensation associated with the right aspect of her jaw. She reported having had tooth No. 31 restored with full cuspal coverage slightly over 2 weeks prior due to complaints of biting sensitivity at the time. Tooth No. 31 was diagnosed with symptomatic irreversible pulpitis and normal apical tissues as she presented a lingering response to the cold test. The bitewing radiograph revealed a restoration that appeared to be moderately close to the pulp chamber of tooth No. 31 (Figure 1).
The final radiograph demonstrates the root canal system obturated with Endosequence® BC Sealer™ (Brasseler USA®, Savannah, Georgia) using thermomechanical compaction in the D root along with a single-cone obturation in the M root system. MF cones were used in all canals (Figure 4). The system
Figures 4 and 5: 4. The final radiograph demonstrating the root canal system obturated with Endosequence® BC Sealer™ using thermomechanical compaction in the D root along with a single-cone obturation in the M root system. 5. All canals were instrumented using the following sequence with the ExactTaperH DC instruments: 14.03, 17.03, 18.04, and 20.06
Case report 1
2. Makati D, Shah NC, Brave D, et al. Evaluation of remaining dentin thickness and fracture resistance of conventional and conservative access and biomechanical prepa ration in molars using cone-beam computed tomography: An in vitro study. J Conserv Dent. 2018;21(3):324-327.
1. Clark D, Khademi J. Modern molar endodontic access, and directed dentin conserva tion. Den Clin North Am. 2010;54(2):249-273.
Conclusion
Figure 8: Frontal and axial CBCT slices
1 and 32 were noted. The patient reported that she had been recommended to have these teeth extracted in the past; however, she was recently advised to keep them under observation due to the possible complications related to their proactive removal. The off-angle radiograph reveals two M canals obturated with conservative shapes in a predictable manner (Figure 5). All canals were instrumented using the following sequence with the ExactTaperH DC instruments: 14.03, 17.03, 18.04, and 20.06.
The value of pericervical dentin has been reported.2,3 Pericervical dentin has been defined as root structure residing in proximity to the cervical crest of bone. This zone was often compromised in the past by overflaring the root canal system in an attempt to provide easier access to the midroot and apical one-third of the canal. While shaping the canal system in this manner can facilitate the practitioner’s ability to create a pathway to the apex of the tooth, it often comes at the expense of healthy root structure, thus potentially compromising long-term function.
As endodontists, we typically have other files that we use in our armamentarium, but I find that this endodontic file provides a balanced combination of optimized metallurgy, conservative maximum flute diameter, and variable taper, allowing for prac titioners of all skill levels to embark on a journey of dentin con servation. This system provides dentists and root canal specialists alike with an armamentarium that empowers them to accomplish all their biological endodontic objectives without compromising the structural integrity of their patient’s natural dentition.
40Endodontic Practice US Volume 15 Number 3 CONTINUING EDUCATION
Figure 7: The PA radiograph
3. Haralur SB, Al-Qahtani AS, Al-Qarni MM, Al-Homrany RM, Aboalkhair AE. Influence of remaining dentin wall thickness on the fracture strength of endodontically treated tooth. J Conserv Dent. 2016;19(1):63-67.
An example of removing too much cervical dentin can be seen in the case of this 51-year-old male who presented with swelling associated with the B aspect of the M root of tooth No. 19. The bitewing radiograph demonstrates findings suggestive of a straight line access design combined with more pronounced coronal shaping (Figure 6). The PA radiograph demonstrated find ings suggestive of significant midroot and coronal root shaping during initial treatment (Figure 7). Frontal and axial CBCT slices taken with a CS 8100 3D (Carestream Dental, Atlanta, Georgia) reveal findings highly suggestive of bone loss associated with the M aspect of tooth No. 19 consistent with a fractured root (Figure 8).
REFERENCES
Case report 2
Figure 6: Bitewing radiograph of a 51-year-old male
EP
a. optimized metallurgy
b. removing as much tooth structure as possible
b. preservation of root structure
b. nickel-titanium
LIMOSANI
c. 0.8 mm d. 0.10 mm
d. flared
a. underpreparing b. overflaring c. over obturation d. under obturation
2 CREDITSCE
8. This zone (root structure residing in proximity to the cervical crest of bone) was often compromised in the past by ________ of the root canal system in an attempt to provide easier access to the midroot and apical one-third of the canal.
41endopracticeus.com Volume 15 Number 3 CONTINUING EDUCATION
4. The ________ of the files has allowed them to maintain shape memory, which allows for them to be precurved prior to their insertion into the canal space.
2. ________ outlined the hierarchy of tooth needs emphasizing the impor tance of being mindful of preserving as much pericervical dentin as pos sible at the expense of tooth structure that offers less structural support.
6. Traditional file designs presented a MFD of 1.2 mm compared to the ExactTaperH DC’s significantly more conservative _______.
c. minimum flute diameter
b. healthy root structure, thus potentially compromising long-term function
10. (In the author’s experience) I find that this endodontic file provides __________, allowing for practitioners of all skill levels to embark on a journey of dentin conservation.
n To receive credit: Go online to https://endopracticeus.com/continuingeducation/, click on the article, then click on the take quiz button, and enter your test answers.
AGD Code: 070
To provide feedback on CE, please email us at education@medmarkmedia.com
d. Al-Homrany and Aboalkhair
d. non-conservative design
d. both a and b
c. Haralur and Al Qahtani
Date Published: September 1, 2022
a. Clark and Khademi
b. Makati and Shah
c. heat-treated nature
c. more pronounced coronal shaping d. potential need for future extraction
a. non-flexible nature
cervical crest of bone. a. Pericervical dentin b. Cementum c. Enamel d. Radicular pulp
Each article is equivalent to two CE credits. Available only to paid subscribers. Free subscriptions do not qualify for the CE credits. Subscribe and receive up to 16 CE credits for only $149; call 866579-9496, or visit https://endopracticeus.com/subscribe/ to subscribe today.
Building confidence and improving repeatability in your endodontic practice
d. maintaining occlusal harmony
3. The heat-treated nature of the __________ instruments has allowed for a significant increase in flexibility, thus providing more resistance to cyclic a.fatigue.stainless steel
c. barbed
b. 0.6 mm
9. (In Case report 2) While shaping the canal system in this manner can facilitate the practitioner’s ability to create a pathway to the apex of the tooth, it often comes at the expense of ________. a. a less expensive procedure
b. conservative maximum flute diameter c. variable taper d. all of the above
a. 0.4 mm
c. lowering the instance of future caries
7. _______ has been defined as root structure residing in proximity to the
Legal disclaimer: Course expires 3 years from date of publication. The CE provider uses reasonable care in selecting and providing accurate content. The CE provider, however, does not independently verify the content or materials. Any opinions expressed in the materials are those of the author and not the CE provider. The instructional materials are intended to supplement, but are not a substitute for, the knowledge, skills, expertise and judgement of a trained healthcare professional.
Continuing Education Quiz
a. increased flexibility
a. decreasing the biological burden to a level that no longer triggers an immune response
b. fluted nature
5. The taper of the ExactTaperH DC System’s file then diminishes in the midroot and coronal aspect, allowing for ________.
Expiration Date: September 1, 2025
1. The practitioner’s primary objective in attempting to preserve the natural dentition that has succumbed to pulpal disease is to extirpate inflamed and infected tissue from the root canal system, thus _________.
Antibiotics are one of the greatest medical advances since their first introduction in the late 1920s. Alexander Fleming’s breakthrough discovery of penicillin paved the way for a domain of medicine that has enabled once deadly infections to be read ily treatable.1Excessive antibiotic use comes with steep consequences of real-time adverse effects; downstream antibiotics resistance (also referred to as collateral damage); and superinfections, such as Clostridioides difficile. Overuse and inappropriate use of antibiot ics has led to an increased prevalence of resistance, which trans lates to limited effectiveness of antibiotics, increased healthcare cost, and rising mortality rates. Antibiotic resistance is recognized as a global health threat. According to the Centers for Disease Control and Prevention (CDC), approximately 2 million Amer icans are infected with resistant pathogens that result in 23,000 deaths annually.2 The CDC conservatively approximates that 30% of all outpatient antibiotic prescriptions written from 2010 to 2011 were unnecessary.3 If the previous statistic was applied to the 2020 CDC data for number of antibiotic prescriptions written by dental practitioners in the United States, 7.29 million antibiotic prescrip tions would be deemed as inappropriate within that 1 year.4
Bacterial pathogens implicated in dental infections
An odontogenic infection is a frequently encountered infec tion of the alveolus, jaws, or face that begins from a tooth or from its supporting structures. The most common cause of den tal infections are dental caries, deep filling or failed root canal treatments, pericoronitis, and periodontal disease. The infection remains where it originates at the tooth or can spread into adja cent tissue or structures. The course of infection depends on sev eral elements, including the virulence of the oral pathogens, the host resistance factors, and the surrounding anatomy.10
• Identify bacterial pathogens implicated in dental infections.
Endodontic Practice US subscribers can answer the CE ques tions by taking the quiz online at endopracticeus.com to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can:
• Identify antibiotic treatment for specific dental infections.
• Recognize considerations related to the administration of medications for pedi atric patients.
This self-instructional course for dentists aims to provide an overview of judicious use of antibiotics in the dental practice.
Dental infections: help avoid antimicrobial resistance — part 1
Determining the drug-of-choice for the treatment of odonto genic infections requires an understanding of which pathogens are implicated and whether antibiotics are truly necessary. Even when antibiotics are needed to treat dental infections, they might not be the first line therapy, but rather an adjunct after surgical drainage of an abscess, tissue debridement, or below the gum manipulation.
Bacteria that are frequently found in dental infections nor mally comprise the typical oral flora, which include a mixture of gram-positive streptococci (e.g., Streptococcus anginosus,
Jessica Price is a Doctor of Pharmacy candidate at South College School of Pharmacy in Knoxville, Tennessee. She has a Bachelor of Arts degree in Advertising and Public Relations, with minors in Business and English Writing from the University of Central Florida. Price completed her post-baccalaureate track in Biology at Florida International University and at the University of Tennessee, Knoxville.
2 CREDITSCE
Educational aims and objectives
Introduction
Expected outcomes
• Analyze how to determine the drug-of-choice for certain Analyztreatments.eprescribing indications related to duration of treatment.
Wiyanna K. Bruck, PharmD, BCPS, BCIDP, BCPPS, is an assistant professor of Pharmacy Practice at South College School of Pharmacy as well as an Antimicrobial Stewardship and Emergency Medicine Clinical Pharmacist practicing at a community hospital. She teaches infectious diseases as well a pediatric pharmacotherapy to both pharmacy and physician assistant students. Dr. Bruck received her bachelor of science in biology, followed by a Doctorate of pharmacy degree, then completed a postgraduate pharmacy residency program at William Beaumont Hospital in Troy, Michigan. Her research interests include antimicrobial stewardship, infectious diseases, as well as food allergy awareness. Dr. Bruck is Board-certified in pharmacotherapy, infectious diseases, and pediatrics.
42Endodontic Practice US Volume 15 Number 3 CONTINUING EDUCATION
tion.8 Along with the concept of the 5Ds of optimal antimicrobial therapy, the CDC has constructed a Checklist for Antibiotic Pre scribing in Dentistry (see Table 1), which serves as an excellent introduction to concepts that will be discussed in further detail.9
Wiyanna K. Bruck, PharmD, and Jessica Price start their discussion on the judicious use of antibiotics in the dental practice
Judicious antimicrobial prescribing is essential in all fields of healthcare, including dentistry.5-7 The 5Ds of antimicrobial stewardship is a popular concept that should be applied to the appropriate prescribing of antibiotics. The 5Ds, include the right Drug, Dose, Delivery route, Duration of therapy, and De-escala
43endopracticeus.com Volume 15 Number 3 CONTINUING EDUCATION
• Weigh potential benefits and risk (i.e., toxicity, allergy, adverse effects, risk for Clostridium difficle infection) of antibiotics before prescribing.
Most patients with gingivitis or periodontitis can be effec tively treated with mechanical debridement or scaling and root planing (SRP) without the need of antibiotic therapy. In patients that lack a response to SRP alone and have few sites of disease, a onetime local delivery of topical antibiotic can be utilized (e.g., chlorhexidine 2.5 mg chip, doxycycline 10% gel, minocycline 1 mg microsphere, or tetracycline 12.7 mg fiber). In patients with refractory cases that have extensive disease or those with severe or aggressive disease, strong evidence suggests adjunctive sys temic antibiotics. Obtaining a culture to guide therapy prior to initiation is strongly encouraged if feasible.17-19
• Ensure evidence-based antibiotic references are readily available during patient visits. AVOID prescribing based on non-evidence-based historical practices, patient demand, convenience, or pressure from colleagues.
Antibiotic treatment in dental infections
Pulpal pain, gingivitis, and periodontitis
• Prescribe antibiotics only for patients of record and only for bacterial infections you have been trained to treat. DO NOT prescribe antibiotics for oral viral infections, fungal infections, or ulcerations related to trauma or aphthae.
Most dental abscesses are secondary to dental caries and, therefore, can largely be prevented when basic and consistent preventative oral health measures are followed. Dental infec tions are common, including suppurative infections (abscesses), but not all need to be treated with antibiotics. It is therefore important to elucidate the presence of regional or hematologic spread suggesting disseminated infection and distinguish local versus systemic signs and symptoms of infection.20
• Assess patients’ medical history and conditions, pregnancy status, drug allergies, and potential for drug-drug interactions and adverse events, any of which may impact antibiotic selection.
• Educate your patients to take antibiotics exactly as prescribed, take antibiotics only prescribed for them, and not to save antibiotics for future illness.
• Ensure staff members are trained in order to improve probability of patient adherence to antibiotic prescriptions .
• Revise empiric antibiotic regimens on the basis of patient progress and, if needed, culture results.
• Use the most targeted (narrow-spectrum) antibiotic for the shortest duration possible (2 to 3 days after clinical signs and symptoms subside) for otherwise healthy patients.
Table 1: Checklist for antibiotic prescribing in dentistry
• Consider therapeutic management interventions, which may be sufficient to control a localized oral bacterial infection.
Streptococcus mutans, Streptococcus intermedius group); anaer obic gram-negatives (e.g., Bacteroides spp, Prevotella spp., Fuso bacterium); anaerobic gram-positives (e.g., Actinomyces spp., Peptostreptococci); and some rarer aerobic gram-negatives such as Eikenella corrodens. In general, the routinely used antibiotic agents (natural penicillin, aminopenicillin, penicillin combined with a β-lactamase inhibitor, and first-generation cephalosporins, tetracyclines, and macrolides) have good empiric coverage of the commonly implicated pathogens with the exception of coverage against anaerobic gram-negative bacilli.11-14 If there is a reason to suspect Prevotella species or other anaerobic gram-negative bacilli such as Fusobacterium or Bacteroides spp. that are positive for β lactamase (e.g., surveillance data suggest high prevalence), metronidazole is often added to the empiric coverage.5
Patient Education
Pretreatment
Abscesses
Prescribing
• Correctly diagnose an oral bacterial infection.
• Prescribe only when clinical signs and symptoms of a bacterial infection suggest systemic immune response, such as fever or malaise along with local oral swelling.
Additionally, the treatment of abscesses depend on the loca tion. If the dental abscess is localized, incision and drainage (I&D) alone is usually sufficient for proper recovery. In these cases, the patient will have a better outcome with a procedural
Antibiotics are infrequently necessary for pulpal pain, gingi vitis, and periodontitis. Irreversible pulpitis is characterized by acute and intense pain and is one of the most frequent reasons that patients seek emergency dental care. Antibiotics are not effective at treating pulpal pain, and treatment is not deemed appropriate if the patient has no signs of a spreading infection or systemic symptoms. Most important to note, inappropriate treat ment of pulpal pain does not prevent the development of severe complications. Evidence suggests that combination therapy with nonsteroidal anti-inflammatory drugs (NSAIDs) and acetamino phen during meals and at bedtime is an effective way to manage pulpal pain.16 Aside from the removal of the tooth, the usual
Staff Education
• Discuss antibiotic use and prescribing protocols with referring specialists.
• Implement national antibiotic prophylaxis recommendations for medical concerns for which guidelines exist (e.g., cardiac defects).
• Make and document the diagnosis, treatment steps, and rationale for antibiotics (if prescribed) in the patient chart.
approach in the management of pulpitis is relieving the pain by drilling the tooth and removing the inflamed pulp and cleaning the root canal. There is no proof of benefit with using analgesics and or antibiotics in irreversible pulpitis.
Table 2: Antibiotics for dental infections in adult patients15,20
clindamycin 300 – 450 mg PO Q6h# moxifloxacinOR 400 mg PO daily* levofloxacinOR 750 mg PO daily + metronidazole 250 – 500 mg PO BID/TID∆
Tachycardia, tachypnea, raised tongue/drooling, difficulty speaking, swallowing, breathing, lymphadenopathy, pyrexia, trismus, dehydration, hypotension, ↑ WBC, periorbital cellulitis
PO = oral, IV = intravenous; BID = twice daily; TID = three times daily; q6h = every 6 hours; WBC = white blood cell
# Considered 1st line in severe cases, those with penicillin/β-lactam allergy, or if anaerobes predominant, does NOT cover Eikenella
ampicillin/sulbactam 3 g IV Q6h ceftriaxoneOR 2 g IV every 24 hours + metronidazole 500 mg IV q8hPorphyromonas,actinomycetemcomitans,(AggregatibacterPeriodontitisTreponema, Prevotella)
With adequate source control, short antibiotic courses have been found to be effective. A prospective clinical study was
Duration of treatment
clindamycin 300 – 450 mg PO Q6h# doxycyclineOR 100 mg PO BID azithromycinOR 500 mg PO Day 1 then 250 mg PO x 4 days
(streptococci,Abscess Peptostreptococcus spp, Bacteroides, and other oral anaerobes [+ Pseudomonas and other gram-negative bacilli IF patient is immunocompromised])
∆ Add-on agent if Prevotella is suspected
However, some experts recommend additional coverage of β-lactamase producing Prevotella and Fusobacterium with amoxicillin/clavulanate or a historic agent combined with met ronidazole. Cephalexin — a first-generation cephalosporin with similar gram-positive aerobic coverage as the historic first line agents but that lacks robust anaerobic activity — is the antibi otic of choice in those with a history of penicillin allergy without history of anaphylaxis, angioedema, or hives. In patients with a severe allergy to penicillin agents or other β-lactams, azith romycin or clindamycin can be prescribed. When deciding on an agent to use for dental infection, consider azithromycin has higher rates of gram-positive aerobic resistance, and clindamycin
I&D to obtain source control in comparison to the ineffective use of antibiotics alone. If the abscess is in the periapical region, treatment, including I&D, endodontic therapy, and adjunctive antibiotics are recommended.20-22 In patients who have severe systemic illness, in-patient treatment with intravenous antibiotics initially is generally justified.
ampicillin/sulbactam 3 g IV Q6h aqueousOR penicillin G 2 – 4 million units + metronidazole 500 mg IV q8h
* Only consider in patients intolerant or allergic to penicillins/β-lactams/clindamycin
substantially increases the risk of developing a Clostridioides dif ficile infection but has much more robust coverage of mouth flora with the exception of Eikenella. Therefore, the risks and benefits of treatment in patients with a severe β-lactam allergy should be weighed prior to prescribing an alternative agent.20-23 A summary of antibiotics used for dental infections in adult patients as well as red flags for progressing infection are available in Table 2.
44Endodontic Practice US Volume 15 Number 3 CONTINUING EDUCATION
If antibiotics are deemed necessary for either non-suppura tive or suppurative odontogenic infections the agent selection is based on the coverage of oral typical oral pathogens. His torically, the drugs of choice were amoxicillin or penicillin V potassium. Although both agents were regarded as first line, amoxicillin was generally preferred due to having more robust gram-negative anaerobic coverage, less frequent dosing, ability to be taken on an empty stomach, and a lower incidence of gastrointestinal side effects.
If treatment is initiated for non-suppurative indications (e.g., gingivitis and periodontitis), antibiotic therapy is usually until oral lesions have healed and pain has subsided, typically 5 to 7 days. Antibiotic duration of therapy for suppurative infections is usually 3 to 7 days depending on clinical improvement. The implementation of follow-up for patients initiated on antibiotic therapy is of utmost importance. Dentists should reevaluate patients for improvement or lack thereof with an in-person visit, telehealth appointment, or follow-up phone call. In gen eral, most patients can stop taking antibiotics after 24 hours of complete symptom resolution, irrespective of re-evaluation after 3 days. If patient symptoms do not improve with initial therapy, clinicians should consider broadening therapy by either adding metronidazole to first-line therapy or discontinuing initial therapy and beginning amoxicillin/clavulanate (both options are typically for a 7-day duration).23
Red flags: might indicate spreading infection
amoxicillin 500 mg PO TID + metronidazole 250 – 500 mg PO BID/TID∆ TID250amoxicillin/clavulanateOR–500mgPOBID/or875mgPOBID¥
± Addition of agent with Pseudomonas aeruginosa and other gram-negative bacilli coverage if patient is immunocompromised
(streptococciGingivitis [e.g., Streptococcus mutans), Actinomyces spp.])
amoxicillin/ clavulanate 250 –500 mg PO BID/ TID or 875 mg PO BID¥
Common Side Effects
Piperacillin/tazobactamOR 4.5 g IV every 6 hours±
Antibiotic Dose Forms Usual Dosing
¥ More expensive than amoxicillin, more gastrointestinal upset (mainly diarrhea), more broad coverage includes anaerobes and gram negative pathogens
(macrolideAzithromycinantibiotic) injectabletablet,Suspension,capsule,
Infants > 3 months of age: 25–45 mg/ kg/day in divided doses every 12 hours (max 875 mg/dose; dosed off the clavulanate component)
Nausea, vomiting, head ache, diarrhea
Infants > 3 months of age < 40 kg: 25–45 mg/kg/day in divided doses every 12 hours (max 875 mg/dose)
Headache, stomach pain or diarrhea, nausea, vomiting
tablet,Suspension,capsule
Infants, children, and adolescents (mild–moderate infection): 25–50 mg/kg/day divided every 6 to 12 hours [max of 2 grams/day]) Severe infection: 75–100 mg/kg/day divided every 6–8 hours (max of 4 grams/day)
(lincomycinClindamycinantibiotic) ablecapsule,Suspension,inject-
May take with or without food
Constipation, diarrhea, stomach pain, stomach cramps, nausea, vomiting, metallic taste, headache, joint pain
Liquid solution, tablet
Should be taken on empty stomach for adequate absorption
Antibiotic Dose FormsUsual Dosing Common Side EffectsComments
caused by antibiotics are the most commonly reported reason for emergency department (ED) visits by those who are under the age of 18, which is represented by 140,000 ED visits each year specifically due to antibiotic adverse drug events.27
45endopracticeus.com Volume 15 Number 3 CONTINUING EDUCATION
Nausea, vomiting, abdom inal pain, diarrhea
Black boxed warning: Clostridioides difficile-associated diarrhea; Option for patients with Type 1 allergy to penicillin and/or cephalosporin agents; no longer recommended for infective endocarditis prophylaxis antibiotic)(tetracyclineDoxycycline ablecapsule,releasetablet,Suspension,delayedtablet,inject-
Children > 8 years old: 2.2 mg/kg/dose every 12 hours (max 100 mg/dose)
Tooth diarrhea,nausea,discoloration,vomiting,lackofappetite
Table 3: Antibiotics for dental infection in pediatric patients33-41
With or without meals, w/meals increases absorption and decreases GI upset. ES needs to be taken with food. Use the lowest dose of clavulanate to decrease GI side effects
Children and adolescents (anaerobic skin and bone infections): 15–50 mg/ kg/day in divided doses 3 times daily (max of 2,250 mg/day)
Children and adolescents: 25–50 mg/ lg/day in divided doses every 6 hours (max of 2 grams/day)
ClavulanateAmoxicillin/ (penicillin/ β-lactam- β-lactam inhibitor antibiotic)combination tabletchewableSuspension,tablet,
Antibiotic treatment — pediatric considerations
Stomach pain, diarrhea, nausea, vomiting, bad taste in mouth
Methicillin resistant Staphylococcus aureus (MRSA) 30–40 mg/kg/day in divided doses every 6–8 hours
The administration of medications for pediatric patients is even more complex compared to adults because of the need to dose based on the child’s weight and take into consideration concerns that are not applicable to adults. Adverse reactions
Amoxicillin (penicillin/ β-lactam antibiotic) tablet,chewableSuspension,tablet,capsule
Nausea, diarrhea,vomiting,diaperrash
Should not be used in those with a history of anaphylaxis, angioedema, or urticaria with penicillin agents
Administer with or without food (with food decreases stomach upset, but can also decrease absorption); take with fluid and remain in upright position to decrease throat irritation) antimicrobial)(nitroimidazoleMetronidazole ablecapsule,releasetablet,Suspension,extendedtablet,inject-
Nausea, discoloration,abdominalvomiting,pain,tonguediarrhea
Penicillin V potassium (penicillin/β-lactam antibiotic)
Children ≥ 6 months up to 16 years old: 10 – 12 mg/kg on day 1 (max of 500 mg), followed by 5 – 6 mg/kg once daily x 4 days (max of 250 mg/day) [total duration of 5 days]
Option for patients with Type 1 allergy to penicillin or cephalosporin antibiotics; can cause cardiac arrhythmias in patients with preexisting cardiac conduction defects
β-lactam antibiotic)
In addition, pediatric patients still have the same risks of side effects from antibiotics as adult patients, including the potential of increased resistance, allergic reactions, development of Clostridioides difficile infections, drug interactions, and common as well as rare side effects. Pediatric patients as young as 4 years old were found to harbor multidrug resistant bacteria in their mouths because of the overuse of antibiotics.28 Moreover, some antibiotics routinely used in adults have either not been studied in children or have demonstrated concern in animal models or in pediatric case reports. Tetracyclines and fluoroquinolones are two classes of antibiotics that are generally avoided in children.29
performed over a 3-year period with the objective to evaluate shortened courses of antibiotics in the management of dentoal veolar abscesses. After abscess drainage, patients were treated with amoxicillin, erythromycin, or clindamycin. A robust 98.6% of the 759 patients had full resolution of symptoms at day three of treatment, and antibiotics were discontinued at that time. The study concluded that the duration of antibiotics in most patients with acute dentoalveolar infections can safely be 2 to 3 days, provided I&D has been performed.26
cephalosporin/(1stCephalexingeneration
Black Boxed Warning: Carcinogenic in rats and mice, unnecessary use should be avoided; ingestion of alcohol as a beverage or an ingredient in medications or propylene glycol-containing products should be avoided
10–25 mg/kg/day in divided doses every 8 hours (max 450 mg/dose)
17. Santos RS, Macedo RF, Souza EA, et al. The use of systemic antibiotics in the treatment of refractory periodontitis: A systematic review. J Am Dent Assoc. 2016;147(7):577-585.
Clinician expertise in addition to evidence should be used when making treatment decisions for patients.
When a dental clinician is considering antibiotic use in chil dren, it is important as with adults to make sure that antibiotics are truly warranted.30-33 If caregivers are pressing for a prescrip tion despite lack of evidence for necessity, it is wise to educate on the downstream negative effects. If antibiotics are considered appropriate, dosing and route of delivery should be taken into consideration as well as common and uncommon red flags for use in pediatrics (summarized in Table 3).33-41 Not only should the negative effects of antibiotics be discussed, but the preven tion of dental caries with appropriate oral health maintenance should be reinforced.32
5. Fluent MT, Jacobsen PL, Hicks LA. Considerations for responsible antibiotic use in dentistry. J Am Dent Assoc. 206:147(8):683-686.
24. Jaworsky D, Reynolds S, Chow AW. Extracranial head and neck infections. Crit Care Clin. 2013;29(3):443-463.
33. American Academy of Pediatric Dentistry. Use of antibiotic therapy for pediatric dental patients. The Reference Manual of Pediatric Dentistry. American Academy of Pediatric Den tistry; 2021. American Academy of Pediatric Dentistry. Useful medications for oral conditions. The Reference Manual of Pediatric Dentistry. American Academy of Pediatric Dentistry; 2019.
41. Penicillin V potassium. Pediatric and Neonatal Lexi-Drugs. Lexicomp Online. https://online. lexi/com. Accessed June 23, 2022.
12. López-González E, Vitales-Noyola M, González-Amaro AM, et al. Aerobic and anaerobic microorganisms and antibiotic sensitivity of odontogenic maxillofacial infections. Odontol ogy. 2019 107(3):409-417
23. Shukairy MK, Burmeister C, Ko AB, Craig JR. Recognizing odontogenic sinusitis. A national survey of otolaryngology chief residents. Am J Otolaryngol. 2020;41(6):102635.
35. Amoxicillin/Clavulanate. Pediatric and Neonatal Lexi-Drugs. Lexicomp Online. https:// online.lexi/com. Accessed June 23, 2022.
20. Robertson DP, Keys W, Rautemaa-Richardson R, et al. Management of severe acute dental infections. BMJ. 2015;350:h1300
2. Centers for Disease Control and Prevention. Antibiotic Resistance Threats in the United States; 2013.
3. Fleming-Dutra KE, Hersh Al, Shapiro DJ, et al. Prevalence of inappropriate prescriptions among US ambulatory care visits, 2010-2011. JAMA. 2016;315(17):1864-1873.
Summary
25. Zawislak E, Nowak R. Odontogenic head and neck region infections requiring hospitalization: An 18-month retrospective analysis. BioMed Res Int. 2021;708763.
15. Tanner A, Stillman N. Oral and dental infections with anaerobic bacteria: clinical features, predominant pathogens, and treatment. Clin Infect Dis. 1993;16(suppl 4):S304-S309.
6. Durkin MJ, Hsueh K, Haddy Y, et al. An evaluation of dental antibiotic prescribing practices in the United States. J Am Dent Assoc. 2017:148(12):878-886
27. Centers for Disease Control and Prevention. Antibiotic/Antimicrobial Resistance Threats in the Unites States, 2013.
32. Fontana M, Karimbux NY, Cabezas C, Kim DM, Dragan IF. Dental Caries and Gingival and Periodontal Infections. In:. Pediatric Infectious Diseases: Essentials for Practice. Shah SS, Kem per AR, Ratner AJ (eds). McGraw Hill; 2019.
36. Azithromycin. Pediatric and Neonatal Lexi-Drugs. Lexicomp Online. . https://online.lexi/com. Lexicomp; 2022. Accessed June 23, 2022.
G. Alexander Fleming: The Man and the Myth. Harvard University Press; 1984.
21. Jaramillo A, Arce RM, Herrera D, et al. Clinical and microbiological characterization of peri odontal abscesses. J Clin Periodontol. 2005;32(12):1213-1218.
Tetracycline antibiotics (including doxycycline) may cause per manent tooth discoloration, enamel hypoplasia in developing teeth, and hyperpigmentation of the soft tissues. Because of the tooth and soft tissue related side effects of tetracyclines, their use is not recommended for pregnant women or children under the age of 8 years old. However, short-term (less than 21-day) use of doxycycline is advocated by the American Academy of Pedi atrics as appropriate when benefits outweigh risks for certain infections due to the lack of evidence of the tooth discoloration side effect.30 Fluoroquinolone antibiotics appear at first glance to be an attractive choice since they are broad-spectrum agents, highly active in vitro against gram-positive and gram-negative pathogens, and are dosed only 1 to 2 times a day. However, these agents have numerous warnings associated with their use in patients of all ages as well as concerns related to increased possibility of musculoskeletal adverse effects in children.30 Fluoroquinolone (moxifloxacin) use within dentistry should be reserved for pediatric patients who are unable to take firstand-second line agents due to allergy or resistance.
9. Centers for Disease Control and Prevention. Antibiotic Stewardship. https://www.cdc.gov/ oralhealth/infectioncontrol/faqs/antibiotic-stewardship.html. Accessed June 23, 2022.
10. Ogle OE. Odontogenic Infections. Dent Clin N Am. 2017(61):235-252.
19. Mylonas I. Antibiotic chemotherapy during pregnancy and lactation period: aspects for con sideration. Arch Gynecol Obstet. 2011:283(1):7-18.
31. Goel D, Geol GK, Chaudhary S, Jain D. Antibiotic prescriptions in pediatric dentistry: A review. J Family Med Prim Care. 2020; 9(2):473-480.
38. Clindamycin. Pediatric and Neonatal Lexi-Drugs. Lexicomp Online. https://online.lexi/com. Accessed June 23, 2022.
40. Metronidazole. Pediatric and Neonatal Lexi-Drugs. Lexicomp Online. https://online.lexi/com. Accessed June 23, 2022.
8. Joseph J, Rovold KA. The role of carbapenems in the treatment of severe nosocomial infec tions. Expert Opin Pharmacother. 2008;9(4):561-574.
16. Moore PA, ZieglerKM, Lipman RD, et al. Benefits and harms associated with analgesic medi cations used in the management of acute dental pain: an overview of systemic reviews. J Am Dent Assoc. 2018; 149(4):256-265.
Disclaimer
14. Brook I, Frazier EH, Gher ME. Microbiology of periapical abscesses and associated maxillary sinusitis. J Periodontol. 1996;67(6):608-610.
26. Martin MV, Longman LP, Hill JB, Hardy P. Acute dentoalveolar infections: an investigation of the duration of antibiotic therapy. Br Dent J. 1997;183(4):135-137.
46Endodontic Practice US Volume 15 Number 3 CONTINUING EDUCATION
29. Jackson MA, Schutze GE, Committee On Infectious Diseases. The Use of Systemic and Topical Fluoroquinolones. Pediatrics. 2016;138 (5):e20162706.
30. Committee on Infectious Diseases, American Academy of Pediatrics. Antimicrobial agents and related therapy, Section 4. In: Kimberlin DW, Barnett ED, Lynfield R, et al. eds. Red Book: 2021-2024 Report of the Committee on Infectious Diseases. 32nd ed. American Academy of Pediatrics; 2021.
28. Ready D, Bedi R, Spratt DA, Wilson M. Prevalence, proportions, and identities of antibiotic-re sistance bacteria in oral microflora of healthy children. Micro Drug Resist. 2003;9(4):367-372.
1.REFERENCESMacfarlane
7. Ralph D, Azarpazhooh, Laghapur N, Suda KJ, Okunseri C. Role of dentists in prescribing opioid analgesics and antibiotics: an overview. Dent Clin North Am. 2018: 62(2):279-294.
11. Dental and Periodontal Infections. In: Ryan KJ. eds. Sherris & Ryan’s Medical Microbiology, 8th edition. McGraw Hill; 2022. https://accessmedicine.mhmedical.com/content.aspx?book id=3107§ionid=260928993. Accessed June 23, 2022.
18. Gonzalez JR, Harnack L, Schmitt-Corsitto G, et al. A novel approach to the use of subgingival controlled-release chlorhexidine delivery in chronic periodontitis: a randomized clinical trial. J Periodontol. 2011;82(8):1131-1139.
37. Cephalexin. Pediatric and Neonatal Lexi-Drugs. Lexicomp Online. https://online.lexi/com. Accessed June 23, 2022.
IP
4. Centers for Disease Control and Prevention. Outpatient Antibiotic Prescriptions – United States, 2020.
13. Peterson LR, Thomson RB. Use of the clinical microbiology laboratory for the diagnosis and management of infectious diseases related to the oral cavity. Infect Dis Clin North Am. 1999;13(4):775-795
22. Ahmad N, Abubaker AO, Laskin DM, Steffen D. The financial burden of hospitalization associ ated with odontogenic infections. J Oral Maxillofac Surg. 2013;71(4):656-658.
34. Amoxicillin. Pediatric and Neonatal Lexi-Drugs. Lexicomp. https://online.lexi/com Lexicomp; 2022. Accessed June 23, 2022.
39. Doxycycline. Pediatric and Neonatal Lexi-Drugs. Lexicomp Online. https://online.lexi/com. Accessed June 23, 2022.
It is important to properly walk the fine line of treating infections that need to be managed with a short course of nar row spectrum antibiotics versus overprescribing antibiotics for either noninfectious indications or localized dental infections that don’t warrant antibiotics. With judicious use of antibiotics, dental practitioners can help curb the global threat of antibiotic resistance as well as avoid unnecessary side effects and increased cost for patients. Table 1 provides a summary of tools that can enable such practice.
d. streptomycin
8. In patients with a severe allergy to penicillin agents or other β-lactams, _________ can be prescribed.
c. below the gum manipulation
a. surgical drainage of an abscess
b. cholera
a. 10% b. 30% c. 40% d. 50%
a. 500,000
b. Irreversible pulpitis
1. Alexander Fleming’s breakthrough discovery of __________ paved the way for a domain of medicine that has enabled once deadly infections to be readily treatable.
n To receive credit: Go online to https://endopracticeus.com/continuingeducation/, click on the article, then click on the take quiz button, and enter your test answers.
AGD Code: 148
2. According to the Centers for Disease Control and Prevention (CDC), approximately _________ Americans are infected with resistant patho gens that result in 23,000 deaths annually.
d. Gram-positive streptococci
Expiration Date: September 1, 2025
c. Pericoronitis
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6. (When choosing an antibiotic for non-suppurative or suppurative odontogenic infections) Although both agents were regarded as first line, ___________ was generally preferred due to having more robust gram-negative anaerobic coverage, less frequent dosing, ability to be taken on an empty stomach, and a lower incidence of gastrointestinal side effects.
c. 2 million d. 3 million
c. tetanus
Dental infections: help avoid antimicrobial resistance — part 1 BRUCK/PRICE
a. azithromycin or clindamycin b. doxycycline and levoflaxin c. cefzil or tetracycline d. metronidazole or moxifloxacin
Date Published: September 1, 2022
2 CREDITSCE
c. amoxicillin
a. penicillin V
d. azithromycin
3. The CDC conservatively approximates that _________ of all outpatient antibiotic prescriptions written from 2010 to 2011 were unnecessary.
47endopracticeus.com Volume 15 Number 3 CONTINUING EDUCATION
a. penicillin
4. Even when antibiotics are needed to treat dental infections, they might not be the first line therapy, but rather an adjunct after ________.
b. 1 million
5. ________ is/are characterized by acute and intense pain and is one of the most frequent reasons that patients seek emergency dental care.
a. Dental caries
To provide feedback on CE, please email us at education@medmarkmedia.com
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b. cephalexin
10. Tetracyclines and fluoroquinolones are two classes of antibiotics that are ________. a. preferred for treatment of children b. generally avoided in children c. always recommended for use by pregnant women d. none of the above
Continuing Education Quiz
b. tissue debridement
7. ______ — a first-generation cephalosporin with similar gram-positive aerobic coverage as the historic first line agents but that lacks robust anaerobic activity — is the antibiotic of choice in those with a history of penicillin allergy without history of anaphylaxis, angioedema, or d.c.b.a.hives.CephalexinCefaclorCefuroximeCeftibuten
9. If treatment is initiated for non-suppurative indications (e.g., gingivitis and periodontitis), antibiotic therapy is usually until oral lesions have healed and pain has subsided, typically _______. a. 1 day b. 2 to 4 days c. 5 to 7 days d. 8 to 10 days
d. all of the above
3. Possible to use with cold or warm technique
EP
48Endodontic Practice US Volume 15 Number 3 PRODUCT PROFILE
With a flow of approximately 24 mm and micronized parti cles smaller than 2 µm, the product has excellent viscosity that quickly penetrates into different ramifications of the complex root canal system, in addition to penetrating more easily into the dentinal tubules, favoring the formation of a hermetic and three-dimensional filling.
BIO-C®
1. Resin-free and eugenol-free material
5. Radiopaquer
5 reasons to choose BIO-C® Sealer ION+
The product contains zirconium oxide as a radiopaquer, resulting in an excellent radiographic image (≥ 7.0 mm Al), in addition to not causing tooth staining like other products on the market that uses bismuth oxide instead.
BIO-C® Sealer ION+ does not have resin in its composition. Therefore, it is easy to clean with water. In addition, BIO-C® Sealer ION+ does not cause posttreatment symptoms and, as an eugenol-free material, also does not interact negatively with other products that can be used in the root canal (such as adhe sive cements).
Root canal filling techniques that use the heated gutta per cha reach a temperature of 392°F. BIO-C® Sealer ION+ remains stable at this temperature unlike other sealers that degrade at temperatures close to 291°F.
In addition to being easy to use, it presents an innovative formula with modified calcium silicate with unique character istics in terms of biological activity, which constantly releases calcium ions that will stimulate the production of hydroxyapatite and accelerate bone regeneration.
BIO-C® Sealer ION+ is a ready-to-use bioceramic root canal sealer
4. Low solubility
2. Excellent flow
With a solubility of less than 3%, bacterial reinfection is avoided as it will not have the formation of gaps in the material after its setting, ensuring a homogeneous filling and increasing the chances of successful treatment.
Image courtesy of Prof. João Vicente Barbizam
BIO-C® Sealer ION+
BIO-C ® Sealer ION+
Sealer ION+ is displayed in a syringe with intracanal tips, which allow the product to be easily inserted directly into the root canal up to the most apical region.
This information was provided by Angelus.
Dr. Eric Herbranson discusses traditional theories and embracing change
clinicians, we like to think of ourselves as scientists — or at least we think we base our opinions and practices on science and the scientific method. You know, that old process: Make an observation. → Ask a question. → Form a hypothe sis. → Test your prediction. → Iterate your opinions. → “Truth” Hopefully, this scientific process leads to some reliable ver sion of the truth we can count on. But does it? What we are actually doing is forming a theory or mental model of how things work. We work off of these models, not off of a direct knowledge of how nature works. Our models are a couple of degrees of separation from the reality of nature — because of that, they are inherently not accurate. The British statistician George F. P. Box quotes, “Remember that all models are wrong; the practical question is how wrong do they have to be to not be useful.”1 Or to put it more succinctly, “All models are wrong, but some are Weuseful.”like our models. We hold many models of different sizes that form blocks of knowledge. These blocks can nest. For instance, a big, overarching model is based on a number of smaller, more specific models. The cognitive psychologist John Sweller called these “schemas.”2 They are very useful in understanding how the brain works, understanding learning in communicating, in problem solving, etc. The acquisition and retentions of domain-specific knowledge in the form of sche mas is what separates the expert from the novice. They form the “library” of information we use in our field. In any given scien tific field, there will be agreed upon schemas with specific lan guage prescribed to them. For instance, in endodontics, we can have a schema labeled “obturation” that would include other schemas like “warm vertical condensation” and that could have “injected backfill” nested within it. And so it goes for the whole knowledge base of the field. There is a certain outline hierarchy to the information. This is the organization of the knowledge base we work off of professionally. This acquisition of knowl edge, theories, models, schemas, or whatever you want to label
“The problem is that our ideas are sticky: once we produce a theory, we are not likely to change our minds — so those who delay developing their theories are better off. When you develop your opinions on the basis of weak evidence, you will have difficulty interpreting subsequent information that contradicts these opinions, even if this new information is obviously more accurate. Two mechanisms are at play here: the confirmation bias … and belief perseverance, the ten dency not to reverse opinions you already have. Remember that we treat ideas like possessions, and it will be hard for us to part with them.”
My friend, John Khademi, in his article titled “Incommensu rability in Endodontics,” characterized the resistance to change this way; “Knowledge blocks learning.”4 We’re comfortable with what we know; why change it! The problem is, to change our knowledge base requires more effort than acquiring it in the first place because we must deconstruct it before we can reconstruct it. Adult learning is more difficult than traditional education for this reason. There also may be an issue with less neuroplasti city with aging that makes change more difficult. Suffice to say, changing our knowledge base requires work and is resisted unless there is a compelling reason to put the effort in.
Eric Herbranson, DDS, MS, received his DDS and MS in Endodontics from Loma Linda University. He is recently retired from active practice in the San Francisco Bay area. He has a long history of lecturing nationally and internationally.
Disclosure: Dr. Herbranson is a member of the Sonendo® Scientific Advisory Board.
50Endodontic Practice US Volume 15 Number 3 ENDOSPECTIVE
Figure 1: This is an SEM of a section of a canal system of an extracted root after the GW cycle was run. While the uninstrumented portion is rougher in appear ance, it is as clean as the instrumented section
In reality, there is a constant slow change based on what Thomas Kuhn calls “normal science,”5 that is science, while
As
Evolution or revolution in endodontic thought
them, takes effort and time. It represents a huge investment and is an asset with personal value. Nassim Taleb describes this in his book, The Black Swan:3
Figure 2: This drawing is from an article arguing for the for aggressive shaping of the apex.8 This approach with its inherent compromise to tooth integrity is no longer needed with the advanced irrigation described here
The tendency is to view this technology as just a better mouse trap and plug that into the “cleaning” schema. That would be a mistake. The implications are more profound than that. There is an opportunity here to redefine our foundation treatment model.
Working through this process to where there is universal acceptance of the new information takes time. It can literally be decades. An example in endodontics would be the adop tion of the surgical operating microscope. The initial push for adoption started in the early 1990s, driven to a significant degree by Dr. Gary Carr. There was much controversy and sig nificant pushback by some established practitioners. Today it is a non-issue, and the assumption is endodontists will use a microscope for most of their work. One could rightly make the claim that the acceptance of surgical microscopes in end odontics was a 25- to 30-year process. Less obvious is how this adoption has changed other areas of the profession. The move toward smaller instruments, while driven by dentin conserva tion ideas, was made possible by the increased vision afforded by the microscopes. General adoption of CBCT technology has led to a significant awareness of tooth anatomy, which combined with improved vision, allows for more detailed and preciseEndodoticsprocedures.isbased on the model described in “Endodontic triad for success” of shaping, cleaning, and packing.6 We believe that achieving success in these three areas will eliminate the pulpal remnants and bacteria that are judged to be the cause of apical periodontitis. Apical periodontitis is the endodontist’s disease. We believe that if we can eliminate organic debris through cleaning and shaping the canal to receive an obtura tion material that hermetically seals off the canal space, we will achieve endodontic “success.”7 This will allow the body to heal the disease of apical periodontitis. We have held this belief for so long and with such reverence that it is rarely challenged. The terms shaping, cleaning, and packing are labels for schemas that are packed with the science data, beliefs, protocols, and biases we use to support our model. They are cross-linked and form the conceptual framework of our general disease treatment theories. Through the years, there has been a lot of refining of these sche mas and some divergence in viewpoint represented by various camps who promote and argue their particular biases. They also contain legacy ideas whose origins are foggy and validity sus pect. But there is general agreement that the biological objec tives of cleaned and sealed canals will result in healing of “our”
based on questions and problem solving, tends to be evolutionary. The changes are small and serve to “polish” or refine the schemas. There is conceptual continuity with cumulative progress in this model. Our sche mas adapt gracefully to this process because the changes are small and not disruptive. But Khun also describes necessary periods of revolutionary science where the discovery of “anomalies” in the base concepts results in new paradigms that lead to new questions and challenges the rules of the game.5 This disruptive process creates tension both in the individual as well as the whole field of endeavor. So rather than our schemas being setteled, they are disrupted, which cre ates echoes into other connected schemas. Having a conceptual change in a schema can affect the whole field.
51endopracticeus.com Volume 15 Number 3 ENDOSPECTIVE
disease. Of course, this is not “truth,” it is just a model of how we think nature works, so it is no doubt wrong in places. To some degree, it is also a house of cards with pockets of inconsistency and cognitive Technologydissonance.reallyhasn’t impacted this. Microscopes and CBCT machines have improved our vision, and NiTi metallu ragy have taken the stress out of shaping, but they have not fundamentally changed the concepts of how or why we do things. New technologies focused on debridement and disin fection will challenge the concepts of how and why we clean andOneshape.such new technology is the GentleWave® System (GW) (Sonendo®, Laguna Hills, California). The method of action of the device is considerably different than our legacy protocols, and this method of action disconnects instrumentation from dis infection. The GW uses a clever manipulation of fluid dynamic to create a multifrequency wall of small shock waves (multisonic sound) in the solutions while it replenishes the solutions. This sonic energy activates the chemical reactions of our traditional irrigation solutions of NaOCl and EDTA. The combination does the work to debride and disinfect the canal system. This energy travels to all aspects of the anatomy equally and is anatomy-ag nostic in its effectiveness. It cleans distant small lateral anatomy as effectively as major anatomy. Its cleaning effectiveness is very good (can approach 100%) and significantly better than any of our legacy irrigation protocols.
We have an opportunity to put aside our biases, rebuild our schemas, reshuffle the treatment deck, and embrace a new way of doing a root canal.
An adjunct and complimentary technology change is the introduction of bioceramic sealers. Their ability to hermetically seal in large film thicknesses has changed obturation dynamics. Instead of the gutta percha being the main obturation material, the sealer is. The gutta-percha point becomes the condensation
Other technologies based on either the Er:YAG laser or the Er,Cr:YSGG laser are also challenging the way clinicians approach cleaning and shaping. The lasers have their own unique set of opportunities based on their individual methods of action. The lasers provide alternatives means for recapitulation, instrumentation, and disinfection.
3. The need for very accurate length determination is sig nificantly reduced. Electronic apex lengths and wire film radiographs are not generally necessary. Lengths judged from a CBCT scan are accurate enough for the debulking instrument pass. The technology will find and clean the apex to its natural end.
FP. All models are wrong. Wikipedia. https://en.wikipedia.org/wiki/ George_E._P._Box. Accessed August 1. 2022.
a. Debulk the canal to reduce the debris load.
device for the sealer. A single cone bioceramic fill with some minimal hydraulics can provide complete three-dimensional obturation to the thinner, rougher shapes that result from this technology. So the “look” will change. The fat smooth shapes of the past will be replaced with skinnier and less smooth fills. This will be the new look and our new definition of beauty.
1. We no longer need to machine dentin to remove biofilm and debride pulp tissue. The sonic energy will do that work. This eliminates shaping as an adjunct to cleaning, which changes the function of the file. The result is a significant change in our protocols. In fact, in some sit uations, it may not be necessary to use a file at all. In a necrotic tooth with open anatomy the canal system can be effectively cleaned without using files. The resultant shape is what nature provided. But practically, files are needed in many cases. They are used to perform these tasks:
The high degree of debridement of this technology creates the following opportunities.
c. Smooth a rough canal to facilitate obturation if necessary.
2. Sweller, J. Cognitive load during problem solving: Effects on learning, Cognitive Sci ence, 1988;12, 257-285
d. In most teeth, a single pass with one file carried to within a couple of mm of the apex will accomplish these objectives.
6. The computer controlled closed-loop system creates con sistent and predictable results.
5. Pre-op pain is minimized. Patients report very low levels of post-op pain, and most have complete relief within 24 hours regardless of their pre-op pain levels.
1.REFERENCESBoxGeorge
3. Taleb NN. The Black Swan: The Impact of the Highly Improbable. Random House; 1997.
4. Khademi J, Clark D. Incommensurability in Endodontics: The Role of the Endodontic Triad. N J Dent Assoc. 2016;87(4):18-20.
7. Schilder H. Cleaning and shaping the root canal. Dent Clin North Am. 1974;18(2): 269-296.
Figure 3: This four-canaled lower molar illustrates the typical dentin-conserv ing shaping this new technology facilitates
4. A single visit is the desired model. The canal system is cleanest right after the device cycle is run, and obturation should proceed immediately if possible.
2. GW technology is capable of cleaning natural apical anatomy. This eliminates the need for apical shaping and recapitulation. It is no longer necessary to aggressively file an apex to clean it. In fact, it can be argued that any instrument placed at the apex is a disadvantage. The son ics will clean the apex without mechanical intervention.
5. Kuhn TS. The Structure of Scientific Revolution. 3rd ed. The University of Chicago Press; 1966.
In conclusion, while evaluating this new technology for effectiveness and efficiency, we need to take a broad view of how it impacts all our protocols to get the maximum benefit. That view will show us we are facing a revolutionary change in how we approach the Endodontic Triad. We have an opportunity to put aside our biases, rebuild our schemas, reshuffle the treat ment deck, and embrace a new way of doing a root canal. The opportunity is greater than we think.
e. Dentin conservation to maintain tooth strength is fully supported. There is no cleanliness advantage with larger shaping. Very small shapes can be cleaned as effectively as larger shapes.
6. Ruddle CJ. Endodontic triad for success: The role of minimally invasive technology. Dent Today. 2015;34(5):76-80.
EP
8. Card SJ, Sigurdsson A, Orstavik D, Trope M. The effectiveness of increased apical enlargement in reducing intracanal bacteria. J Endo. 2002;28(11)779-783.
b. Guarantee a path for the solutions.
52Endodontic Practice US Volume 15 Number 3 ENDOSPECTIVE
A 42-year-old white male, experiencing pain on the lower left side of his mouth for several weeks, was referred from his general dentist. Clinical examination and periapical radiograph revealed a large carious lesion on tooth No. 19 and decay that was close to the pulp (Figure 1). Pulp and periapical testing were performed, confirming a diagnosis of irreversible pulpitis. The patient agreed to have root canal treatment performed the same day.
Zarc4Endo creates the first multi-alloy file system — who’s currently ahead in instrumentation/shaping techniques?
Case discussion
The patient was anesthetized with two carpules of 2% lidocaine 1:100,000 epi via an inferior alveolar block. Buccal and lingual infiltration were then performed with one carpule of articaine 1:100,000 epinephrine. The tooth was isolated with a rubber dam, and the decay was removed in the clinical crown. Upon access and debridement, MB, ML, DB, and DL canals were located. Irrigation was performed using full-strength sodium hypochlorite with side-vented Z-Rinse irrigation needles (ZARC, Madrid, Spain) while very carefully applying positive pressure. Working length was established with an apex loca tor. The four canals were cleaned and shaped with the ZARC BlueShaper double-alloy system, finishing with Z4 (25, 6% taper) and using the standard sequence Z1-Z2-Z3, and Z4.
54Endodontic Practice US Volume 15 Number 3 PRODUCT SPOTLIGHT
Anticurvature shaping and lateral con densation has been relegated to antiquity. Modern endodontic obturation techniques now incorporate primarily a rotary or recip rocating mechanical procedure. When choosing shaping files, endodontists look for security (low risk of breakage), cutting efficiency, and flexibility. In early 2021, Zarc4Endo (ZARC) launched BlueShaper® , the world’s first double-alloy file system. ZARC’s 6th-generation instruments mix multiple alloys, including ZARC’s new and proprietary pink alloy, giving more stiffness (stiffer alloy) without unwinding to the instruments that need higher cutting efficiency, and more flexibility and cyclic fatigue resistance (softer alloy) for the larger diameter instruments to prepare the apical area. The BlueShaper system simplifies and optimizes most root canal procedures. BlueShaper can shape canals faster with security while keeping the original anatomy largely intact.
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Introduction
A cone-fit radiograph was obtained to ensure proper length and fit after cleaning and shaping. A final rinse of 17% EDTA and 6% NaOCl was used in all four canals after which the canals were dried with paper points. NeoSEALER® Flo bioceramic sealer (Avalon Biomed™, Houston, Texas) was placed in all the canals with the Avalon Biomed ultra-low-waste Flex Flo™ dis pensing tip. The stopper was approximately 5 mm to 7 mm from the working length to minimize extrusion of the sealer. Finally, gutta-percha cones were placed inside the canals, and warm vertical compaction was used for the obturation. The bioceramic sealer flowed evenly and compacted well with no drying out at a temperature of 180ºC.
The postoperative radiograph (Figure 2), confirmed that the BlueShaper file system allowed for uniform and consistent shap ing of the canals while maintaining the original canal anatomy despite significant curvatures.
Summary
Dr. José Aranguren, endodontist, and cofounder of Zarc4Endo – Madrid, Spain, discusses the new revolutionary ZARC BlueShaper® file system.
The patient experienced no postoperative pain and will be recalled in 6 months. He was referred back to his general dentist for a final restoration within 30 days and to-date has remained asymptomatic.
We and our patients need security and efficiency in our treat ments and, at the same time, a file system that provides flexibility to maintain the original canal anatomy. The BlueShaper file system is extremely versatile, yet simple, and combines all these char acteristics. Contact Dr. José Aranguran at josearanguren@hotmail. com and on Instagram @endojosearanguren. This information was provided by Avalon Biomed™.
Figures 1 and 2: 1. Pre-op radiograph of tooth No. 19 with large decay and irreversible pulpitis. 2. Post-op radiograph after completion of the root canal maintaining the original anatomy using the BlueShaper® file system from ZARC and NeoSEALER® Flo bioceramic sealer from Avalon Biomed™
THE WORLD’S FIRST DUAL ALLOY SYSTEM Launching at ADA Smilecon 10.13.2022
• How would an outside coach view my practice?
Albert Goerig, DDS, MS, is a Diplomate of the American Board of Endodontics and a sought-after speaker who has lectured extensively on the field of endodontics and practice success throughout the United States, Canada, and abroad. He is the author of more than 100 published articles and contributing author to numerous endodontic textbooks. Dr. Goerig has a private endodontic practice in Olympia, Washington, in the top 1% nationwide for practice profitability. He has almost 40 years of experience as an endodontic educator and practice coach to over 1,000 endodontists. www.endomastery.com | 1-800-482-7563 | info@endomastery.com
Here are some perspective questions you should cultivate to overcome your blind spots. Think about each one as a blind per son touching just one part of your practice. What do you sense, and what conclusions do you reach?
• What are my pluses and minuses compared to other end odontic practices?
Most doctors have difficulty developing their outside-in perspective because they don’t have the in-depth knowledge to evaluate their businesses objectively. Blind spots usually lead them to underestimate opportunities. The light goes on once you shift your perspective and start looking at your elephant in the right way.
• What is the perspective of team members who work in my practice? Beyond clinical care, what would my team describe as my main priorities as a business leader?
endodontists spend the vast majority of their time focused on treatment, which is a very limited perspective for a business owner and the source of many blind spots. Viewing your practice only from the position of a doctor in the operatory is akin to looking from the inside-out. As a practice owner, you need to look from the outside-in.
• If I were a different doctor who was buying my practice, what opportunities would I see, and what limitations have been allowed to persist?
The elephant in your life
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Dr. Albert (Ace) Goerig offers practice perspectives that you’ll never forget
An ancient elephant parable tells the story of how six blind men each touched different parts of the elephant and tried to describe it. Depending on what part they touched, they formed different perspectives on how the elephant appeared: The tail was a rope, the side was a wall, the ear was a fan, the leg was a tree, the tusk was a spear, and the trunk was a snake. None of them had the full Similarly,picture.
• Is the practice as happy and healthy as possible financially?
know any more about elephants than the average person, but I am confident that specialized skills are required to keep an elephant as happy and healthy as possible. Since endodontists go to dental school and not business school, practice owners are responsible for an elephant in the form of your practice. It’s a huge, dominating ele ment in your life.
• What perception do patients have when they call my practice, arrive at my facility, and experience my team and me during their appointment?
Idon’t
• How does my practice and team appear to referring doc tors and their team?
The light goes on once you shift your perspective and start looking at your elephant in the right way.
56Endodontic Practice US Volume 15 Number 3 PRACTICE MANAGEMENT
A relationship with US Endo Partners gives you access to a vast network of partners, empowering you to network and connect with endodontists at the top practices across the nation. This access to the US Endo network also means you have the ability to gain mentors, resources and the security of working in well established practices as you start or grow your career. Today.
“There’s the feeling of teamwork — that we’re all pulling on the rope in the same direction for our practices, and for the future of endodontics.”
Scan to listen!
Own YourFuture
– Jeffrey Hembrough, DDS, MS, Oakbrook Endodontic Associates, Partner and believer since 2021
SignificantlyEASIER,RETREATMENT:FASTER.higherapicalpatencyrate in less time (P<0.05) for NeoSEALER Flo silicate sealers. versus Endosequence/Edge BC (only 64%, 70%).* ASK WHY WE'RE BETTER $75 avalonbiomed.com info@avalonbiomed.comMADE IN THE U.S.A. Offer ends Oct. 28th, 2022 USE CODE: FREETIPS * Carrillo CA, Kirkpatrick T, Freeman K, Makins SR, Aldabbagh M, Jeong JW. Retrievability of Calcium Silicate-based Root Canal Sealers During Retreatment: An Ex Vivo Study. J Endod. 2022 Jun;48(6):781-786. doi: 10.1016/j.joen.2022.02.009.
