Endodontic Practice US Jan-Feb

clinical articles • management advice • practice profiles • technology reviews

Top ten tips

5

#

Access cavities and canal location Dr. Tony Druttman

Results of retreated root canals with a methacrylate resin-based sealer Drs. Osvaldo Zmener and Cornelis H. Pameijer

PAYING SUBSCRIBERS EARN 24 CONTINUING EDUCATION CREDITS PER YEAR!

Maxillary premolars with three canals Drs. Keith Plain, Stephen Clark, Ricardo Caicedo, and Joseph Morelli

Practice profile Dr. Wyatt Simons Involved and impactful

see back cover

Workflow integration | Humanized technology | Diagnostic excellence

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ASSOCIATE EDITORS Julian Webber BDS, MS, DGDP, FICD Pierre Machtou DDS, FICD Richard Mounce DDS Clifford J Ruddle DDS EDITORIAL ADVISORS Paul Abbott BDSc, MDS, FRACDS, FPFA, FADI, FIVCD Professor Michael A Baumann Dennis G Brave DDS David C Brown BDS, MDS, MSD L Stephen Buchanan DDS, FICD, FACD Gary B Carr DDS Arnaldo Castellucci MD, DDS Gordon J Christensen DDS, MSD, PhD B David Cohen PhD, MSc, BDS, DGDP, LDS RCS Stephen Cohen MS, DDS, FACD, FICD Simon Cunnington BDS, LDS RCS, MS Samuel O Dorn DDS Josef Dovgan DDS, MS Tony Druttman MSc, BSc, BChD Chris Emery BDS, MSc. MRD, MDGDS Luiz R Fava DDS Robert Fleisher DMD Stephen Frais BDS, MSc Marcela Fridland DDS Gerald N Glickman DDS, MS Kishor Gulabivala BDS, MSc, FDS, PhD Anthony E Hoskinson BDS, MSc Jeffrey W Hutter DMD, MEd Syngcuk Kim DDS, PhD Kenneth A Koch DMD Peter F Kurer LDS, MGDS, RCS Gregori M. Kurtzman DDS, MAGD, FPFA, FACD, DICOI Howard Lloyd BDS, MSc, FDS RCS, MRD RCS Stephen Manning BDS, MDSc, FRACDS Joshua Moshonov DMD Carlos Murgel CD Yosef Nahmias DDS, MS Garry Nervo BDSc, LDS, MDSc, FRACDS, FICD, FPFA Wilhelm Pertot DCSD, DEA, PhD David L Pitts DDS, MDSD Alison Qualtrough BChD, MSc, PhD, FDS, MRD RCS John Regan BDentSc, MSC, DGDP Jeremy Rees BDS, MScD, FDS RCS, PhD Louis E. Rossman DMD Stephen F Schwartz DDS, MS Ken Serota DDS, MMSc E Steve Senia DDS, MS, BS Michael Tagger DMD, MS Martin Trope, BDS, DMD Peter Velvart DMD Rick Walton DMD, MS John Whitworth BchD, PhD, FDS RCS

PUBLISHER Lisa Moler

Email: lmoler@endopracticeus.com Tel: (480) 403-1505

MANAGING EDITOR Mali Schantz-Feld

Email: mali@medmarkaz.com Tel: (727) 515-5118

ASSISTANT EDITOR Kay Harwell Fernández

Email: kay@medmarkaz.com

Dear Readers: Happy 2013! It seems like only yesterday that we were busily preparing to welcome 2012, but in fact, so much has happened in the dental profession and in our publications that the time has just flown by. The positive momentum of the past year continues to propel us forward. We are happy to note that this year brings a fresh, contemporary look for the magazines. New design elements, an easy-to-read print style, and expanded page size are just a few of the exciting changes that you will find in this, and future issues.

Endodontic Practice US is growing and evolving to help you grow and evolve. We strive to keep up with current trends in endodontics and to keep our readers up-to-date on the latest techniques, technology, and trends in the specialty. Our dentist-authors give their time and expertise to share the methods that result in better dental care for patients.

We are always seeking out new ideas and innovation in our clinical, technology, and continuing education articles, and case studies. Our corporate profiles tell the stories of companies that facilitate innovation, and practice profiles share the insights and concepts that inspire practice excellence. And, practice management columns spotlight ways to improve the business aspects of the dental office that can make lives easier for the staff and the boss!

Besides our magazine, Endodontic Practice US also features a vital and continually changing website (www.medmarkaz.com/web) and e-newsletter with the latest industry news, articles, and information. Our social media mavens keep the action going on Facebook, Twitter, and LinkedIn. So whether you like to turn the pages or click the mouse, information can be in your lap or on your laptop!

Publishing a thought-provoking, diverse magazine with such high standards is a challenging task, but our authors, peer reviewers, editorial advisory board, advertisers, and columnists makes it a smooth and enjoyable process. Our editors, sales and production staff, and I appreciate all of our authors and readers and value feedback as we continue to strive for excellence. Please feel free to call or email – we’d love to hear from you.

January is a time for resolutions. We strive to keep up the momentum so that we all can grow together in 2013.

All the best,

PRODUCTION MANAGER/CLIENT RELATIONS Kim Murphy Email: kmurphy@medmarkaz.com NATIONAL SALES/MARKETING MANAGER Drew Thornley Email: drew@medmarkaz.com

Tel: (619) 459-9595 NATIONAL SALES REPRESENTATIVE Sharon Conti Email: sharon@medmarkaz.com

Tel: (724) 496-6820 E-MEDIA MANAGER/GRAPHIC DESIGN Greg McGuire Email: greg@medmarkaz.com PRODUCTION ASST./SUBSCRIPTION COORDINATOR Lauren Peyton Email: lauren@medmarkaz.com

Lisa Moler Publisher

MedMark, LLC 15720 N. Greenway-Hayden Loop #9 Scottsdale, AZ 85260 Tel: (480) 621-8955 Fax: (480) 629-4002 Toll-free: (866) 579-9496 Web: www.endopracticeus.com SUBSCRIPTION RATES Individual subscription 1 year (6 issues) 3 years (18 issues)

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© FMC, Ltd 2013.

All rights reserved. FMC is part of the specialist publishing group Springer Science+Business Media. The publisher’s written consent must be obtained before any part of this publication may be reproduced in any form whatsoever, including photocopies and information retrieval systems. While every care has been taken in the preparation of this magazine, the publisher cannot be held responsible for the accuracy of the information printed herein, or in any consequence arising from it. The views expressed herein are those of the author(s) and not necessarily the opinion of either Endodontic Practice or the publisher.

Volume 6 Number 1

Endodontic practice 1

MEMO FROM THE PUBLISHER

January/February 2013 - Volume 6 Number 1

INTRODUCTION

The reality of predictably successful endodontic therapy

A

s we embark upon a new calendar year, it is appropriate to reflect on the past as we make our plans for the future. In some respects, we are practicing in a golden era of endodontics. The technological advances in recent years, many of which have been highlighted in Endodontic Practice US, have made the delivery of endodontic therapy easier and faster than ever before.

In particular, the development of small volume CBCT technology and new instruments/systems for canal preparation, irrigation, and obturation have made this an exciting time to be practicing endodontics. Unfortunately, increased speed can have the potential to detrimentally affect the quality of the treatment rendered if we allow complacency to creep into the picture.

Many new instrument systems advertise the ability to completely shape a root canal system with one or a few instruments, but is it possible to finish a root canal too quickly? I believe it can be if we don’t keep basic biologic principles at the forefront of our treatment decisions. It has been said that the ultimate goal of endodontic therapy should be the treatment and prevention of apical periodontitis.

Concurrent with this biologic goal is the reason most of us have chosen to practice endodontics: to relieve pain and save natural teeth.

However, too often it seems the actual goal of endodontic treatment for some dentists is the placement of gutta percha in canals with results that leave much to be desired from a biologic perspective. Since nonsurgical retreatment cases make up a significant part of many endodontic specialty practices, the issue we deal with on a daily basis is inadequately performed root canal therapy. Cognitive dissonance tells us that not all of the poorly executed root canals will fail, and conversely, not all of the well-done root canals will be successful. However, eradicating the pathologic flora that is the etiologic cause of the disease we are trying to control should be the driving factor in our treatment decisions.

In recent years, there has been much debate on the subject of endodontics versus implants. Some individuals pit these two proven treatment modalities against each other, when in actuality, they should be viewed as complementary. The current best available research is unequivocal; these two treatment modalities are equally successful, and therefore, treatment decisions should be based on factors other than success rates. Elements such as restorability, esthetics, periodontal, and systemic conditions should be given due consideration in the treatment-planning process. In this regard, I believe endodontists should play a much larger role in helping to determine restorability of teeth referred for root canal therapy than we have in the past. Even though a skilled endodontist can complete root canal therapy on just about any remaining tooth or root, it is certainly not always in the patient’s best interest, and in corollary, not in the best interest of the specialty to complete therapy on teeth with very poor long-term prognoses. Similarly, endodontists should strive to have a role in evaluating teeth prior to extraction and implant placement to help retain teeth that will be predictably successful with well-performed endodontic and restorative treatment. This is certainly easier to accomplish in an institutional setting, but with education beginning in the pre-doctoral level, this ideal can become more of a reality in the future.

With the advances in endodontics that we have seen in recent years, predictably successful endodontic therapy in 2013 should be more of a reality than ever before.

Timothy C. Kirkpatrick, Col USAF DC Program Director, Wilford Hall Endodontics Residency Military Consultant to the Air Force Surgeon General for Endodontics Joint Base San Antonio – Lackland, Texas

The opinions expressed on this document are solely those of the author and do not represent an endorsement by or the views of the United States Air Force, the Department of Defense, or the United States Government.

2 Endodontic practice

Volume 6 Number 1

Achieve the Optimal Treatment Room with ASI The Cart, With Only One Foot Control The versatility of ASI’s custom integrated cart system allows for infinite positioning of the cart to easily maneuver within close reach during procedures and then out of patient view after procedures. Adding a monitor mount creates an intimate environment for both patient education and clinical use.

Side Delivery An ASI cart positioned at the doctor’s dominant side requires the least amount of tasking movements during a procedure and works efficiently with microscope dentistry.

Foot Control Placement The foot control tubing of an ASI system can be run underneath the floor through a conduit from the junction box to the patient dental chair. The end result creates easy access to the foot control without tubing running across the floor.

The Junction Box In addition to attractively concealing the standard connections of compressed air, suction and electricity, ASI’s unique in-wall junction box allows computer connections such as video, USB, network and other IT connections throughout the office to be easily organized and safely hidden from view.

“The ASI Endodontic carts are a great convenience. This space saving design allows me to be organized and efficient with only one foot control and without all of the cords draped over my counters.”

– Dr. Kelly Jones

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TABLE OF CONTENTS

Practice profile Dr. Wyatt Simons, involved and impactful “Always put the patient first. Authentically demonstrate that you care, and you want what is best for them. Everything else helps, but nothing else matters.”

8

Clinical Maxillary premolars with three canals Drs. Keith Plain, Stephen Clark, Ricardo Caicedo, and Joseph Morelli offer a review of cases treated in an endodontic residency program.... 22

Corporate profile Planmeca: Innovative, upgradeable imaging technology Planmeca is the world’s largest privately held dental imaging company and one of the industry’s leading manufacturers of panoramic and cephalometric X-rays. Over the past four decades, it has expanded its sales network in more than 100 countries worldwide.

14 Case study Endodontic management of a tooth with complex root canal anatomy using the i-endo motor Dr. Conor Durack presents a case report illustrating the use of a contemporary, dualfunction endodontic motor

16

Endodontic success: “100% – X” Dr. Raphael Bellamy discusses why Dr. Herbert Schilder had the right philosophy about endodontics..... 26

Continuing education Results of retreated root canals with a methacrylate resin-based sealer Drs. Osvaldo Zmener and Cornelis H. Pameijer discuss the clinical, radiographic, and histologic outcomes of retreated root canals with a methacrylate resin-based sealer after 8 years...................... 30 Evaluation of the shaping performance of the WaveOne single file reciprocating system with and without glide path Drs. Anil Dhingra and Punit Srivastava evaluate the influence of glide path on the canal curvature and axis modification after instrumentation with WaveOne™ primary reciprocating files............ 36

4 Endodontic practice

Volume 6 Number 1

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TABLE OF CONTENTS

Aribex joins the KaVo Group’s portfolio of dental brands

54

In memoriam

Abstracts

Product profile

Dr. Franklin S. Weine..................13

The latest in endodontic research Dr. Kishor Gulabivala presents the latest literature, keeping you up-todate with the most relevant research. .....................................................46

TDO Practice Management

Practice management

Industry news

Endodontics in focus

Software Additional features provide endodontists with more tools and resources......................................52

Top ten tips: Tip number 5 – Access cavities and canal location In the fifth article of the series, Dr. Tony Druttman discusses how to make the preparation of the root canals easier.................................28

Mounce’s apex In search of the best materials and methods Dr. Rich Mounce notes that the “cookbook approach” is not always the best recipe for success............41

Technology 3D Apical Cork – Part 1 Dr. Wyatt Simons explains the basics of the CORK technique..................42 6 Endodontic practice

Know your liability as a business owner Dr. Robert M. Fleisher discusses how to mitigate general liability risks besides malpractice claims............48

Anatomy matters Long-term case report Dr. John West continues his exploration of the Endodontic Seal and endodontic predictability.........50

Aribex acquired by the KaVo Group Aribex, the leader in portable X-ray technology, joins the KaVo Group’s portfolio of dental brands...............54

Ruddle on the radar Quackwatch Meinig’s root canal cover-up.........56

Diary.......................................53 Materials & equipment.......................55 Volume 6 Number 1

ORTHOPHOS XG 3D The right solution for your diagnostic needs.

Implantologists

Endodontists

Orthodontists will benefit from highquality pan and ceph images for optimized therapy planning.

will enjoy instantly viewable 3D volumetric images for revealing and measuring canal shapes, depths and anatomies.

will appreciate the seamless clinical workflow from initial diagnostics, to treatment planning, to ordering surgical guides and final implant placement.

General Practitioners will achieve greater diagnostic accuracy for routine cases.

ORTHOPHOS XG 3D

“With my Sirona 3D unit, I can see the anatomy of canals, calcification, extent of resorption, fractures, and sizes of periapical radiolucencies, all of which influence treatment plans for my patients.

Combine that with the metal artifact reduction software that reduces distortions from metal objects, my treatment process is a lot less stressful. My patients benefit from the technology and my referrals appreciate the value.� ~ Dr. Kathryn Stuart, Endodontist - Fishers, Indiana

The advantages of 2D & 3D in one comprehensive unit ORTHOPHOS XG 3D is a hybrid system that provides clinical workflow advantages, along with the lowest possible effective dose for the patient. Its 3D function provides diagnostic accuracy when you need it most: for implants, surgical procedures and volumetric imaging of the jaws, sinuses and other dental anatomy.

For more information, visit www.Sirona3D.com or call Sirona at: 800.659.5977 www.facebook.com/Sirona3D

PRACTICE PROFILE

Dr. Wyatt Simons Involved and impactful

Why did you decide to focus on endodontics?

What can you tell us about your background?

I was born, raised, and attended most of my primary education in Northern California. I was a rambunctious youngster with a lot of energy. Fortunately, I was blessed with family, friends, and an overall community that was able to direct my enthusiasms.

Receiving wisdom and love from those around me did more than shape my character. It gave me an early experience of the power we can have over one another. A uniquely qualified person was always there to guide my development at each adversity I encountered as a youth. This is why, although not lavish, I consider my upbringing as charmed.

These interactions were clearly more than coincidental, and being the benefactor of this early guidance and kindness is likely at the foundation of why I strive to be involved and impactful today.

After high school, I moved to San Diego because I was attracted to beach life and surfing. There, I completed a degree in physiology and neuroscience at UCSD. To support myself through college, I waited 8 Endodontic practice

tables. While waiting on a table, I met and fostered a relationship with Dr. Jeffrey Moses, a local oral surgeon. I was lucky he showed interest in my ambitions and that he allowed me to volunteer alongside him. I went from assisting surgeries in his office and local hospitals to assisting on field surgical trips to Mexico to correct cleft palate deformations in infants. These experiences had a profound influence on me. The power to have a positive impact on people’s lives was overwhelming to me and solidified my desire to pursue a career in dentistry.

Fate then took me to the Arthur A. Dugoni School of Dentistry (known then as UOP). This stroke of luck took my journey to an environment of excellence beyond anything I had ever known. I was receptive to UOP’s humanistic approach and their desire to produce productive people (not dentists).

This progressive institution nurtures its students to make a difference.

Dr. Dugoni’s actions were a clear example of what he encouraged: “If not you, who, and if not now, when?”

I fostered a love and passion for endodontics while in the trenches of dental school. At the time, cosmetic dentistry was booming, and while many students found pleasures in restorative dentistry, I was fascinated by the art of endodontic anatomy.

The chair of the UOP’s endodontic department, Dr. Alan Gluskin, opened my eyes to the excitement of clinical endodontics. He instilled a respect for the biologic implications of the specialty, and he gave me my first glimpse at the art of endodontic excellence. Interestingly, my passion for endodontics grew further with my study of the textbook Pathways of the Pulp. The level of excellence and art that transcends this textbook was pivotal in my early courtship with the specialty. In particular, the cases illustrated in Dr. John West’s chapter on cleaning and shaping blew my socks off. Then, when I packed my first case with complex pulpal anatomy, I was hooked. To this day my heart races as I wait for the post pack image to pop onto the monitor. Talk about being lucky!

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

I have focused the scope of my dental practice solely on endodontics over the last 13 years.

An overview of my main armamentarium is as follows: Recordkeeping and reports: All documents related to a patient are kept in PracticeWorks. I make custom reports for every case in Word. It is easy to produce personalized reports with all of the details of each treatment. This includes cutting and pasting most treatment images. These reports are easily converted to PDFs and emailed.

Imaging: Carestream 9000 CBCT and Carestream 2D digital imaging systems.

Microscope: Global 6-Step with inclinable binoculars, Carr extender, and beam splitter with video and photo feeds. The video feed goes to a monitor in the ceiling so that the Volume 6 Number 1

Volume 6 Number 1

PRACTICE PROFILE

patient can watch the procedure. This helps in patient education, and it allows the patient to enjoy in the game. Images are seamlessly taken throughout the procedure, and uploaded into the patient’s records and reports.

Rubber dam: 5X5, Blue, Medium Texture.

I performed a root canal treatment on the world’s tallest man, and even he didn’t need the standard 6X6 rubber dam. In my opinion, it is too much extra material hanging on the patient’s face. Blue is a pleasing color to me, and it provides a great contrast when taking clinical photos.

Medium texture provides a nice balance of being relaxed to manipulate, yet doesn’t tear easily.

Clamps: I usually use a #7 for molars and #2 for premolars and anteriors. It is nice to have a wide array of clamps, but I find myself using these two clamps 90% of the time.

Burs: My workhorse bur is the 1158 carbide. I use round diamonds to get through ceramic restorations carefully.

Surgical length carbide burs are often helpful to me. I like to use a surgical length #1 bur to locate calcified canals.

The microscope allows me to read the pulpal road map. A quick rinse of EDTA has the potential to highlight this roadmap.

Calcified dentin is quite distinctive. I feel safe in conservatively exploring for canals when I can see the roadmap. The canal will always be in the center of the calcified canal, and dentin chips highlight canals at times when using a small round carbide.

The SS White Endo Guide® burs show potential to conservatively produce the shapes we desire, particularly in opening fins in between main systems.

Files: Roydent™ hand files. ProTaper® rotary files.

Solutions: 6 % NaOCL and EDTA. Irrigation devices: Max-i-Probe® (Dentsply), EndoVac® and EndoActivator®.

I always use all three on every case. I am also moving towards laser and photoactivated systems for the highest level of disinfection.

Obturation: CORK Delivery Devices to accomplish apical warmth and apical 3D

Patients are engaged by watching the procedure and seeing noteworthy discoveries throughout treatment

molding. I then use backfill guns to deliver heated gutta percha for 3D molding in the body of the canal. I use both in conjunction with SybronEndo zinc oxide eugenol sealer.

Coronal seal: Providing the coronal seal on all of my cases enables me to give the patient the best potential for a sustained successful outcome. This is because the root canal system is at its highest level of disinfection at the time of obturation. I use etch, prime, a dual-cured bonding agent, and white LuxaCore® (DMG America). If this core restoration ends at the cavosurface, I also use composite. If I am bonding to porcelain, I use hydrofluoric acid and OptiBond® (Kerr). In many cases, I attempt to use the LuxaCore to block out the alloys within PFMs. This minimizes the complication of the PFM’s alloy from showing through the surface composite.

What training have you undertaken?

Like most, I draw fulfillment through learning. I think it is part of human nature to seek understanding. The foundation of my endodontic training came from UOP dental

and BU endo. The process of becoming a Diplomate of the American Board of Endodontics was a great circling of the wagons in my endodontic knowledge.

Still, learning and practicing is like success; it is a journey, not a destination. In addition to seeking wisdom from colleagues, literature, and courses, I strive to learn from my patients. What I mean by this is that my clinical experience has helped guide me. For example, continually assessing my clinical outcomes led me to develop the CORK system of obturation. In the beginning of my career, I understood and accepted that my apical molding was incomplete. However, consistently seeing missed opportunities to three-dimensionally mold in apical regions of diseased pulpal systems caused my complacency to turn to frustration.

I dedicated myself to overcome this limitation of heat penetration to gutta percha within deep regions of pulpal system. The result of this commitment is the CORK system of obturation. This technique empowers us to deliver a controlled heat delivery to all regions Endodontic practice 9

PRACTICE PROFILE

Dr. Simons can project the video feed from the microscope in the treatment room to monitors throughout the office. This allows for live patient demonstrations during courses

Treatment room used for live patient courses

of the pulpal system. It allows for the use of an apex locator at the time of obturation, and it has the overwhelming benefit of simultaneously molding as precise, programmed temperatures are accomplished. This design required many pilot studies to validate, test, and refine the technique. This design and testing process was a powerful learning experience for me.

Finally, one of the greatest ways to learn is to teach. The relentless preparation needed to teach allows for vast personal growth, and I learn something new each time I teach. There is no greater feeling than that of perceiving you helped another clinician reach closer to his/her potential.

Besides this, the benefit of teaching is in the capacity to learn from others.

and I had the honor of providing him with references from UOP’s resources. Upon graciously thanking me for contributing to his project, he wrote me a simple note: “Be your potential.” These were extremely powerful and meaningful words to me at the time. He likely said this to many, and he likely had no idea that his words touched me so much, yet this personal inspiration reinforced a sense of purpose in me.

Seeing his ability to capture endodontic anatomy, and his devotion to excellence motivated me to take on his challenge to pursue my potential.

Who has inspired you?

Professionally, I owe everything to the mentors and heroes that inspired and guided my career. I am humbled by their contributions, and I respect that I am fortunate to continue along the trails they blazed. Five of these giants are as follows: 1: Dr. Arthur Dugoni is the most charismatic person I have ever known. His dedication was self-evident, and his inspiration to make a difference was meaningful to me.

2: Dr. Alan Gluskin holds many talents. His compassionate character draws people in, and his dedication to excellence has inspired countless practitioners. He is gifted in working with and directing others gracefully, and I am truly lucky for his generous guidance.

3: Dr. Cliff Ruddle’s commitment to the advancement of endodontic understanding and levels of care is overwhelming. My first interactions with him came when he was compiling a literature review on endodontic retreatment while I was in dental school, 10 Endodontic practice

4: Dr. Herbert Schilder’s presence was always known, as only the highest of standards were accepted in his presence.

I have never encountered anyone in my life that commanded and deserved such respect. Dr. Schilder expressed a sense of belief and confidence in me. He made a point to let me know that he felt that I was special, and because of that I had much to live up to. This positive reinforcement was at the pinnacle of me establishing a sense of purpose to make a difference.

5: Dr. John West is my North Star. I respect his life’s work and the bar that he has set regarding the level of care he provides and his dedication to help others realize their potentials. His infectious energy is exhilarating, which gives him an uncanny ability to nurture talent in others. He generously shares his time, experiences, and wisdom with an authentic desire to inspire greatness. Many have benefited from his devotion to the specialty, and his legacy will be one of progressive development and influence.

What is the most satisfying aspect of your practice?

The most satisfying aspect of my clinical practice is the opportunity to help those

in my community with their endodontic needs. I have come to value that the potential impact I may have starts with the level of treatment I render case by case.

Much fulfillment comes from delivering high levels of clinical outcomes and receiving genuine appreciation from patients and referring dentists. Second to that is the enjoyment I find in clinical practice. When doing treatment, I often say that I feel like a kid in a candy store. We are fortunate to play in a profession that has such art.

Finally, I find fulfillment in aspiring to make a difference within the profession. I am thankful for opportunities to directly work with others, and attempt to help them raise their levels of clinical outcomes. The profession benefits when we share our experiences and the tricks we pick up along our individual journeys. This resurgence in doing live patient demonstrations provides a remarkable venue for learning. It brings the excitement of clinical practice to all involved in a realistic manner.

Professionally, what are you most proud of?

I am most proud of bringing attention and solutions to our need to increase levels of three-dimensional apical molding.

The first step in solving a problem is to acknowledge there is one. Conventional obturation techniques are insufficient in consistent apical molding. For example, even in the warm vertical technique, there is incomplete heat delivery to the apical regions of many root canal systems. This results with a single cone and sealer as our apical seal in many cases. Most of us recognize that although gutta percha can accept temperature quite well, its thermomechanical properties are such that its capacity to transfer temperature is very limited. This results in inadequate apical warmth for three-dimensional molding in many clinical situations.

The CORK system of obturation was innovated to overcome this limitation.

It accomplishes this by transferring a precise, direct heat delivery to the entire apical gutta-percha cone with a removable silver carrier. This thin, silver sheath wraps the gutta percha along its full length and has the capacity to consistently reproduce ideal conditions for molding. This design allows for molding to occur while the carrier is in place and delivers a precise, calibrated heat. Once the initial wave of compaction occurs, the carrier is removed, allowing for final three-dimensional molding of the Volume 6 Number 1

What do you think is unique about your practice?

The easiest and most profound way that I have been able to demonstrate my uniqueness within my practice is to share a live video feed of what I see through the microscope with patients and referring dentists. This simple setup (microscope, beam splitter, camcorder, video feed to an ergonomically positioned monitor in the ceiling) allows the patient to visualize treatment being rendered.

This helps facilitate patient knowledge and ultimately produces a higher level of patient appreciation. Treatment images are seamlessly documented and sent as part of the patient report, allowing for distinctive communication with referrals. As I often joke, “An image equals a thousand words,

alter the report, and it decreases the size of the document. Decreasing the size of the document makes it easier to email and for referrals to grab and save. In addition to this photo page, a comprehensive report is sent. This is dictated while treatment is being rendered. This allows information to be documented in real time, which increases accuracy, and decreases the burdens of chart notes building up after treatment. Again, this requires talented and knowledgeable staff.

Finally, designing my office to function as a live learning facility helps bring distinction to my practice. A live video feed can also go to all of the monitors within the office. Course attendants can comfortably sit in the front or back of the office and watch live treatment. Courses are designed to review a topic, do it live on patients, and then discuss again. This format has proven to be useful.

What has been your biggest challenge?

I am a person who strives to do my best to take care of and please others. This can

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

During much of high school, I worked in construction. I enjoyed building things, and if I did not gravitate towards school so heavily, I could envision a fulfilling life with a construction or development career.

What is the future of endodontics and dentistry?

The strength of dentistry’s future is endless.

Our society recognizes and seeks quality dental health. We are living longer, and good oral health is one of the reasons. Therefore, all phases of dentistry will ultimately be as strong as the skilled and committed clinicians who lead their respective disciplines.

There is no limit to the success and future of endodontics. There are a lot of people with a lot of teeth. These teeth experience life, and become complicated with endodontic disease. People rightly have an innate desire to retain their teeth.

Our ability to resolve these complications has never been greater, and progressive advances in technology will inevitability

Always put the patient first. Authentically demonstrate that you care, and you want what is best for them.

Everything else helps, but nothing else matters. especially for a person like me who doesn’t know a thousand words.” Said differently, it is far more powerful to show something than explain it.

The next aspect of my practice that is unique is the personalized treatment reports produced for each patient. This may sound daunting, but with good systems and staff, this can become as seamless as it is rewarding. Standard photos are taken in every case when various treatment milestones are reached. In addition, unique findings are documented when discovered.

These images are cut and pasted into template pages that my staff has produced in Word. A collection of photos and radiographs that highlight each case are sequenced and put into appropriate templates by the staff. We then finalize the patient’s photo page by reviewing the image descriptions, adding arrows at times, and then converting to a PDF. This conversion decreases the ease of others to Volume 6 Number 1

lead to problems in time management.

When you say “yes” to one thing, you are ultimately saying “no” to another. I have been more aware of this over the last 3 years because of my dedication to the development of CORK. This has caused me to be acutely aware that time is finite, and there is value in constantly reminding ourselves to cherish our limited time.

I feel personally responsible for not having a greater presence in supporting the value of quality endodontics in patient treatment planning. It seems that many restorative dentists are being encouraged to remove viable teeth for implants without the knowledge that corrective or even straightforward endodontic treatment may be a better option for the patient’s dental health. I feel that I am failing my community because I haven’t even been at the table for these discussions. I have been challenged in managing my time and priorities such that I can be more involved in this regard.

continue to empower us to break down whatever barriers we face. Recent advances in all phases of endodontics have been remarkable. CBCT has completely changed our ability to diagnose endodontic disease, and its ability to guide successful treatment is profound. Shaping files will always improve, but we are quite blessed with the amazing advances that have been made over the last few decades in this area.

Disinfection is rightly the current frontier as evidenced by the many progressive technologies emerging. Our next logical step is to close the gap in disinfection.

The CORK system of obturation shows great promise in increasing levels of threedimensional molding. The broader practice of placing the coronal seal at the time of obturation will unquestionably increase our collective successes. Finally, the potentials of regenerative endodontics are exciting and unprecedented. Continued efforts in all of these areas will give us the tools to Endodontic practice 11

PRACTICE PROFILE

homogeneous gutta percha that remains.

I have used this technique on all my cases over the last year, and I am proud of the potential it shows.

(Please refer to the article on Page 42 for more details on the CORK system and technique of obturation.)

PRACTICE PROFILE

clinical skills are a prerequisite to endodontic outcomes, and it is further true that a firm grasp of the literature and respect for the microbiological component of endodontics is critical to success. However, desire to do our best is the most important factor in each of our potentials.

Dr Simons, his wife, Tara, and his boys, James and Nicholas

deliver high levels of outcomes, and keep us at the forefront of dentistry.

The future of endodontics is in our hands. We will thrive if we do our best to meet the well-established objectives for successful outcomes in the cases we treat.

This will help us continue to demonstrate our high success rate. We can share current outcome studies like the one by Salehrabi and Rotstein. They looked at the success rate of over 1.4 million cases over 8 years and showed a 97% success rate.

Value will come from being active in our local dental communities. We can show what quality endodontics can do for the future of dentistry.

What are your top tips for maintaining a successful practice?

First, put your patients first. An authentic desire to help people will always stand out. Your patients will praise you for it, and your referrals will want to be represented by you because of it. It is the lifeline to sustained success.

Second, commit yourself to the highest standards in clinical outcomes, such that the consistency of your endodontic craft is known and sought after. Endodontics is a very tangible profession. Your endodontic signature is clear on your postoperative images. If your work does not stand out to your referrals, then you won’t. Finally, have a staff and facility who represent your standards.

Patients weigh their experience heavily on their impression of your staff and facility.

12 Endodontic practice

What advice would you give to budding endodontists?

1. Always put the patient first. Authentically demonstrate that you care, and you want what is best for them. Everything else helps, but nothing else matters.

2. Hire staff who have the potential and desire to fulfill your vision.

3. Build the practice that represents you.

Not many things will represent you as much as your practice. If you would like to take care of those seeking the highest level of care for their dental health, then pull out all the stops, and build a facility that is cutting edge at all fronts. This does not mean you have to have an aquarium or marble, but it does mean you have to spend the money on a cone beam machine and microscopes for all operatories (as examples). In other words, embrace innovation. Staying at the forefront of the specialty will not always pencil out financially, but technological advances will empower you with the tools needed to provide the highest levels of treatment attainable. It will undoubtedly invigorate your love for your craft.

4. As Dr. Schilder taught me, always respect the complexities of root canal anatomy. If you don’t, you will get burned.

Endodontics is a challenging field that can be quite humbling. Our desire to push ourselves and commit to the highest level of standards will ultimately gauge our contribution. It is true that certain levels of

5. Be confident. Be confident in yourself, and be confident in your fees.

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

Being consumed with work, I spend most of my spare time with my family. I have an amazing, supportive wife (Tara) and two wonderful boys (James, 4 and Nicholas, 2) with another on the way. We spend much of our time at the beach. We enjoy stand-up paddle surfing, boating, and the boys are just starting to play sports. They give my life extra meaning, purpose, and tremendous joy. At earlier stages of my life, I enjoyed the competition of sports. High school football and track were a big part of my youth. I have always liked to surf, ski, golf, and play basketball. EP

TOP FAVORITES 1. Spending time with my wife and boys 2. Being able to help a patient in a time of need 3. Having excellent staff to help me 4. Heart palpitations as I wait for the post pack image to come up on the monitor 5. Capturing the complex anatomy in the pack 6. Monitoring the healing of the complex case 7. Receiving a heartfelt thank you card from the patient 8. CORK 9. CareStream 9000 CBCT 10. ProTaper 11. EndoVac and EndoActivator

Volume 6 Number 1

IN MEMORIAM

Dr. Franklin S. Weine

Dr. Weine (left) with University of Illinois at Chicago College of Dentistry Dean Bruce Graham

Dr. Franklin S. Weine was a distinguished member of the Editorial Advisory Board of Endodontic Practice US. His contribution to the field of endodontics and our publication are greatly appreciated. The following information and photos were received from the University of Illinois at Chicago College of Dentistry.

Admired by alumni of both the University of Illinois at Chicago (UIC) College of Dentistry and the Loyola University Chicago School of Dentistry, Dr. Weine passed away on July 10 at age 78. He was a 1957 alumnus of the UIC College of Dentistry and was awarded the College’s 2005 Distinguished Dental Alumnus Award. He earned his MSD and Certificate in endodontics from Indiana University in 1966.

For 23 years, he was Professor and Director of Graduate Endodontics at Loyola and, at his passing, continued to hold the rank of Professor Emeritus at Loyola’s Medical Center, Adjunct Professor in the UIC College of Dentistry’s Department of Endodontics, and Visiting Professor of Volume 6 Number 1

Endodontics at Osaka Dental University in Japan.

For many years, he was considered the most popular speaker on endodontics in the United States and many foreign countries, and he also had practiced endodontics in downtown Chicago. A new surgical suite in the College’s Department of Endodontics is named for him.

“Dr. Franklin Weine was a partner of mine in clinical practice at 30 N. Michigan Ave. for over 30 years,” said Dr. Christopher S. Wenckus, ’71, Endodontics ’74, Head of the Department of Endodontics. “He was also a mentor in my early practice years, and more importantly, a very close personal friend. He gave of himself like no other professional who I have interacted with over the years. There is nothing Frank would not do for those close to him. After he retired from clinical practice, there was nothing he enjoyed more than volunteering his time to teach and share his practice experiences with our residents. Dr. Franklin Scott Weine will be missed.”

His textbook, Endodontic Therapy, is

published in seven languages. Dr. Weine was a Diplomate of the American Board of Endodontics and a Fellow of both the American and International Colleges of Dentistry. Among the more than 85 papers of his published in peer-reviewed journals was the first article written on the potential canal configurations of the maxillary first molar and the initial studies on preparation of curved canals.

Dr. Weine also had been a member of Bill Veeck’s Chicago White Sox ownership group in the 1970s.

He is survived by his wife, Dorothy, sons Perry, Kenneth, and Allan, daughtersin-law Leslie, Karen, and Jackie, and five grandchildren.

Memorial contributions may be made to the Dr. Franklin S. Weine Surgical Suite in the College c/o the University of Illinois Foundation, Office of Advancement and Alumni Affairs, UIC College of Dentistry, 801 S. Paulina St., MC 621, Chicago, IL 60612 or call (312) 996-8495. EP

Endodontic practice 13

CORPORATE PROFILE

Innovative, upgradeable imaging technology Company history Planmeca is the world’s largest privately held dental imaging company and one of the industry’s leading manufacturers of panoramic and cephalometric X-rays. Over the past four decades, it has expanded its sales network in more than 100 countries worldwide.

Planmeca’s imaging units offer superior image quality, reduced radiation during routine procedures, easy upgradeability, and advanced, user-friendly imaging software. Planmeca has been a leader in digital imaging and advanced computer-integrated dental care concepts for years, and remains in the forefront of technology.

Since the company’s establishment, Planmeca’s developers have worked closely with dentists and leading universities to anticipate future trends, using this data to design an advanced line of high-tech products. From the introduction of the first microprocessor-controlled chair, to the development of the ProMax™ line of imaging units with SCARA (Selectively Compliant Articulated Robotic Arm) technology, Planmeca has always led the way with new technology. The company’s goal is to supply dental professionals with the highest quality dental equipment that is uniquely designed for today’s modern, technologically advanced practice.

Unique 3D combination for open CAD/CAM

Patented SCARA technology What truly sets Planmeca apart from the competition is the company’s patented, exclusive SCARA technology. This robotic arm, which comes standard on all ProMax units, enables free geometry based on image formation and can produce any movement pattern required. The precise, free-flowing arm movements allow for a wide variety of imaging programs not possible with any other X-ray unit on the 14 Endodontic practice

The company’s goal is to supply dental professionals with the highest quality dental equipment that is uniquely designed for today’s modern, technologically advanced practice.

Volume 6 Number 1

True extraoral bitewing program Planmeca’s ProMax imaging units offer an exclusive extraoral bitewing program, possible only with SCARA technology.

This innovative program consistently opens interproximal contacts, eliminates patient positioning errors, and is more diagnostic than other intraoral modalities. ProMax extraoral bitewings are ideal for a number of patients, from the elderly and those requiring periodontal work to those with claustrophobia, sensitive gag reflexes, or those in pain. All of this comes in a true bitewing program that enhances clinical efficiency and takes less time and effort than a conventional intraoral bitewing.

the ALARA radiation principle (As Low As Reasonably Achievable). Through specially designed programs, such as horizontal and vertical segmenting, autofocus, and pediatric pans, dental professionals are able to provide their patients with excellent care without compromising their safety.

Horizontal and vertical segmenting options limit the exposure to diagnostic areas of interest. By selecting these options, patient dosage can be reduced by up to 93%, which is highly advantageous when follow-up images are needed.

Autofocus automatically positions the focal layer using a low-dose scout image of the patient’s central incisors, and uses landmarks within the patient’s anatomy to calculate placement. The result is a fast, diagnostic pan every time, which drastically reduces retakes caused by false

level of customer care, dealer support, and product education. The company offers inhouse training sessions for dealers, as well as in-office trainings for dentists performed by a national team of highly trained sales representatives. Other training programs, such as live webinars and video tutorials, ensure that dealers and dentists alike are able to confidently use all equipment features and programs.

Digital Perfection™ – the new standard Building on the well-established all-in-one idea of integration, Planmeca introduced the Digital Perfection concept in 2011.

Seamless integration of dental equipment and software creates efficient diagnostic tools, optimized workflow, and advanced infection control methods that result in a

Planmeca sets new standards with world’s first dental unit integrated intraoral scanner for open connectivity to various CAD/CAM systems.

Upgradeable innovation One of Planmeca’s greatest contributions to dental imaging is its innovative, upgradeable product platform – all based on exclusive, patented SCARA technology. This robotic arm enables limitless possibilities to upgrade existing equipment, allowing the new dentist on a smaller budget to grow while making only appropriate and necessary equipment investments. For example, Planmeca products can be upgraded from a 2D panoramic X-ray to a combination of pan/ ceph capabilities, which can be further upgraded to accommodate 3D imaging needs. Whether it is the transformation of a film to a 3D unit, or the addition of a cephalometric arm, Planmeca offers solutions for every upgrade need. This single piece of technology makes the ProMax the most versatile all-in-one X-ray unit available on the market.

Reduced radiation procedures

for

safer

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positioning.

Pediatric programs automatically select the narrow focal layer of young patients, adjust the collimator, and reduce the area of exposure from the top and the sides. This reduces the dosage area, while providing full diagnostic information.

Exclusive dealer network In order to meet the growing demand for high-quality dental imaging units in the United States, Planmeca has partnered with an exclusive network of dealers to create a unique sales and distribution system for all Planmeca products. The company has chosen a very selective distribution network, which consists of Henry Schein Dental, Patterson Dental, six ADC members, and two independents.

Through this network, Planmeca is able to accommodate its growing customer base with a support team of professionals throughout the country.

Planmeca strives to provide its dealer partners and the dental community with products that are backed by an unmatched

treatment environment where all equipment shares an open interface.

The company works worldwide with all aspects of the dental industry, including dental schools, dentists, and dental team members, as well as dealers, and uses the latest technologies to create the best products for dental offices and patients alike. As a forerunner in digital imaging technology, Planmeca delivers complete dental solutions based on integrated hightech device and software options with exquisite design.

For more information, please visit www.planmecausa.com EP This information Planmeca.

was

provided

by

Endodontic practice 15

CORPORATE PROFILE

market; this allows the dental professional to take images based on diagnostic needs, not machine limitations.

CASE STUDY

Endodontic management of a tooth with complex root canal anatomy using the i-endo motor Dr. Conor Durack presents a case report illustrating the use of a contemporary, dual-function endodontic motor

S

uccessful endodontic treatment is dependent on adequate chemomechanical debridement of the root canal system. Negotiating complex root canal anatomy carries with it the risk of intraoperative mishaps, as the physical limits of the metal alloys forming the endodontic instruments are approached, and their design features are tested.

Instrument separation as well as ledging, transportation, and perforation of the canal walls are very real risks (Weine, et al., 1976; Mullaney, 1979; Roane, et al., 1985), potentially compromising the outcome of the endodontic treatment (Zheng, et al., 2009).

The advent of nickel-titanium endodontic instruments has better allowed clinicians to safely and successfully negotiate difficult root canal anatomy (Parashos, Messer, 2006). However, it is not only the unique physical properties of these instruments, but also the manner in which they are worked in the canal that will affect their performance (Dougherty, et al., 2001; Gambarini, et al., 2001).

Motor-driven preparation of root canal systems, using nickel-titanium instruments in a continuous rotary fashion, has become a popular method of mechanical root canal debridement in endodontic practice.

The development of controlledtorque motors with features such “autoreverse,” designed to prevent the nickeltitanium instruments from exceeding their elastic limit, have added to the safety of

Conor Durack graduated from Cork Dental School and Hospital in 2001. Over the subsequent 5 years, he worked in private dental practice in the UK, Australia, and Ireland before taking a position as senior house officer in restorative dentistry at Cork Dental Hospital in 2006. In 2007, he was awarded Membership of the Faculty of Dental Surgery (MFDS) from the Royal College of Surgeons, Ireland. He commenced specialist training in Endodontology in 2007 at Guy’s Hospital in London, England. He gained the MClin Dent in Endodontology in 2011 and was awarded Membership in Endodontics (M Endo) by the Royal College of Surgeons, Edinburgh, Scotland. He is a registered specialist in endodontics.

He currently works in private specialist endodontic practice.

16 Endodontic practice

Figures 1A and 1B: Clinical views of the LL6 tooth. (A) Occlusal view of the LL6 tooth, with a GP point in the adjacent draining sinus. (B) Buccal view of the LL6 tooth, with the draining sinus evident on the adjacent buccal mucosa

this method of preparation (Gambarini, 2000). However, despite this, instrument separation (Spili, et al., 2005) and aberrant canal preparation (Poulsen, et al., 1995) can potentially occur in difficult cases when these instruments are used.

To that end, the most recent advances in engine-driven root canal preparation have seen the development of systems that work endodontic instruments in a reciprocating fashion. The potential benefits include a prolonged cyclical fatigue life, resulting in improved safety (De-Deus, et al., 2010), which is of particular importance in cases with severe canal curvatures.

Case report A 50-year-old female was referred by her general dental practitioner (GP) for specialist endodontic assessment and treatment of her mandibular left, first molar tooth. The tooth was largely asymptomatic, but the patient reported that a fluctuant soft tissue swelling had been present on the mucosa adjacent to the tooth for several months. It was the presence of the swelling that encouraged the patient to seek dental attention.

Clinical examination of the teeth in the lower left quadrant revealed that while all teeth were asymptomatic, only LL6

failed to respond to thermal and electric sensitivity tests. Radiographic examination of the tooth was carried out. A paralleled periapical radiograph, and a parallax view, with a distal shift in the horizontal angulation of the X-ray tube, were taken; the latter was taken with a gutta-percha (GP) point inserted in the buccal draining sinus (Figure 2).

The radiographs revealed a periapical radiolucency associated with the distal root of LL6.

In addition, the course taken by the GP point inserted in the sinus confirmed the LL6 tooth as the source of the draining exudate. Of note, and of particular relevance to the treatment of the case, was the morphology of the mesial root of the LL6 tooth. The root had a severe distal curvature which, when measured using the radiographic software, was found to have a Schneider (1971) angle of approximately 60° (Figure 3). Furthermore, the root canal was continuously curved from its orifice to its apical terminus and measured almost 19 mm (Figure 3). This measurement excluded the distance between a coronal reference point and the orifice.

The canal, while patent, appeared narrow throughout its course on the radiograph. Given the length and degree Volume 6 Number 1

Figures 3A-3D: Diagrammatic illustration demonstrating the effect that eliminating coronal interferences and creating straightline access has on the length and degree of canal curvature. (A) The blue line traces the mesial root canal from its orifice to the radiographic apex and gives an indication of the length of the canal curvature in the mesial root of the LL6 tooth. The uninstrumented canal is continuously curved from its origin to its terminus, both of which are denoted by the yellow arrows. (B) The angle formed between the red and yellow lines and denoted by a white arc, on the mesial root of the LL6 tooth, is termed the Schneider angle. According to Schneider’s (1971) classification, the angle in this case can be categorized as severe. (C) By eliminating coronal interferences (area formed by the green arc and the red line) straightline access to the apical portion of the canal can be achieved (red line). This reduces the length of curvature (blue line between the yellow arrows), which needs to be negotiated by the stiffer and larger finishing files. (D) Creating straightline access by eliminating coronal interferences (area formed by the green arc and the red line) also serves to reduce the angle of curvature (angle formed between the red and yellow lines and denoted by a white arc), which must be negotiated by the larger and stiffer finishing files

Volume 6 Number 1

Endodontic practice 17

CASE STUDY

Figures 2A and 2B: Diagnostic periapical radiographs of the LL6 tooth. (A) Paralleled periapical radiograph of the LL6 tooth.

(B) Periapical radiograph of the LL6 tooth taken with a distal shift in the horizontal angulation of the X-ray tube head in order to ascertain further information about the tooth’s root canal morphology. This radiograph was taken with a GP point in the draining sinus, which tracked the origin of the sinus to the distal root of the LL6 tooth

of the curvature associated with the mesial root, and taking into account the apparent narrowness of the mesial canals, the potential risk of aberrant canal preparation and/or instrument separation occurring during instrumentation was recognized.

A treatment plan was devised to reduce these risks.

The instrumentation protocol utilized a combination of hand stainless steel files and a motorized nickel-titanium file system (ProTaper®, Dentsply Tulsa Dental Specialties). All of the hand files used were compatible. The ProTaper files were used alternately in both a continuous rotary and a reciprocating fashion, depending on the portion of the canal that was being prepared. The dual-function i-endo motor (Figure 6) [Satelec® Acteon] was chosen for this purpose, as it offered rotary and reciprocating settings.

Access was gained to the pulp chamber and the root canal orifices. A medium-gritted round diamond bur (644, Dentsply Maillefer) was used to create the access cavity outline in the tooth’s occlusal surface and penetrate the roof of the pulp chamber. The entire roof of the pulp chamber was then removed using a blunt ended, tungsten carbide bur (Endo-Z™, Dentsply Maillefer). The floor of the pulp chamber was examined with the aid of the dental operating microscope (Global).

Exploration of the floor of the pulp chamber using a DG-16 probe (Hu-Friedy) resulted in the identification of the two mesial and one distal canal orifice. The symmetry of the canal orifices and the pattern of the dark coloration on the pulpal floor provided evidence that only one distal canal was present (Figure 4).

The access cavity was refined with the ET 18 D ultrasonic tip (Satelec Acteon) to ensure unimpeded access to the orifices and coronal portion of the canals. The working length of the mesial root canals, from the radiographic apex to the occlusal surface, was estimated using the radiographic imaging software. A size 08 stainless steel file (Dentsply Maillefer) was inserted into the mesial canals until resistance was met. This occurred in the coronal third in each canal. Working with a lubricant and in a wet canal, the length

CASE STUDY

at which resistance was encountered was measured from the mesiobuccal (MB) and mesiolingual (ML) cusps. The canals were negotiated to this level with sequentially larger files, up to a size 20 stainless steel file (Dentsply Maillefer), using alternate watchwinding and push-pull actions. At this stage, S1 and then S2 ProTaper files were worked in a continuous rotary motion in the canals, using a brushing motion away from the furcal wall. This provided straightline access to the level of the initial resistance.

A size 10 file was then inserted into the canals until resistance was encountered again. The depth of insertion of the file was marked and measured approximately two-thirds of the length estimated on the preoperative radiograph.

The ProTaper shaping files were employed again at this point, in the manner already described. With this, straightline access to the apical third and most curved portion of the canal was established, allowing preparation of this part of the canal to be carried out.

A size 08 stainless steel file was worked patiently, using watch-winding and push-pull actions, to the apical terminus of the canal until a zero reading was obtained on the apex locator (Raypex速5, VDW速).

The working length was measured for each mesial canal using the MB and ML cusp tips as reference points.

The canals were prepared to the apical constriction with hand stainless steel files (Dentsply Maillefer), up to a size 20 file, using the balanced force technique. With patency established throughout the entire canal lengths, the ProTaper shaping files could then be taken, as described already, to the full working length with little risk of the file tips binding in the canals. Once this had been carried out, the ProTaper finishing files were employed. These finishing files were worked with a reciprocating action, with unequal bidirectional movement, using the i-endo motor.

The F1 ProTaper file was worked intermittently, with light apical pressure, to the full working length. The flutes were cleaned of debris each time the file progressed 3-4 mm. Once this had been completed, a size 25, and then a size 30 stainless steel hand file (Dentsply Maillefer), were used to prepare the apical canal terminus. The F2 ProTaper file was then taken to the full working length in a manner identical to that in which its predecessor 18 Endodontic practice

Figures 4A-4C: Clinical views of the orifices of (A) the prepared root canals and the obturated; (B) mesial canals, and (C) distal canal. The symmetry of the canal orifices and the pattern of dark coloration on the floor of the pulp chamber are all consistent with the presence of only one distal canal

Figures 5A-5D: Periapical radiographs of the LL6 tooth taken (A) preoperatively and (B) immediately postoperatively. (C) Clinical view of the buccal aspect of the LL6 tooth at the review appointment. The draining sinus has healed completely.

(D) Six- month review radiograph of LL6. The radiolucency associated with the distal root of the LL6 tooth has almost completely resolved

Volume 6 Number 1

Volume 6 Number 1

CASE STUDY

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was used. The apical terminus was finally prepared by hand with a size 35 stainless steel file. The distal canal was prepared using the ProTaper file sequence in a continuous rotary motion. The preparation was finished with the F3 ProTaper and a size 40 hand stainless steel file.

Sodium hypochlorite (3%) [Merck, Darmstadt, Germany] was used as the primary irrigating solution throughout the preparation, and the canals were irrigated after each instrumentation step. On completion of the mechanical preparation, the canals were flushed with 17% EDTA (Schottlander, UK). This was agitated in the canal for 1 minute using an ultrasonically activated file before the chelating agent was replaced with 3% sodium hypochlorite, which was activated in the same manner.

The canals were dried and obturated with the Elements Obturation Unit™ system (SybronEndo) using the continuous wave compaction technique. Due to the complexity of the case, insufficient time remained at the end of the appointment to provide the definitive core at that visit.

The canals’ orifices were sealed with 1 mm plugs of IRM, the access cavity was restored with the same material, and the patient returned 1 week later for the provision of a composite resin core and to have the tooth reassessed.

At the review appointment, the buccal draining sinus was still present. It was considered appropriate that a decision on whether to restore the tooth with a crown should be deferred until the sinus had resolved, or until it became clear that this was not going to happen.

The existing coronal restoration was completely removed, and the tooth was restored with an incrementally-placed, hybrid composite resin material (Herculite® Ultra, Kerr Corporation) under rubber dam. An orthodontic band was placed around the crown of the tooth, and a recall appointment was scheduled for 3 months later. The patient cancelled the appointment at short notice stating that she had “not been having any problems with the tooth.” She also reported that “the swelling had gone.” The importance of reviewing the tooth was emphasized to the patient over the phone, and she eventually conceded to returning to the clinic in another 3 months (6 months after the completion of the treatment).

At this review appointment, the tooth

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was asymptomatic, and the sinus had completely resolved. The orthodontic band was removed at the patient’s request.

Given that the patient decided not to attend for the first appointment, a decision was made to take a review radiograph at this visit, with the patient’s consent. The radiograph revealed complete resolution of the periapical radiolucency associated with the LL6 tooth (Figure 5).

Discussion Nickel-titanium, engine-driven endodontic instruments working in a root canal fail due to cyclical (flexural) fatigue, torsional (shear) fatigue, or a combination of both (Sattapan, et al., 2000).

Torsional failure occurs when the tip of the instrument being used in the canal binds, and the instrument, driven from the shank, continues to rotate until its shear strength is exceeded, and the bound tip becomes separated from the main bulk of the rotating instrument.

Cyclical fatigue occurs when the instrument, rotating in a curved canal, is subjected to repeated cycles of surface tension and compression on opposite

www.engineeredendo.com

sides of the points of curvature, weakening the file at these points, and predisposing the instrument to failure. Therefore, the greater the diameter of the file at the point of maximum curvature, the larger the stress the file is under at that point, and the greater the risk of separation due to cyclical fatigue. Longer canal curvatures are logically associated with primary angles of curvature, which are located more coronally, and this ensures that more of the working portion of the file is subjected to cyclical fatigue. Furthermore, greater angles of curvature increase the degree of stress that the instrument is subject to.

In the current case, the lengths and curvatures of the mesial canals were estimated preoperatively, the latter according to the method described by Schneider (1971). Using the software available with the digital radiographic system, the length of the curved portion of the mesial canals was estimated to be 19 mm, and the maximum curvature of the mesial canals was assessed to be approximately 60° preoperatively.

According to Schneider’s (1971) classification, this degree of curvature Endodontic practice 19

CASE STUDY

Figure 6: The i-endo motor from Satelec Acteon

is considered severe. However, by eliminating coronal interferences and providing straightline access to the apical half of the canals, the maximum angle of canal curvature could be reduced to approximately 40° (Figure 4B).

Providing straightline access in this manner also served to shift the position of the maximum angle of curvature more apically, as the length of the original curvature was also reduced. The benefits of these alterations in the length, degree, and position of the canal curvatures were that the instruments used when preparing the apical portion of the canals would be subject to less cyclical fatigue, reducing the risk of failure.

However, despite this, the length of curvature following the creation of straightline access still remained relatively long, and the estimated degree of maximum canal curvature remained severe, according to Schneider’s (1971) classification (Figures 3C and 3D). As such, it was considered prudent to utilize preparation techniques that further reduced the stresses on the instruments during preparation.

Preparation of the mesial canals with the ProTaper shaping files was undertaken 20 Endodontic practice

using the conventional rotary action. This was considered safe, as the portion of the canal being instrumented in this manner had already been prepared with hand files with greater tip diameters than those of the ProTaper shaping files.

The chance of torsional failure occurring while using these files was therefore low, as only the more tapered coronal portions of the instruments would engage the dentinal walls. Any potential cyclical fatigue was considered likely to be minimal, given the nature of the taper of the files. Consequently, it was considered that the rotary action would work more efficiently. However, a decision was made to use the ProTaper finishing files with a reciprocating action. These files are designed with greater tapers towards their tips and increasing cross-sectional dimensions along the file length away from the tip – albeit with a reducing taper coronally.

Given the significant length, and the relatively coronal position, of the maximum curvature of the mesial canals in this case, a larger diameter of any given finishing file would be operating at the inflexion of curvature, than would be the case if the length of the curvature was less, and the

point of maximum curvature was more apically positioned. Having recognized this fact, it was reasoned that using these finishing files in a reciprocating motion would reduce the considerable cyclical fatigue that they were likely to undergo during instrumentation. Indeed, De-Deus, et al., (2010), demonstrated that ProTaper finishing files have an extended cyclical fatigue life when used in a reciprocating fashion.

To minimize the potential for the tips of the finishing files to bind in the canals and potentially fail in torsion, patency was established to the full working length with hand stainless steel files possessing tip diameters greater than that of the finishing files that were to be used in the canals.

The dual-function i-endo motor was chosen for this treatment protocol. This relatively new endodontic motor allows full control of speed and torque settings, and permits the chosen file system to be used with both rotary and reciprocating actions.

The clinician, therefore, has complete clinical freedom to prepare the canals in the manner deemed most appropriate to the specific case.

In this case, the torque control was set according to the instrument manufacturer’s Volume 6 Number 1

CASE STUDY

instructions when using the shaping files in rotation, and “auto-reverse” was employed to limit the risk of exceeding the elastic limit of these instruments.

When using the finishing files, the i-endo motor permitted any degree of clockwise (CW) and counterclockwise rotation (CCW), between 10° and 360° to be selected. An unequal bidirectional reciprocating action was chosen, with a clockwise rotation of 144° and a counterclockwise rotation of 72°, as described by Yared (2008).

According to the report by Yared (2008), these degrees of CW and CCW rotation allow the ProTaper F2 finishing files to function safely, without exceeding their fracture strength. In addition, it has been demonstrated that these reciprocating settings are as effective at safely excavating dentin from the canal as is using the full sequence of ProTaper files in the conventional rotary motion (De-Deus, et al., 2010). Given that it can be used with any commercially available engine-driven nickel-titanium file system, the i-endo dual-function motor can be considered a very useful adjunct to the endodontist’s armamentarium.

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Conclusion In endodontics, a good clinical outcome can be predicted when the biological goals of the treatment are achieved. However, inherent in successful treatment is an appreciation of the complexity of the case being undertaken and an understanding of the limitations of the instruments being used for mechanical preparation. The radius of the curvature of the root canal is the main tooth-related determinant of the strain that will be applied to the instrument being used during endodontic treatment and is, therefore, the foremost tooth-related, contributing factor to instrument separation. This is because the radius of curvature takes into account the abruptness of the canal curvature as well as its angle (Haikel, et al., 1999). However, this is more difficult to quantify in a clinical situation, and so the length and angle of the mesial canal curvatures were estimated in this case.

In the opinion of the author, the preoperative planning and combined instrumentation technique, which were facilitated by the i-endo motor, contributed in no small way to the successful clinical outcome in this case. EP Volume 6 Number 1

References De-Deus G, Moreira EJL, Lopes HP, Elias CN. Extended cyclic fatigue life of F2 ProTaper instruments used in reciprocating movement. Int Endod J. 2010:43:1063-8.

Dougherty DW, Gound TG, Comer TL. Comparison of fracture rate, deformation rate, and efficiency between rotary endodontic instruments driven at 150 rpm and 350 rpm. J Endod. 2001;27:93-5.

Gambarini G. Rationale for the use of low-torque endodontic motors in root canal instrumentation.

Endod Dent Traumatol. 2000;16:95-100.

Gambarini G. Cyclic fatigue of nickel–titanium rotary instruments after clinical use with low-and hightorque endodontic motors. J Endod. 2001;27:772-4.

Haikel Y, Serfaty R, Bateman G, Senger B, Allemann C. Dynamic and cyclic fatigue of engine-driven rotary nickel-titanium endodontic instruments. J Endod.

1999;25:434-40.

Parashos P, Messer HH. Rotary NiTi instrument fracture and its consequences. J Endod.

2006;32:1031-43.

Schneider SW. A comparison of canal preparation in straight and curved root canals. Oral Surg, Oral Med, Oral Path. 1971;32:271-5.

Sattapan B, Nervo GJ, Palamara JE, Messer HH. Defects in rotary nickel-titanium files after clinical use. J Endod. 2000;26:161-5.

Spili P, Parashos P, Messer HH. The impact of instrument fracture on outcome of endodontic treatment. J Endod. 2005;31:845-50.

Roane JB, Sabala CL, Duncanson MG Jr. The balanced force concept for instrumentation of curved canals. J Endod. 1985;11:203-11.

Weine FS, Kelly RF, Bray KE Effect of preparation with endodontic handpieces on original canal shape.

J Endod. 1976;2:298-303.

Yared G. Canal preparation using only one Ni-Ti rotary instrument: preliminary observations. Int Endod J. 2008;41:339-44.

Zheng QH, Zhou XD, Jiang Y, Sun TQ, Liu CX, Xue H, Huang DM. Radiographic investigation of frequency and degree of canal curvatures in Chinese mandibular permanent incisors. J Endod. 2009;35:175-8.

Mullaney TP. Instrumentation of finely curved canals.

Dent Clin North Am. 1979;23:575-92.

Poulsen WB, Dove SB, del Rio CE. Effect of nickeltitanium engine-driven instrument rotational speed on root canal morphology. J Endod. 1995;21:609-12.

Endodontic practice 21

CLINICAL

Maxillary premolars with three canals Drs. Keith Plain, Stephen Clark, Ricardo Caicedo, and Joseph Morelli offer a review of cases treated in an endodontic residency program Background Complications associated with nonsurgical root canal therapy can be caused by failure to diagnose variations in canal morphology. Knowledge of the most common variations of anatomy is essential to ensure successful and complete endodontic treatment of any tooth.

Radiographic and clinical recognition of these anatomical anomalies is crucial, and knowledge of how to successfully manage the condition clinically is also imperative.

The occurrence of three canals in the maxillary first or second premolar can make endodontic treatment of this tooth significantly more complicated. Previous in vitro studies on the prevalence of maxillary first premolars with three canals have reported a range in prevalence from 0â&#x20AC;&#x201C;7.5%. Pineda and Kuttler (1972) examined 259 teeth and determined the prevalence to be only 0.5%. Carns and Skidmore (1973) examined 100 extracted teeth and reported that 6% of the teeth contained three canals. Vertucci, et al., (1979) found 20 out of 400 maxillary first premolars to have three canals (5%).

The prevalence of maxillary second premolars with three canals has been reported to be significantly less than that of the maxillary first premolar in previous in vitro research. Pineda and Kuttler

Keith Plain, DMD, FRCD, graduated from the Case School of Dental Medicine and received his Endodontic certificate from the University of Louisville, Kentucky. He currently maintains an endodontic private practice in Saskatoon, Saskatchewan, Canada.

(1972) examined 282 maxillary second premolars and were unable to identify any with three canals. Green (1973) studied 50 extracted teeth, and also failed to identify any maxillary second premolars with three canals. Vertucci, et al., (1974) examined 200 maxillary second premolars and were able to identify only two teeth with three canals, for a prevalence of 1%.

In vivo research on the prevalence of maxillary premolars with three canals is more limited. In a retrospective radiographic study of 1,144 maxillary premolars, Bellizzi and Hartwell (1984) found an overall prevalence of maxillary premolars with three canals to be 2.1%. Of the 514 maxillary first premolars reviewed in their study, 3.3% had three canals. Six hundred and thirty maxillary second premolars were also reviewed, and only seven teeth with three canals were identified (1.1%).

The purpose of this retrospective study was to compare the prevalence of three canals in maxillary first and second premolars treated at the University of Louisville post-graduate endodontic program with the prevalence reported in the previous in vitro and in vivo studies.

Materials and methods Clinical patient records from the University of Louisville post-graduate endodontic

Figure 1: Example of endodontically treated maxillary premolars with three canals

program were reviewed for all maxillary premolars treated with non-surgical root canal therapy over a 6-year period. Digital radiographic images and the electronic health record were reviewed by two endodontic residents, and all treated maxillary premolars with three canals were identified.

The following data for these teeth were then collected: patient gender and age, tooth number, type of pretreatment restoration, pulpal diagnosis, periapical diagnosis, working length of each canal, and master apical file size of each canal.

The quality of canal instrumentation and obturation in each canal for each tooth with three canals was reviewed by two calibrated board-certified endodontists.

Table 1: Prevalence of maxillary first premolars with three canals

Stephen Clark, received his DMD degree and Endodontic certificate from the University of Kentucky and is currently a Professor of Endodontics at the University of Louisville.

Ricardo Caicedo received his Dr Odont from the Colegio Odontologico Colombiana in Bogota, Colombia, and an Endodontic certificate from the University of Louisville.

He is currently Associate Professor of Endodontics at the University of Louisville.

Joseph Morelli received his DDS degree from Loyola University and Endodontic certificate from Tufts University. He is currently Associate Professor of Endodontics at the University of Louisville.

22 Endodontic practice

Volume 6 Number 1

CLINICAL

Table 2: Prevalence of maxillary second premolars with three canals

,

Results A total of 744 maxillary premolars were treated by endodontic residents from 2006 through 2011. Of these, 328 were first premolars, and 416 were second premolars. A total of 26 maxillary premolars with three identified canals were treated for an overall prevalence of 3.49%. Of these, 11 were first premolars (3.35% prevalence), and 15 were second premolars (3.61% prevalence). Of the 26 premolars, 13 were in females and 13 in males. The mean age of patients treated was 31.6, with a minimum of age 13 and a maximum of age 64.

Mean working lengths (mm) for the 26 treated teeth were 20.9 (MB), 20.5 (DB), and 20.6 (P). The mean master apical file size was 32 (MB), 30.8 (DB), and 34.4 (P).

Quality of canal obturation was rated as satisfactory in 88.5% of MB canals, 84.6% of DB canals, and 100% of P canals.

A possible reason for the difference in prevalence of three canals in the maxillary second premolar between this study and the research conducted by Bellizzi and Hartwell in 1984 could include differences in patient populations. Due to the retrospective nature of the study, patient ethnicity or race was not a variable that was noted and could be evaluated.

Also the sample size for this study was larger than most of the in vitro studies, and comparable to Bellizzi and Hartwell’s in vivo study, possibly providing a more accurate

Volume 6 Number 1

Conclusion Twenty-six maxillary premolars with three canals were evaluated from 744 nonsurgical root canal cases performed on maxillary premolars in the graduate endodontic clinic at the University of

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Discussion The prevalence of maxillary first premolars with three canals found in this study (3.35%) is almost identical to the prevalence noted

by Bellizzi and Hartwell in 1984 (3.3%), and comparable to previous in vitro studies.

However, the prevalence of three canals in maxillary second premolars found in this study (3.61%) was greater than that found

by Bellizzi and Hartwell (1.1%), as well as previous in vitro studies.

It is important to remember that the results of this study represent the minimum numbers of premolars presenting for treatment with three canals. Despite the fact that all treatment performed in the endodontic residency program is covered by an endodontist during treatment, and all completed cases are subsequently reviewed for quality of treatment by two additional endodontists, the presence of a third canal in some treated teeth may have gone undetected.

representation of the actual prevalence of maxillary premolars with three canals.

Interestingly, the prevalence of maxillary first premolars with three canals was almost identical to the prevalence reported

by Bellizzi and Hartwell.

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Endodontic practice 23

CLINICAL Table 3: Prevalence of maxillary first and second premolars with three canals in cases treated by University of Louisville endodontic residents from 2007-2012

Table 4: Master Apical File Sizes

Table 5: Obturation Quality MB root

DB root

P root

Louisville over a 5-year period. The prevalence of maxillary first premolars with three canals was found to be 3.35%, which is almost identical to the prevalence noted

by Bellizzi and Hartwell in 1984 (3.3%).

However, the prevalence of maxillary second premolars with three canals was found to be 3.61%, which was greater than the prevalence found by Bellizzi and Hartwell (1.1%), as well as other in vitro research.

The results of this study indicate that the clinician performing endodontic treatment on maxillary premolars can expect to encounter three canals in approximately 3 to 4% of both maxillary first and second premolars. The astute clinician will take time to explore the possibility of additional canal systems in maxillary first and second premolars. EP 24 Endodontic practice

References Bellizzi R, Hartwell G. Evaluating the maxillary premolar with three canals for endodontic therapy.

J Endod. 1981;7:521-6.

Sieraski SM, Taylor GT, Kohn RA. Identification and endodontic management of three-canalled maxillary premolars. J Endod.1985;15:29-32.

Bellizzi R, Hartwell G. Radiographic evaluation of root canal anatomy of in vivo endodontically treated maxillary premolars. J Endod.1985;11:37-41.

Soares JA, Leonardo RT. Root canal treatment of three-rooted maxillary first and second premolars â&#x20AC;&#x201C; a case report. Int Endod l. 2003;36:705-710.

Carns EJ, Skidmore AE. Configuration and deviations of root canals of maxillary first premolars. Oral Surg.

1973;36:880-6.

Vertucci FJ, Gegauff A. Root canal morphology of the maxillary first premolar. J Am Dent Assoc.

1979;99:194-8.

De Deus QD. Topographia da cavidade pulpare e do perapice. In: Endodontia, De Deus QD (ed). Belo Horizonte: Livraria Odontonedicia and Juridica; 1973;41-110.

Vertucci FJ, Seelig A, Gillis R. Root canal morphology of the human maxillary second premolars. Oral Surg Oral Med Oral Pathol. 1974;38:456-64.

Green D. Double canals in single roots. Oral Surg.

1973;35:689-96.

Pineda F, Kuttler Y. Mesiodistal and buccolingual roentgenographic investigation of 7,275 root canals.

Oral Surg Oral Med Oral Pathol. 1972;33:101-10.

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CLINICAL

Endodontic success: “100% – X” Dr. Raphael Bellamy discusses why Dr. Herbert Schilder had the right philosophy about endodontics

T

he challenge of endodontic success is clear to the conscientious clinician of general dentistry and to the endodontist who is entirely committed to excellence in root canal therapy. However, the human body is an extraordinary organism in that its ability to continue to function under adverse biological conditions is remarkable and a major reason why we have dominated this planet of ours while other organisms have not. This capacity to adapt, tolerate, and even mend in the presence of biological adversity, whether normal or pathological, is a phenomenon based upon biological systems that want to work properly by design. This is termed homeostasis.

Blessing and a curse Homeostasis describes the tendency of such a system, especially the physiological system of higher animals, to maintain internal stability, owing to the coordinated response of its parts to any situation or stimulus that disturb its normal condition or function.

This can be both a blessing and a curse to the clinician. Why? A curse, because it allows us to fall short of our goals for whatever reason, be it difficult anatomy, difficult access, lack of patient compliance, lack of suitable technology, or simply that we didn’t try hard enough; and we can get away with it because the patient appears to be fine or even better. A blessing, because sometimes we must do extreme things to teeth in order to secure tooth survival. They heal remarkably well in spite of what we do.

I have written before on this subject, but those who have not been exposed to my writings may wish to know that Dr. Schilder, the world’s greatest endodontist, stated that in endodontics there are three

Raphael G. P. Bellamy, BDS (NUI), Cert Endo Dip ABE, is an American Board of Endodontics-certified endodontist and became a Diplomate in 2007. A member of the Irish Endodontic Association and past president of the Irish Academy of American Graduate Dental Specialists, Dr. Bellamy is a visiting lecturer and mentor to the graduate students of Boston University, Massachusetts, and Boston University in Dubai, UAE. He can be contacted at RBel5553@aol.com, and for more information visit www.ltd2endo.ie and www. schilderinstitute.com.

26 Endodontic practice

Figure 1: Simulated canal injected with ink

Figure 2: Canal shaping with WaveOne primary reciprocating file after glide path preparation

critical factors that drive the clinician to excellence, and they are knowledge, skill, and desire.

Much like the organism described earlier, these three factors are interdependent. Knowledge in the absence of skill and desire is futile in endodontics.

Skill in the absence of knowledge and desire is futile. Desire in the absence of skill and knowledge is futile, but where desire differs is that it drives us to gain skills, and attain the knowledge that allows us to carry out successful endodontics. Therefore, if we acknowledge that endodontics works, then successful endodontics is plain and simply a decision. That brings me to the title of this article: “100% – X.”

(1931).

Dr. Seltzer stated, “It can’t be done.”

Everybody accepts now that it can be done. The more complete the cleaning, shaping, and obturation of the root canal system, then the higher the success rate in endodontics. Put simply: if extraction works, then well-performed endodontics works. It is a sine qua non.

Dr. Schilder was right, of course.

This unpalatable truth is as unsavory today as it was then. It strikes right at the heart of the clinician; it centers the spotlight on knowledge, skill, and desire; it asks questions of us. Are we really as conscientious as we say we are? Are we committed to excellence like we say we are? I don’t think so (Figure 1).

Capacity to heal In 1962, Dr. Herbert Schilder turned the endodontic world on its head when he announced: “The capacity of lesions of endodontic origin to heal is 100% – X.” At the time, others in the field of endodontics said such a statement was nonsense.

For example, Dr. Seltzer’s study of teeth that he had treated endodontically (note I did not use the words clean and shape) revealed that all the teeth still contained necrotic tissue after such treatment; the recognized cause of failure based upon the “hollow tube theory” of Rickert and Dixon

Poor endodontics retreated Dr. Schilder indoctrinated all of his students about the 1962 study — I know because I am one. It is a basic tenet of the Schilder philosophy, and it is what every Schildertrained endodontist believes in. If you carried out root canal therapy, and it failed to heal, then you failed to deal with the root canal system. This is a heavy burden indeed for a clinician to carry.

Dr. Schilder didn’t teach selfrighteousness; he taught us to be guilty of failure, and persist for our best effort.

Volume 6 Number 1

Dr. Schilder’s study Dr. Schilder carried out orthograde root canal therapy utilizing his warm vertical compaction technique on 100 necrotic, anterior teeth of healthy subjects. The teeth possessed lesions of endodontic origin (LEOs) that varied in size from 8 mm to 35 mm. The treated subjects were recalled over a minimum of 24 months at 6-month intervals, and radiographs were taken of the treated teeth.

Within 6 months, 56% of the treated teeth showed an intact periodontium.

Within 24 months, 99% of the treated teeth showed an intact periodontium. One subject, an elderly female, had a lateral incisor that did not respond favorably after the 24-month period. Dr. Schilder treated this tooth once more using a surgical approach. Access to the apical extent of the tooth revealed the presence of two distinct root tips, one filled but the other unfilled. The unfilled palatal canal remained hidden on X-ray behind the treated, more buccally placed canal. The apicoectomy, with a retrograde amalgam

CHART–One hundred human teeth

filling placed, removed this anomaly and the contaminated root tip.

Can you guess what happened? It healed, bringing the success rate to 100% with 100 successfully treated teeth. What comes after this graphic demonstration is all down to us and the way we deal with the root canal system. When we fail in endodontics, we fail to deal with the root canal system.

X marks the spot “What is X?” you may ask. The value of X as it is used in the context of “100% – X” is the variable for any given endodontic case and, of course, it needs to be as small as possible in order to secure the most favorable outcome for treatment.

If you are in the “blame game,” as I call it, X for you, could represent a multitude of things that do not allow you to satisfy the absolute criteria for the healing of the periodontal apparatus. It could be a clinician’s limited knowledge of endodontics, the anatomy, the smear layer, the bacteria involved, the biofilm, the necessary irrigants to kill the pathogens responsible, the inability to gain patency, to shape the system, to clean the system, to obturate the system, the interappointment medicament, or the temporary dressing.

X also represents the more tangible aspects that can influence our behavior and therefore the outcome, like the time we allocate a patient in the schedule for the procedure, whether they have one visit or two visits, whether we like the patient, whether we charge enough, whether we feel valued by the patient, whether we care enough. The list is without end and contains every other thing that you can visualize that will compromise the outcome

of the case by increasing the value of X. If you are in the “blame game” you will find plenty of reasons indeed.

True professionals Based upon some research, the “average” endodontic treatment doesn’t seem to last a very long time – at least if we want to secure the prevention or healing of apical periodontitis. If we only focus on tooth survival, much as the implant promoters do for such fixtures, then the tooth survival for endodontically treated teeth would be phenomenal indeed. In many dental articles, comparing the efficacy of implants versus retention of the natural tooth, the authors rarely compare like with like.

If we are to aspire, as we should if we are true professionals, to reach 100% success in endodontics, then the profession’s attitude needs to change and follow Dr. Schilder. Wouldn’t it be a disgrace for the profession if we accepted implants as a solution for badly performed endodontics, knowing that the potential of endodontic treatment is much higher than what the profession actually gets out of it?

Not always easy Fifty years after Dr. Schilder made it glaringly obvious to clinicians as to how to achieve clinical success, we have embraced all the technological developments that dentistry has to offer like children in a sweet shop, yet consistently we fall short of the goals that he set for us.

I believe the trouble lies within our own behavior as a profession. We have bought into the idea that root canal therapy is easy when it is not. It never was and never will be. I have experience, deliver excellent anesthesia, rubber dam, a microscope, digital radiography, apex locator, nickeltitanium rotary files, sophisticated delivery systems, irrigation systems, disinfection systems, and obturation systems, yet I spend more time, not less time, on my cases than ever before in an effort to secure success.

If you believe the dental industry, then you believe that anybody can do endodontics because it’s easy and getting easier. Well, let me tell you that it is not.

Every easy case is a hard case. Every case is a hard case. Dr. Schilder said many times that “the technology will never save you.” He was right. EP References available upon request.

Volume 6 Number 1

Endodontic practice 27

CLINICAL

Clinicians will always choose to blame something or somebody for their failures, but Dr. Schilder asked us to look at ourselves in the mirror as clinicians, human beings, and articulate the words slowly: “I failed...I failed,” and then, try harder next time.

Often it occurs to me that both general dentists, and maybe even endodontists, don’t really believe that with the correct technique we have the ability to predictably save teeth by restoring the periodontal apparatus to health and function. The real power of this study comes from its simplicity. Let us examine it more closely.

ENDODONTICS IN FOCUS

Top ten tips: Tip number 5 â&#x20AC;&#x201C; Access cavities and canal location In the fifth article of the series, Dr. Tony Druttman discusses how to make the preparation of the root canals easier

T

his article is part of a series that appears in 10 consecutive issues and is designed to offer practical advice on some of the most common challenges that endodontists face. The purpose is to make the practice of endodontics easier.

Some of the information will give a better understanding of what endodontists are dealing with, some will make it easier to avoid pitfalls, some will show how to improve the quality of endodontic work, and some will advise what to do when difficulties arise.

Although each article covers a specific topic, they interrelate, and some of the questions that arise may be answered in other articles. By nature, it cannot be comprehensive; otherwise it would be a textbook, but hopefully, it will give valuable, practical information.

The importance of access A well-known endodontist, Dr. Frank Weine, coined the adage â&#x20AC;&#x153;Access is success.â&#x20AC;? What this means is that if you get the access cavity design right, it makes the preparation of the root canals much easier.

The access cavity should be large enough so that direct line access to the canals can be achieved, but small enough so that as much of the coronal tooth tissue as possible can be preserved. In the 21st century, we are asked to root treat all types of teeth including third molars. The oldest patient referred to me for endodontic treatment was 99 years old, and many of the teeth we have to deal with have suffered the ravages of dentistry before we treat them.

Often finding the canals can take longer than shaping them. You have to follow some basic rules. You have to know where to look; otherwise, a large amount of tooth

Tony Druttman, MSc, BChD, BSc, has extensive expertise in treating dental root canals, resolving difficult endodontic cases, and saving teeth from being extracted. His two London practices, one in the West End and the other in the City of London, are restricted to endodontic treatment. www.londonendo. co.uk

28 Endodontic practice

Figure 1: The floor of the pulp chamber has been considerably damaged including a perforation while looking for the canals

Figure 2: Important information can be gleaned from a good quality periapical radiograph

tissue can be unnecessarily destroyed and the long-term prognosis for the tooth affected (Figure 1).

A good quality preoperative long cone periapical radiograph gives important information about the depth of the pulp chamber, the mesiodistal position of the canal or canals, the canal curvature, and whether the canals divide along the way (Figure 2). The pulp chamber and the canals reduce in size through life as secondary dentin is laid down, but they also react to trauma and insult, and tertiary or reparative dentin can be laid down to completely or partially obliterate the pulp chamber and canal, especially in the coronal part. This was discussed in the third article of this series on radiography (Endodontic Practice US, September/October 2012).

The pulp chamber and the root canals should flow one into the other so that instruments can be introduced into the root canals without hitting obstructions on the way. Once entry into the pulp chamber has been achieved, the preliminary shape of the pulp chamber can be created using safe-ended Endo-Z burs (Dentsply Maillefer) [Figure 3]. This allows the walls to be shaped without damaging the floor of the pulp chamber. Once the canals have been located and the first instruments placed, a sense of the canal anatomy starts to form, and the access design may have to be modified during canal preparation as progressively larger and stiffer rotary instruments are used.

Canal positions

Basic canal positions can be found in any textbook on endodontics, so this is not the

Figure 3: Endo-Z bur

place to repeat the information. However, it is worth reminding readers how to find an MB2 canal in upper molars. Inability to find the MB2 canal is the most common cause for failure of endodontic treatment in upper molars (Figures 4A and 4B). The incidence varies depending on the papers you read (and how adept the authors are at finding them). The range seems to be about 7090%, so the answer is always: look for the canal.

For those of you who did not see the earlier article on anatomy in the series, I repeat the schematic diagram to show the relative positions of the canals in an upper molar. Draw a line between the palatal canal and the MB1, and then drop a perpendicular line from the DB canal to the line between the other two canals. You will usually find the MB2 where they intersect (Figure 5).

There are basic rules about canal position which, if followed, make canal location easier and conserve tooth tissue.

1. The floor of the pulp chamber is always located at the center of the tooth and at the level of the CEJ (Figure 2).

2. The walls of the pulp chamber are concentric to the external surfaces of the tooth at the level of the CEJ (Figure 6).

3. The CEJ is the most consistent landmark in locating the position of the pulp chamber.

4. Except for maxillary molars, the orifices of the canals are equidistant from a line drawn in a mesiodistal direction across the floor of the pulp chamber (Figure 6).

Volume 6 Number 1

Figure 4B: Retreatment including identification and treatment of the MB2 canal

Figure 5: Schematic of an upper molar showing the relationship of the MB2 canal to the other canals

Figure 6: Position of the pulp chamber and canals in relation to the external outline of the tooth

Figure 7A: Floor of the pulp chamber is covered with reparative or tertiary dentin

Figure 7B: The floor of the pulp chamber is revealed

Figure 10: Even though the canal was clearly visible from the preoperative radiograph, the canal was difficult to locate until a check radiograph had been taken Figure 8: Pulp stone in the entrances to the canals

Figure 9: Bur selection used in endodontics

5. The pulp chamber floor is always darker than the walls (Figure 6).

6. The orifices of the root canals are always located at the junction of the walls and the floor (Figure 6).

removed with ultrasonic files. It is helpful, of course, to do this under magnification and with good light, but more about that in the next column on magnification and illumination.

Difficulties

Check radiographs

Often, we experience difficulties in being able to recognize the difference between the roof and the floor of the pulp chamber.

If the roof is not removed, then canals can never be cleaned properly, and there will always be a source of bacteria to contaminate the canal system (Figure 7A). It is therefore necessary to examine the floor of the access cavity carefully to determine that any tertiary dentin has been removed (Figure 7B). Small long shank burs are then used to remove pulp stones over the canal entrances, and remaining pulp stones in the canals themselves (Figure 8) can be

Occasionally canals that are very clear on a radiograph can be very difficult to find, often in crowned teeth where the natural shape of the coronal tooth tissue has been lost. In these cases, it is important to take check radiographs to ensure that a new canal is not being created, heading off towards the periodontal membrane (Figure 10). In heavily restored, damaged, or traumatized teeth, the canal may be sclerosed and difficult to locate. The radiograph may well not even show the presence of a canal.

The canals always sclerose from coronal to apical, and very often, there

Volume 6 Number 1

is a trail left behind where the canal used to be. If you follow that trail, you may well find the canal, but this does usually require the use of magnification. If having created a reasonable access, you are unable to find the canals, the best thing to do is to stop and refer the case to a more experienced colleague, preferably a specialist endodontist, who should have the skill and the equipment to locate the canals and complete the case. Sometimes the wisest course of action is to assess the case from the preoperative radiograph and refer the patient before you start. That way, you donâ&#x20AC;&#x2122;t cause unnecessary damage to the tooth and spend a great deal of unproductive and frustrating time. EP Next issue: Magnification and illumination

Endodontic practice 29

ENDODONTICS IN FOCUS

Figure 4A: Endodontic lesion above the mb root

CONTINUING EDUCATION

Results of retreated root canals with a methacrylate resin-based sealer Drs. Osvaldo Zmener and Cornelis H. Pameijer discuss the clinical, radiographic, and histologic outcomes of retreated root canals with a methacrylate resin-based sealer after 8 years Introduction One of the goals of root canal therapy is to eliminate intraradicular infection, which (along with proper obturation) generally results in the resolution of periapical pathosis. Failure to accomplish this often results in nonsurgical endodontic retreatment as the treatment of choice in most cases (Friedman, Stabholtz, 1986).

Retreatment of a root canal system requires complete removal of the original filling material followed by reinstrumentation and a repeat obturation of the canal system (Bergenholtz, et al., 1979a; Bergenholtz, et al., 1979b; Gorni, Gagliani, 2004).

In a 4-year retrospective clinical and radiographic study (Zmener, Pameijer, 2009), we evaluated the outcomes of endodontic retreatment performed in 67 patients with 163 root canals that had failed.

Regardless of the preoperative periapical status, all retreatments were completed in a single visit using a standardized instrumentation protocol (Zmener, Pameijer, 2009), and the canals were filled with gutta percha and EndoREZ® (ER; Ultradent Products Inc.), a methacrylate resin-based endodontic sealer. The overall success was 84.61%, and the recall rate was 77.61%.

The purpose of the present study was to correlate periapical radiographic observations and histological findings on eight of these retreated teeth that had to be extracted because they failed for various reasons.

Materials and methods This study was approved by the Argentine Dental Association Ethics Committee for animal and human research. The eight extracted teeth from three males and five

Osvaldo Zmener, DDS, Dr Odont, is head professor for the postgraduate program for specialized endodontics at the Faculty of Medical Sciences, School of Dentistry, University of El Salvador, Buenos Aires, Argentina.

Cornelis H. Pameijer, DMD, MScD, DSc, PhD, is professor emeritus at the University of Connecticut School of Dental Medicine, Farmington, Connecticut.

30 Endodontic practice

Educational aims and objectives The purpose of this article is to look at the results of retreated root canals with a methacrylate resin-based sealer.

Expected outcomes Correctly answering the questions on page 35, worth 2 hours of CE, will demonstrate you can identify the clinical, radiographic, and histologic outcomes of retreated root canals with a methacrylate resin-based sealer after 8 years.

Case one

A

D

B

C

E

1A: A maxillary lateral incisor of a 61-year-old female showing incomplete and poor root fill and the presence of periapical pathosis 1B: Immediate postoperative radiograph. Note accidental extrusion of sealer 1C: The 8-year follow-up radiograph shows a normal periapical area and a thickened PDL. This may explain the patient’s complaint of some discomfort and sensitivity to percussion.

Furthermore, the patient had lost all teeth except for the upper central and lateral incisors.

The treatment plan of her general dentist called for extraction of all remaining incisors and a complete maxillary denture supported by four implants 1D: Photomicrograph of the apical part of the lateral incisor showing extruded gutta percha and sealer (H&E, original magnification x100) 1E: Higher magnification of the square area in D. Fibrous connective tissue with randomly distributed sealer particles, and some persistent inflammatory cells can be seen in direct contact with the overfilled material, while the surrounding tissues showed a healthy fibrous capsule (H&E; original magnification x850). Clinical and radiographic evaluation: grade one – marginally successful. Histologic evaluation: grade one – marginally successful Volume 6 Number 1

2A: Preoperative radiograph of a mandibular right second molar from a 56-year-old female showing an endodontic failure. Note periapical radiolucency and a metal parallel post in the distal canal 2B: Immediate postoperative radiograph showing slight accidental overfilling with ER 2C: This radiograph after 8 years showed normal periapical conditions. Two months later, the tooth was extracted in order to place implants. After extraction, the tooth was immediately immersed in 10% neutral buffered formalin

A

B

2D: Histologic picture of the most apical area of the root showing PDL tissue attached to the root (H&E, original magnification x150)

C

2E: Higher magnification of the square area in D showing the tip of the root (F) and a dense healthy connective tissue with a few isolated inflammatory cells (H&E, original magnification x1000). Clinical and radiographic evaluation: grade zero – success. Histologic evaluation: grade zero – success

D

females, aged 42-62 years, comprised 11 roots that had been examined during the previous 4-year retreatment study (Zmener, Pameijer, 2009).

The reason for extraction was because the tooth was unrestorable or the root(s) had fractured. After being informed about the objectives of the study, the patients signed an informed consent form.

Clinical and radiographic evaluation The designated teeth and surrounding tissues were examined, and radiographs were taken, leading to a clinical diagnosis.

Extractions took place during a period of 7 to 8 years after completion of the original retreatment.

Before extraction, at least three radiographs were taken at different angulations using the parallel technique and Kodak Ultra-speed film (Eastman Kodak Co.). The radiographs were processed in a dark room, according to the manufacturer’s recommendations and then compared to the immediate postoperative films on file using a viewer and magnifying glass by two independent endodontists with more than 25 years of clinical experience. They had been calibrated by analyzing a standard set of 100 individual pairs of postoperative and recall radiographs twice.

The evaluation of the clinical and radiographic outcome of the endodontic retreatment was based on previously established parameters (Zmener, Pameijer, 2009).

Volume 6 Number 1

E

Case three

A

D

B

C

E

3A: Preoperative radiograph of a mandibular left first premolar from a 52-year-old male showing endodontic failure with a periapical radiolucency. Note short root fill and a cast post and core 3B: The post and core were removed 3C: Immediate postoperative radiograph showing two retreated root canals, one with a slight overfill 3D: A radiographic after 7.7 years normal periapical tissues. Note substantial cast post and core. The patient reported discomfort that started 2 days before the appointment. Periodontal probing revealed a deep mesial pocket. A root fracture was diagnosed. The arrow indicates the approximate location of the oblique root fracture, which was not seen on the radiograph. As a result, the tooth was extracted 3E: Histological photomicrograph of the periapical PDL attachment showing healthy fibrous tissue with numerous collagen fibers and fibroblasts. Note dark brown particles of sealer and gutta percha (M). A close-up view (insert) of the mesial aspect of the root after extraction showing a longitudinal fracture (H&E, original magnification x1000). Failure was due to root fracture and unrelated to endodontic treatment. Clinical and radiographic evaluation: grade zero – success. Histologic evaluation: grade zero – success Endodontic practice 31

CONTINUING EDUCATION

Case two

CONTINUING EDUCATION Success or failure was based on health of periapical tissues, widened or thickened periodontal ligament space (slightly widened was acceptable), loss of cortical bone, changes in trabecular bone patterns, and radiographically discernible periradicular radiolucencies.

Disagreement between the evaluators was resolved by joint assessment until a consensus was reached. Success or failure of retreatment was determined on the basis of radiographic findings, and clinical signs and symptoms. Retreatment was considered a failure when periapical radiolucencies were observed in the preoperative radiograph and remained unchanged or increased over the 7- to 8-year period.

If the radiolucency decreased in size, and the patient was comfortable, while

the contours and width of the periodontal space had returned to normal, retreatment was considered successful. Absence of periapical radiolucency in the preoperative radiographs and an appearance that remained unchanged was determined successful. A root that developed a radiolucency was considered a failure. Failure of one canal in multirooted teeth was considered a complete failure.

Histologic processing Immediately after extraction, the specimens were fixed in 10% neutral buffered formalin for at least 96 hours. Demineralization was performed in 7.0% nitric acid, followed by washing in running tap water for 48 hours. Specimens were then dehydrated in ascending series of ethanol, cleared in xylene, and embedded in paraffin.

Case four

Serial sections ~6.0µm thick were cut parallel to the long axis of the root canal until the specimen had no further root structure.

Sections were stained with haematoxylin and eosin (H&E). When curves were present, the roots were sectioned into two pieces, taking care to not damage the apical third and then embedded separately.

The sections were analyzed blind by two trained evaluators who independently scored the presence of fibrous tissue, vascular changes, and the various types of inflammatory cells under a light microscope equipped with a digital Canon PowerShot A510 camera (Canon, Tokyo, Japan).

Histologic evaluation criteria For evaluation of the histopathologic status of the periodontal ligament (PDL) attached

Case five

D A

A

B

B

C

C

E

F

G

5A: Preoperative radiograph of a maxillary central incisor from a 42-year-old male showing a root canal filling ending short of the apical constriction

D

E

4A: Immediate postoperative radiograph of a maxillary left canine from a 56-year-old male, which was endodontically retreated through a metallic crown. The root canal was prepared to accommodate a post 4B: A 7.8 year postoperative radiograph suggested that the periapical conditions were normal. A ceramometalic bridge and a short cast post can be seen. The patient complained about mobility of the coronal part of the restoration. The arrow on the X-ray indicates the approximate level of an oblique root fracture, which cannot be seen on the radiograph 4C: The ceramometal crown was separated from the bridge and the root extracted. The extracted root showed an oblique root fracture and a corroded post. Although the other abutment was still restorable, the patient opted for extraction and placement of implants 4D: Overview of the apex surrounded by healthy connective tissue attached to the root (H&E, original magnification x100) 4E: Detail of the area marked with arrow in D showing the presence of sealer particles encapsulated by a fibrous connective tissue free of inflammatory cells (H&E, original magnification x1000). Clinical and radiographic evaluation: grade zero – success.

Histologic evaluation: grade zero – success 32 Endodontic practice

5B: The tooth was retreated in order to accommodate a prosthetic restoration. The root canal filling now extended to the apical limit 5C: A radiograph taken 8 years postoperatively shows normal periapical tissues and the presence of a cast post and core. The tooth had an acrylic (temporary) crown, which was replaced three times, as the patient never wanted a final restoration 5D: Seven days after the 8-year postoperative radiograph, the patient suffered a traumatic event, which caused the root to fracture. The clinical photograph illustrates the clinical condition of the tooth 2 days after the accident. The root was extracted during the same appointment 5E: After fixation in formalin, the tooth was photographed to illustrate the severity of the root fracture (white arrow) exposing part of the cast post (black arrow) 5F: Low power histology shows the apical limit of the canal preparation and some packed debris and dentin chips, as well as sealer (H&E, original magnification x40) 5G: Higher magnification of the square area in F shows debris and dentin chips (DCH) packed against a calcified tissue apposition, which seemed to partially fill the foramen (thin arrow). This calcified tissue was irregular with lacunae containing vital tissue or dentin chips. Beyond the calcified tissue, note the presence of a non-inflamed fibrous connective tissue (heavy arrow) [H&E, original magnification x400]. Clinical and radiographic evaluation: grade zero –- success. Histologic evaluation: grade zero – success

Volume 6 Number 1

Results For the clinical and radiographic evaluation, teeth were grouped according to the presence or absence of preoperative periapical radiolucent areas.

Five cases (case one, two, three, six, and eight) showed preoperative

Case six

periapical radiolucent areas while three cases (case four, five and seven) appeared radiographically normal. After 7 to 8 years, two of the eight patients presented with pain (case one and eight).

After 8 years, the root canal fillings were considered radiographically to be of high quality. The root fillings appeared homogeneous and were short 0-2 mm from the radiographic apex, in spite of the fact that three had been overfilled as shown on the immediate postoperative radiographs (cases one, two, and three).

The five instances that showed a preoperative periapical radiolucency presented with a resolution after 7 to 8 years, except case eight, in which the radiolucency persisted. Upon analysis, six cases were histologically classified as being a grade zero and had a healthy PDL attachment, while two cases were judged grade one and two (subsequently case one and eight).

The eight cases that were analyzed correlated clinical and radiographical observations with histological findings. The histological findings were the determining factors whether the root canal treatment was successful or a failure.

Discussion A

D

B

E

In this study, teeth that were diagnosed as a failure were processed for histological analysis. All teeth that were collected after a 7- to 8-year period had been endodontically retreated.

A correlation between clinical and

C

F

Case seven

6A: A mandibular second premolar of a 62-year-old female patient was retreated owing to incomplete root canal therapy accompanied by a slight apical radiolucency 6B: Immediate postoperative radiograph 6C: The 8-year postoperative radiograph shows normal periapical conditions, a cast post and core and a two-unit ceramometal cantilever restoration (not visible on the X-ray). The patient reported some discomfort especially during chewing 6D: The tooth was diagnosed with a fractured root and extracted. A vertical root fracture on the mesial aspect of the root can be seen 6E: Histologic section at the apical level shows the obturating material (M), a partial newly calcified formation (arrow), and a healthy PDL (H&E, original magnification x100) 6F: Higher magnification of the square area in E, showing a PDL composed of a dense fibrous connective tissue without inflammatory cells (H&E, original magnification x400).

Clinical and radiographic evaluation: grade zero – success. Histologic evaluation: grade zero – success

A

B

7A: Retreatment of a maxillary lateral incisor was performed on a 59-year-old female patient. At recall (7.11 years postoperatively), the tooth presented with a prosthetic failure. Note a slight apical widening of the PDL space, which was interpreted as apical scar. The root remnant was extracted as it was deemed nonrestorable 7B: A histological view of the apical areas confirmed the diagnosis of apical scar.

Note the presence of a dense fibrous connective tissue free from inflammation and cementoblast-like cells at the tip of the root (H&E, original magnification x1000). Clinical and radiographic evaluation: grade zero – success. Histologic evaluation: grade zero – success

Volume 6 Number 1

Endodontic practice 33

CONTINUING EDUCATION

was considered a histological success.

Cases with a grade one were considered marginally acceptable, while a grade two was considered a histological failure.

The objectives of this study were to compare clinical findings with a histological analysis of the apical areas of the extracted teeth to determine whether a correlation existed between clinical and radiographic diagnosis and histological analysis. Cases were rated either successful, marginally successful, or a failure.

close to the apical foramen (when present), a slight modification of the histologic criteria described by Ricucci, et al., (2009) was used. The PDL status was categorized as follows: • Grade zero: Absence of inflammatory cells and a well-organized fibrous connective tissue. This may or may not be accompanied by the presence of cement apposition in the apical part of the root canal. The presence of a few chronic inflammatory cells in the PDL was determined acceptable • Grade one: Presence of small concentrations of chronic inflammatory cells and dispersed sealer particles • Grade two: Presence of large concentration of inflammatory cells and congested blood vessels.

A sample classified as grade zero

CONTINUING EDUCATION Case eight

A

B

radiographical evaluation and the true status of the periapical tissues can only be determined by means of periapical biopsies, which requires the removal of periradicular bone along with the apical portion of the root. If this is done for experimental purposes, the invasiveness of this procedure reduces the number of cases because of ethical restrictions.

On the other hand, teeth scheduled for extraction due to failure, other than endodontic treatment, can provide important information on the periapical status of the PDL, as it is frequently removed with the root when extracting a tooth.

Conclusion

C 8A: This maxillary lateral incisor of a 45-year-old female patient was retreated due to a failed endodontic treatment and persisting periapical pathosis 8B: At recall (8 years after retreatment) the patient reported some mobility of the tooth. Radiographic examination revealed a substantially reduced periapical radiolocency, albeit it had not resolved entirely. Loss of bone support and a horizontal fracture line (arrow) can clearly be seen. After extraction, the tooth was prepared for histological analysis 8C: The histologic section shows granulomatous tissues surrounded by a dense fibrous connective encapsulation containing scattered accumulations of inflammatory cells (H&E, original magnification x400).

Clinical and radiographic evaluation: grade two – failure. Histologic evaluation: grade two – failure

Although the number of studied samples was limited, the results demonstrated a successful outcome of retreatments in seven of the eight cases per parameters outlined by Bergenholtz, et al., 1979 as well as Zmener and Pameijer, 2009.

The results are also in agreement with previous histological investigations (Green, et al., 1997; Ricucci, Langeland, 1998; Ricucci, et al., 2009), which demonstrated a good correlation between radiographic and histologic evaluation of the periapical tissues.

Within the limitations of the study, it can be concluded that, in agreement with previous reports Zmener, 2004; Zmener, et al., 2005; Zmener, Pameijer, 2009, the results indicate a favorable outcome of cases that are retreated and obturated with the endodontic sealer ER. EP

References Bergenholtz G, Lekholm U, Milthon R, Engstrom B. Influence of apical overinstrumentation and overfilling on retreated root canals. J Endod. 1979;5:310-314.

Bergenholtz G, Lekholm U, Milthon R, Heden G, Odesjo B, Ergstrom B. Retreatment of endodontic fillings.

Scand J Dent Res. 1979;87:217-224.

Friedman S, Stabholtz A. Endodontic retreatment – case selection and technique. Part 1: criteria for case selection. J Endod. 1986;12:28-33.

Gorni FGM, Gagliani MM. The outcome of endodontic retreatment: a two-year follow-up. J Endod. 2004;30:14.

34 Endodontic practice

Green TL, Wakton RE, Taylor JK, Merrel P. Radiographic and histologic periapical findings of root canals treated teeth in cadaver. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1997;83(6):707-711.

Zmener O. Tissue response to a new methacrylatebased root canal sealer: preliminary observations in the subcutaneous connective tissue of rats. J Endod.

2004;30:348-351.

Ricucci D, Langeland K. Apical limit of root canal instrumentation and obturation, part 2: a histological study. Int Endod J. 1998;31:394-409.

Zmener O, Pameijer CH, Banegas G. Bone tissue response to a methacrylate-based endodontic sealer: a histological and histometric study. J Endod.

2005;31:457-459.

Ricucci D, Lin LM, Spangberg LSW. Wound healing of apical tissues after root canal therapy: a long-term clinical, radiographic and histopathologic observation study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009;108:609-621.

Zmener O, Pameijer CH. Clinical and radiographic evaluation of root canals retreated with anatomic endodontic technology and filled with gutta percha and a methacrylate-based endodontic sealer: a four-year follow-up. Endod Pract. 2009;12:13-18.

Volume 6 Number 1

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Results of retreated root canals with a methacrylate resin-based sealer 1. One of the goals of root canal therapy is to eliminate ________, which (along with proper obturation) generally results in the resolution of periapical pathosis. a. granulomous tissues b. intraradicular infection c. connective encapsulation d. existing dental restorations 2. Retreatment of a root canal system requires complete removal of the original filling material followed by _______________. a. reinstrumentation b. a repeat obturation of the canal system c. extraction of the tooth d. both a and b 3. (For this study,) Success or failure was based on health of periapical tissues, widened or thickened periodontal ligament space (slightly widened was acceptable),____________. a. loss of cortical bone b. changes in trabecular bone patterns c. radiographically discernible periradicular radiolucencies d. all of the above 4. Retreatment was considered a failure when periapical radiolucencies were observed in the ______ and remained unchanged or increased

Volume 6 Number 1

over the 7- to 8-year period. a. adjacent tooth b. photomicrograph c. preoperative radiograph d. intraoral photograph 5. If the radiolucency ______ , and the patient was comfortable, while the contours and width of the periodontal space had returned to normal, retreatment was considered successful. a. increased in size b. remained the same size c. decreased in size d. both a and b 6. Absence of periapical radiolucency in the preoperative radiographs and _______ was determined successful. a. the absence of fibrous tissue b. some vascular changes c. an appearance that remained unchanged d. increased cortical bone 7. A root that developed a radiolucency was considered _____. a. a failure b. a success c. an indication that the tooth has healed d. an acceptable outcome

8. Failure of ______ in multirooted teeth was considered a complete failure. a. one canal b. two canal c. three canals d. all of the above 9. Immediately after extraction, the specimens were fixed in 10% neutral buffered formalin for at least ______. a. 24 hours b. 48 hours c. 72 hours d. 96 hours 10. Within the limitations of the study, it can be concluded that, in agreement with previous reports, the results indicate _______of cases that are retreated and obturated with the endodontic sealer ER. a. no definitive result b. a favorable outcome c. an unfavorable outcome d. the need for further exploration

Endodontic practice 35

CE CREDITS

ENDODONTIC PRACTICE CE

CONTINUING EDUCATION

Evaluation of the shaping performance of the WaveOne single file reciprocating system with and without glide path Drs. Anil Dhingra and Punit Srivastava evaluate the influence of glide path on the canal curvature and axis modification after instrumentation with WaveOne™ primary reciprocating files

Figure 1: Simulated canal injected with ink

E

ngine-driven nickel-titanium instruments are in common usage. Fracture of nickel-titanium engine instruments may occur for two different reasons, either because of torsion or fatigue through flexure (Serene, Adams, Saxena, 1995).

The torsional fracture occurs when the tip or any other part of the instrument binds to the canal walls, whereas the handpiece keeps turning. When this occurs, and the elastic limit of the metal is exceeded, fracture of the instrument is inevitable. This type of fracture has been associated with the application of excessive apical force during instrumentation.

Fracture resulting from flexural fatigue occurs when an instrument that has already been weakened by metal fatigue is placed under stress. The instrument does not bind to the canal wall but rotates freely until the fracture occurs at the point of maximum flexure (Sattapan, Nervo, Palamara, Messer, 2000; Sattapan, Palamara, Messer, 2000). This type of failure is believed to be an important factor in the fracture of nickel-titanium rotary instruments in clinical usage and may be because of their use in curved canals (Pruett, Clement, Carnes, 1997).

Various factors have been associated

Anil Dhingra, MDS, is professor and head of department at the Department of Conservative Dentistry and Endodontics in DJ College of Dental Sciences and Research, Modinagar, India.

Punit Srivastava, BDS, is a postgraduate student at the Department of Conservative Dentistry and Endodontics in DJ College of Dental Sciences and Research, Modinagar, India.

36 Endodontic practice

Figure 2: Canal shaping with WaveOne primary reciprocating file after glide path preparation

Figure 3: Canal shaping with WaveOne only (without glide path preparation)

Educational aims and objectives The aim of this article is to evaluate the influence of glide path on the canal curvature and access modification after instrumentation with WaveOne primary reciprocating files without glide path and with glide path.

Expected outcomes Correctly answering the questions on page 40, worth 2 hours of CE, will demonstrate that the reader can recognize that canal modifications seem to be significantly reduced when previous glide path is performed using the WaveOne nickel-titanium single file system.

with the fracture of nickel-titanium rotary instruments, including: • Rotational speed (Pruett, Clement, Carnes, 1997; Gabel, et al., 1999; Daugherty, Gound, Comer, 2001) • Angle and radius of curvature (Pruett, Clement, Carnes, 1997) • Instrument design and instrumentation technique (Bryant, et al., 1998) • Torque (Gambarini, 2000) • Operator experience (Yared, Bou Dagher, Machtou, 2001).

The reciprocating motion might decrease the impact of cyclic fatigue on a nickel-titanium rotary instrument, compared with rotational motion (You, et al., 2010; Varela-Patino, et al., 2010).

The WaveOne (Dentsply Tulsa Dental Specialties) nickel-titanium single file system has been designed to be used with a dedicated reciprocating motion motor. It consists of three single-use files: • Small (ISO 21 tip and 6% taper) for fine canals • Primary (ISO 25 tip and 8% taper) for

the majority of canals • Large (ISO 40 and 8% taper) for large canals.

The files are manufactured with M-Wire nickel-titanium alloy (Johnson, et al., 2008).

According to Webber, et al., (2011), the WaveOne clinical procedure does not contemplate the preliminary creation of a glide path before use. WaveOne Primary is indicated when a size 10 K-file moves to length easily.

The aim of this study was to compare modification of the canal curvature and axis with the new WaveOne single file reciprocating system in endo training blocks, with and without glide path.

Materials and methods Thirty ISO 15, 0.02 taper endo training blocks were used. Each simulated canal was colored with ink injected from a syringe (Figure 1). Each specimen was then mounted on a stable support consisting of a rectangular slot the size of the specimen Volume 6 Number 1

Figure 4: Alignment of the axis of blocks

Figure 5: Elimination of the blocks

Figure 7: Inversion and polarization

Figure 8: Superimposition

Figure 9: Degree of angle of curvature of group one

Figure 10: Degree of angle of curvature of group two

(30x10 mm) and a support for a digital camera, positioned centrally and at 90˚ to the specimen.

Digital images of all specimens before instrumentation were obtained and saved as jpeg format files. Specimens were then randomly assigned to two different groups (n=15).

In group one, the mechanical glide path was performed using Glyde File Prep™ (Dentsply Maillefer) as a lubricating agent, with PathFile™ nickel-titanium rotary instruments (Dentsply Maillefer). The system consists of three instruments with 21 mm, 25 mm, and 31 mm length and 0.02 taper; they have a square section.

PathFile size 1 (purple) has an ISO 13 tip size; PathFile size 2 (white) has an ISO 16 tip size; and PathFile size 3 (yellow) has an ISO 19 tip size.

PathFile size 1 was used immediately after a size 10 hand K-file had been used to scout the root canal to full working length by using an endodontic engine (X-Smart Plus™, Dentsply Maillefer) with 16:1 contra-

angle at the suggested setting (300rpm on display, 5Ncm) at full working length; then PathFile size 2 and PathFile size 3 were used to working length.

Each canal was then shaped with WaveOne primary reciprocating files (Dentsply Maillefer), used with a pecking motion, until reaching full working length (Figure 2). The WaveOne dedicated reciprocating motor was used with the manufacturer’s configuration setup.

In group two, glide path was not performed. Each canal was shaped with WaveOne primary reciprocating files, used with a pecking motion until reaching full working length, using Glyde as lubricating agent (Figure 3). After instrumentation, all specimens in each group were repositioned in the slot and photographed as described earlier.

By using digital imaging software CorelDraw® Graphic Suite X5 (Corel Corporation, Canada), Adobe Photoshop CS3 (Adobe Systems Inc, CA) and Solidworks® Student Edition software

(Dassault Systems Solidworks Corp, France), the pre- and post-instrumentation images were processed and superimposed.

The processing of the images was completed in the following steps.

Volume 6 Number 1

Alignment, elimination, and auto color Alignment of the axis of blocks is completed with reference to the scales in the toolbox of CorelDraw Graphic Suite X5 (Figure 4).

Elimination of the blocks is then done using the software (Figure 5).

Using auto color – an image correction tool – provides better visibility and maintains the color gamut difference per pixel (Figure 6).

Inversion and polarization Both images are processed using the “invert” adjustment in Adobe Photoshop CS3 (Figure 7).

Superimposition Superimposition is the placement of an Endodontic practice 37

CONTINUING EDUCATION

Figure 6: An image correction tool such as auto color provides better visibility

CONTINUING EDUCATION

Figure 11: Mean and standard deviation (SD)

image on top of an existing image to add to the overall image effect (Figure 8). Thus the differences were calculated based on optimization.

Degree of angle of curvature – group one Two reference points were assumed to precisely calculate the angle of curvature (Figure 9). Two intersection points were defined for the ProTaper®, and the angles for the same were calculated via SolidWorks Student Edition software. The angular calculation was based on the principle of geometry. Also, the angles were confirmed using the trigonometric formulas for each block.

Figure 12: One-Way Anova

Degree of angle of curvature – group two This was calculated in a same manner as the previous step (Figure 10).

Results All the values of WaveOne without glide path and WaveOne with glide path are expressed in terms of mean and standard deviation (SD) of angle of curvature respectively (Figure 11). The mean and standard deviation of glide path with WaveOne (group one) was more than without glide path (group two).

38 Endodontic practice

Figure 13: One-Way Anova

Figure 14: Correlation test (t-test) Volume 6 Number 1

One-Way Anova shows there was a significant difference between WaveOne with glide path and WaveOne without glide path at 5% level of significance when p was less than 0.05 using t-test (correlation test) [Figures 12, 13, 14].

Discussion The present study aimed to compare the shaping performance of the WaveOne single-file reciprocating system in endo training blocks, both with and without glide path.

Even though they do not represent the anatomic variability of a human root canal system, simulated resin canals have been widely used to point out differences

in performance of instruments under standardized experimental conditions (Webber, et al., 2011).

Studies suggest that the analysis of modifications in canal curvature after instrumentation is a reliable method to evaluate the tendency of a shaping technique to maintain the original canal anatomy or to straighten the curves (DeDeus, et al., 2010).

In this study, a quantitative analysis was performed through observation of changes between pre-instrumentation and post-instrumentation curvature.

The WaveOne nickel-titanium primary reciprocating file, if used after a previous glide path, produced less modification

References

rotary instruments. J Endod. 2008;34:1406-9.

Bryant ST, Thompson SA, al-Omari MA, Dummer PM. Shaping ability of ProFile rotary nickel-titanium instruments with ISO sized tips in simulated root canals: part 1. Int Endod J. 1998;31:275-81.

Moore J, Fitz-Walter P, Parashos P. A microcomputed tomographic evaluation of apical root canal preparation using three instrumentation techniques. Int Endod J. 2009;42:1057-64.

Daugherty DW, Gound TG, Comer TL. Comparison of fracture rate, deformation rate, and efficiency between rotary endodontic instruments driven at 150 rpm and 350 rpm. J Endod. 2001;27:93-5.

Pruett JP, Clement DJ, Carnes DL Jr. Cyclic fatigue testing of nickel-titanium endodontic instruments.

J Endod. 1997;23:77-85.

De-Deus G, Moreira EJ, Lopes HP, Elias CN. Extended cyclic fatigue life of F2 ProTaper instruments used in reciprocating movement. Int Endod J. 2010;43:1063-8.

Gabel WP, Hoen M, Steiman HR, Pink FE, Dietz R. Effect of rotational speed on nickel-titanium file distortion. J Endod. 1999;25:752-4.

Gambarini G. Rationale for the use of low-torque endodontic motors in root canal instrumentation.

Endod Dent Traumatol. 2000;16:95-100.

Johnson E, Lloyd A, Kuttler S, Namerow K. Comparison between a novel nickel-titanium alloy and 508 nitinol on the cyclic fatigue life of ProFile 25/.04

Volume 6 Number 1

Sattapan B, Nervo GJ, Palamara JE, Messer HH. Defects in rotary nickel-titanium files after clinical use. J Endod. 2000;26:161-5.

Sattapan B, Palamara JE, Messer HH. Torque during canal instrumentation using rotary nickel-titanium files.

J Endod. 2000;26:156-60.

Serene TP, Adams JD, Saxena A. Nickel-titanium instruments: applications in endodontics. St Louis, MO: Ishiyaku EuroAmerica; 1995.

Siqueira JF Jr, Rocas IN, Favieri A, et al. Incidence of postoperative pain after intracanal procedures based on an antimicrobial strategy. J Endod. 2002;28:457-60.

Varela-Patino P, Ibanez-Parraga A, Rivas-Mundina B, Cantatore G, Otero XL, Martin-Biedma B. Alternating versus continuous rotation: a comparative study of the effect on instrument life. J Endod. 2010;36:157–9.

Webber J, Machtou P, Pertot W, Kuttler S, Ruddle C, West J. The WaveOne single-file reciprocating system.

Roots. 2011;1:28-33.

Wu MK, Fan B, Wesselink PR. Leakage along apical root fillings in curved root canals. Part 1: effects of apical transportation on seal of root fillings. J Endod.

2000;26:210-6.

Yared G. Canal preparation using only one nickeltitanium rotary instrument: preliminary observations. Int Endod J. 2008;41:339-44.

Yared GM, Bou Dagher FE, Machtou P. Influence of rotational speed, torque and operator’s proficiency on ProFile failures. Int Endod J. 2001;34:47-53.

You SY, Bae KS, Baek SH, Kum KY, Shon WJ, Lee W. Lifespan of one nickel-titanium rotary file with reciprocating motion in curved root canals. J Endod.

2010;36:1991-4.

Endodontic practice 39

CONTINUING EDUCATION

Figure 15: Bar chart of angle of curvature without and with glide path

in canal curvature compared with the WaveOne alone, as actually suggested by the clinical procedure flowchart (De-Deus, et al., 2010). WaveOne nickel-titanium files appear to maintain the original canal anatomy, and the presence of a glide path of the canal further improves their performance.

In this study, it was observed that fewer pecking motions were needed to reach full working length with WaveOne single files, when glide path was previously performed.

It might be hypothesized that this could reduce the risk of excessive undesired instrument brushing on the canal walls and subsequent root canal transportation (You, et al., 2010; Siqueira, et al., 2002; Wu, Fan, Wesselink, 2000; Moore, Fitz-Walter, Parashos, 2009; De-Deus, et al., 2010).

In this study, the absence of a previous glide path affected the performance of WaveOne nickel-titanium files, which showed greater alteration of the canal curvature compared with the performance of WaveOne files with previous glide path.

These findings suggest the clinical implication of root canal anatomy maintenance in susceptible anatomies.

Excessive coronal flaring was found to increase the risk of strip perforation on the concave aspect of the curved roots (Yared, 2008).

Within the limits of this study, it is possible to conclude that the creation of a previous glide path before any reciprocating motion instrumentation appears to be appropriate for safely shaping the canal. EP

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Evaluation of the shaping performance of the WaveOne single file reciprocating system with and without glide path 1. Fracture of nickel-titanium engine instruments may occur for two different reasons, either because of ______. a. torsion b. fatigue through flexure c. insufficient force or insufficient speed d. a or b 2. The torsional fracture occurs when the tip or any other part of the instrument binds to the canal walls, whereas the handpiece ______. a. keeps turning b. stops suddenly c. overheats d. vibrates excessively 3. This type of fracture has been associated with the application of ______during instrumentation. a. a chemical chelating agent b. excessive apical force c. a gentle pecking motion d. insufficient speed 4. Fracture resulting from flexural fatigue occurs when an instrument that has already been weakened by metal fatigue is _______. a. autoclaved b. brushed onto the canal walls c. placed under stress d. used to alter the canal curvature

40 Endodontic practice

5. One-Way Anova shows there was _______between WaveOne with glide path and WaveOne without glide path at 5% level of significance when p was less than 0.05 using t-test (correlation test). a. an insignificant difference b. a great similarity c. no difference d. a significant difference 6. Studies suggest that the analysis of modifications in canal curvature after instrumentation is ________to evaluate the tendency of a shaping technique to maintain the original canal anatomy or to straighten the curves. a. an unreliable way b. a reliable method c. an unusual method d. a risky way 7. The WaveOne nickel-titanium primary reciprocating file, if used after a previous glide path, produced _______in canal curvature compared with the WaveOne alone, as actually suggested by the clinical procedure flowchart. a. more modification b. no significant difference c. less modification d. a large variation

8. WaveOne nickel-titanium files appear to maintain the original canal anatomy, and the presence of a glide path of the canal _____ their performance. a. further improves b. depreciates c. slows down d. alters 9. In this study, it was observed that _____ pecking motions were needed to reach full working length with WaveOne single files, when glide path was previously performed. a. more b. fewer c. quicker d. harder 10. Excessive coronal flaring was found to _____the risk of strip perforation on the concave aspect of the curved roots. a. decrease b. increase c. negate d. mitigate

Volume 6 Number 1

Dr. Rich Mounce notes that the “cookbook approach” is not always the best recipe for success

M

uch is written in trade magazines about clinical technique in endodontics.

We all have biases as to what we regard are the best materials and methods to treat root canal systems. Some biases may be well thought out and researched, others accepted without critical and skeptical scientific evaluation, and many lie somewhere in between.

I am leary when I see and hear key opinion leaders, teachers, and manufacturers claiming superiority. My bias is simple: There is no one best way to treat root canal systems. Treatment should be principle centered. Specific technique and material recommendations often need modification relative to the anatomy at hand. While there are proven methods, there is no singular best literature-based means to do anything. There are many.

For example, does it matter if a glide path is created with nickel-titanium Pre Shapers™ files (Specialized Endo) or reciprocated with a hand file (Mani SEC-O K-files and a W&H reciprocating handpiece [MounceEndo])? Does it matter if gutta percha is removed with Gates Glidden drills or rotary nickel-titanium files? In a multitude of such comparative examples, for the vast majority of cases, the answer is no. What matters more is the clinician being able to see the exceptional cases preoperatively where one method or another will provide a benefit.

Using the examples above, if a canal with a three-dimensional multiplanar curvature (especially in a longer than average root) has been carefully negotiated by hand, it may be optimal to prepare a hand-reciprocated glide path to improve tactile control and reduce fracture. This said, roots in which a rotary nickel-titanium

Rich Mounce, DDS, is in full-time endodontic practice in Rapid City, South Dakota. He has lectured and written globally in the specialty.

He owns MounceEndo, LLC, marketing the rotary nickel-titanium MounceFile in Controlled Memory© and Standard NiTi. MounceEndo, LLC is an authorized dealer of Mani, Inc. stainless steel hand files and burs and W&H reciprocating handpiece attachments. Dr. Mounce can be reached at RichardMounce@MounceEndo.com, MounceEndo. com. Twitter: @MounceEndo

Volume 6 Number 1

glide path file preparation is contraindicated are relatively few and far between.

Furthermore, understanding how a Gates Glidden drill is properly used in removing gutta percha is critical. Improper use of a Gates Glidden drill carries with it a greater risk of mid-root perforation, especially if the root wall towards the furcation is thin. In this particular clinical example, a thin furcation should be assessed with several questions: for any given case, how much gutta percha should be removed with a heat tip, mechanical means (files), and solvents? Is it possible and desirable to remove the gutta percha without enlarging the root and making the

particular means or method of treatment.

In essence, knowing when to treat and who to treat is more important in many ways than exactly how one treats (what file system used being one example of many possible clinical choices to be made).

A clinician can provide excellent canal shapes with a wide variety of files, instrumentation techniques, and obturation schemes. For example, a clinician can shape a root canal well with hand files and Gates Glidden drills alone, crown down, or step back, or any one of a number of proven RNT file systems (ProTaper® [Dentsply Tulsa Dental Specialties], Specialized Endo, Twisted Files™ [SybronEndo],

While exercising caution, finding the path to both the clinical apex and professional apex of one’s abilities requires patience, perseverance, and practice. root wall thinner? What is the risk of either vertical root fracture or perforation as a result of retreatment? What is the risk of rotary nickel-titanium file tip separation while removing the gutta percha? What is the optimal speed of rotation for gutta percha removal to prevent fracture in the given anatomy? The list of such questions could go on, but the point is that there are many considerations to take into account at any stage in any procedure regarding the best set of materials and methods to employ for the task at hand.

Clinical experience and preoperative risk assessment trumps a one-size-fits-all “cookbook” clinical endodontic approach.

Can a canal be obturated well with a carrier? Can it also be obturated well with a master cone utilizing various methods of heat and apical compaction? The answer to both questions is yes.

It is my observation after 20 years of full-time specialist experience that the value of preoperative case assessment of both the patient’s needs and the risk factors involved in treating any given case far outweighs the value of using any given

MounceFiles, etc.). Clinicians use what feels most comfortable within their own hands. This comfort level is not unlike preferences in cars; some people like Lexus, some people Ford. In essence, in the big picture, the market determines which files and techniques are the most economical, safe, and efficient.

The above comments beg the question, how does one gain experience and learn which instruments and methods give them the most predictable results?

While exercising caution, finding the path to both the clinical apex and professional apex of one’s abilities requires patience, perseverance, and practice. It requires obtaining as much CE as possible, reading all the material available both in the refereed journals and more trade-oriented magazines as well as clinical practice (especially in extracted teeth before taking new techniques into the operatory). Finding the path to the apex is a neverending journey well worth the effort. I welcome your feedback. EP

Endodontic practice 41

MOUNCE’S APEX

In search of the best materials and methods

TECHNOLOGY

3D Apical Cork – Part 1 Dr. Wyatt Simons explains the basics of the CORK technique

T

he amazing complexities that pulpal systems possess can serve both as havens for bacterial colonization and portals for the extension of endodontic disease. Figure 1 is a cone beam computed tomography (CBCT) rendering of a lateral lesion of endodontic origin. As usual, the portal of exit from this diseased pulpal system is found in the center of the lesion. Many have documented the vast array of anatomical possibilities of pulpal systems, including the frequency of apical ramifications.1-2 Micro CT reconstruction is one way to visualize the randomness and beauty of pulpal systems. The micro CTs in Figures 2A-2D demonstrate varying apical pulpal anatomy of maxillary premolars.3 These illustrations do not depict special, unique, or rare pulpal anatomy. The rarity is the single, uncomplicated pulpal system. Clinical success is influenced by the capacity to three-dimensionally disinfect and seal these sophisticated internal caverns and terminations.4-6 Many recent technological advances facilitate high levels of shaping and disinfection of root canal systems. This article is the first in a series that examines the CORK system of obturation. The CORK technique comprehensively warms and softens apical gutta percha for simultaneous compaction and three-dimensional molding.

Shown in Figure 3, the CORK delivery device consists of a thin silver carrier that partially wraps and extends the entire length of various apical shapes of gutta

Wyatt Simons, DDS, is a Diplomate of the American Board of Endodontics who lives and practices in San Clemente, California.

He received his doctorate in dental surgery from the University of the Pacific, Arthur A. Dugoni School of Dentistry in 1999. He then completed his postdoctoral specialty training in Endodontics at Boston University in 2001. Dr. Simons is an Adjunct Assistant Professor of Endodontics at the University of the Pacific, Arthur A. Dugoni School of Dentistry. He lectures nationally and has published several articles in national and international journals. In 2004, Dr. Simons founded Signature Specialists in San Clemente, California, where he practices and presents live patient demonstrations. Dr. Simons is passionately committed to the advancement of the profession of endodontics.

He is the innovator of the CORK system of obturation and three-dimensional plugger. He can be reached at: email: wdsimons@corkendo.com, phone: 888–905– 7668, fax: 949-498-2473. www.corkendo.com and www.signaturendo.com.

42 Endodontic practice

percha. This design provides several technological advantages. First, heat is transferred to all levels of the gutta percha directly through the silver. This overcomes gutta percha’s thermomechanical inability to transfer temperature more than a few millimeters.7-9 A precise and relatively uniform temperature is transferred throughout the apical gutta percha,

Figure 1: CBCT evaluation displays the extension of endodontic disease from a lateral portal

Figures 2A to 2D: In teeth that are commonly thought of as “single-rooted teeth,” these micro CTs represent apical bifurcations, deltas, communications, and multiple ports of exit commonly present within premolars3. (Image courtesy of the American Dental Association)

Figure 3: CORK delivery device. Note the apical gutta-percha cone is partially wrapped in silver to facilitate a thorough temperature penetration to the apical end of the gutta percha. The design also allows for simultaneous molding of the apical guttapercha cone when precise heat is delivered as the attachment for heat delivery is at the top of the CORK delivery device. In addition, the design enables the use of an apex locator to gauge placement

resulting in even softening. In addition, the heat delivery is controlled such that phase transitions are avoided, thereby eliminating potential shrinkage problems.10 Secondly, three-dimensional molding occurs simultaneously as calibrated temperatures are achieved. This sequence of heat delivery and three-dimensional molding is followed by the removal of the delivery device and final three-dimensional molding, leaving a homogenous fill of gutta percha and sealer. Thirdly, the CORK design allows for confirmation of the position of the delivery device to the PDL with the use of an apex locator at the time of final placement.

The CORK technique is illustrated in

Figure 4. Like a traditional master cone, a CORK delivery device that matches the final apical shape is fit (trimmed as needed), and sealer is applied. Apex locator confirmation of the final placement to the PDL is made. Heat is then applied at the top of the delivery device in a calibrated way producing ideal warmth of the entire apical gutta-percha cone. When ideal thermal conditions are met, simultaneous three-dimensional molding occurs. When the initial three-dimensional molding is complete, the delivery device is removed, leaving only homogenous gutta percha for a final wave of three-dimensional compaction. The result is a predicable, Volume 6 Number 1

Figure 5A: As shown in the graph above, the CORK system establishes substantially uniform thermal conditions at all levels of the gutta percha.

The apical gutta percha is held at 40-42Âş C

Figure 5B-C:. Intracanal thermocouples at D1, D3, and D6 illustrate the ability of the CORK delivery device to establish and control ideal warmth of gutta percha

Figure 5D: As shown in this graph, even deep penetration of conventional heat sources can be random and inadequate in many clinical situations

Figure 5E-F: Although gutta percha can accept direct heat well, its thermomechanical properties are such that the ability to transfer heat is limited

Figure 6A: CORK fit. Final placement of the CORK delivery device was confirmed with the use of an apex locator

Figure 6B: Post CORK. Radiograph taken directly after precise heat delivery, three-dimensional molding, and removal of the CORK delivery device for final apical compaction

Figure 6C: One-year recall reveals good osseous healing

safe, apical cork of the root canal system.

In vitro tests were done on the CORK delivery device to validate and refine precise heat transfer to all levels of gutta percha. Heat penetration was recorded with thermocouples placed flush to internal canal walls. As shown in this series of images (Figures 5A-5D), the CORK technique produces a relatively uniform warming of apical gutta percha. In contrast, the known limitation of a gutta-percha master cone to transfer temperature is displayed.7-9 The CORK technique is able to accomplish this level of temperature penetration by wrapping the apical gutta-

percha cone in the thermoconductive, removable delivery device. The delivery device provides a calibrated, direct heat transfer to the gutta percha at all levels.

In addition, the design allows for the temperature absorption of the gutta percha to stay below phase transition temperatures at all levels. This allows softening for threedimensional molding, while eliminating the potential for shrinkage. Furthermore, it has been shown that when gutta percha is heated for molding, but phase transitions are not reached, a 1% beneficial expansion may occur.10 Figures 6A-6C illustrate a clinical CORK case. This 92-year-old patient pre-

sented with a mandibular second premolar that had a fairly large lesion of endodontic origin. It was an integral part of the double abutment at the anterior end of this patientâ&#x20AC;&#x2122;s five-unit bridge. After shaping and disinfection, the CORK delivery device was able to gauge a favorable, accurate, final position at the terminus (Figure 6A). In this case, the delivery device was snipped twice based on feedback by the apex locator as to its position at the large and possibly resorbed apical foramen. When the desired reading of a 1/4 mm from the PDL was accomplished, heat was applied to the delivery device in a calibrated way. When the delivery device produced a consistent,

Volume 6 Number 1

Endodontic practice 43

TECHNOLOGY

Figure 4: CORK technique. 1. Fit a CORK delivery device that matches the final apical shape. Trim as needed based on apex locator feedback and apply sealer to the canal or the delivery device. 2. Attach heat source to the top of the CORK delivery device and deliver a calibrated precise, relatively even heat delivery to the entire apical gutta percha.

3. When heat is achieved three-dimensionally mold the softened apical gutta percha. 4. Remove the delivery device, and complete the threedimensional compaction of the homogenous gutta percha, resulting in the canal CORKed

TECHNOLOGY

Figure 7A: Three-dimensional apical molding accomplished with a CORK delivery device

Figure 7B: Micro CT of similar, common apical branching. (Image courtesy of the American Dental Association)

Figure 8A: CBCT three-dimensional rendering of a complicated maxillary second molar in need of endodontic treatment

Figure 8C: CORK delivery device pre-curved to facilitate placement in the MB system

Figure 8B: Working file digital radiograph highlights the complexity and length of the main canal, i.e. switch the word image to radiograph.

Figure 8D: CORK Fit within the MB1 canal. Note the merging MB2 canal was down-packed with a conventional master gutta-percha cone

osseous healing was achieved as noted when the 93-year old patient returned for her 1-year recall (Figure 6C).

The CORK system and technique were utilized to three-dimensionally obturate the maxillary second premolar shown in Figure 7A. The CORK delivery device was able to establish conditions that allowed for three-dimensional filling of the apical branching found in this case. The micro CT reconstruction displayed in Figure 7B highlights this common branching of pulpal systems.

Figures 8A-8F illustrate a clinical

case in which the CORK delivery device facilitated ease of placement and heat delivery to deep regions of the complex pulpal anatomy encountered. The ability to deliver heat to the apical end of this maxillary second molarâ&#x20AC;&#x2122;s long, curved roots can be difficult, if not deficient, with conventional techniques. Once disinfected and dried, the CORK delivery device was precurved for ease in negotiating the severe curvature. Upon confirmation of the final placement with the apex locator, heat was applied to delivery device. As the desired temperature reached all levels of the apical

thorough apical temperature of 40 â&#x20AC;&#x201C; 42Ë&#x161;C, the initial phase of three-dimensional molding was done. At these temperatures, gutta percha exists at a softened and moldable state.7 When gutta percha is heated at higher temperatures, it becomes runny and sticky. In contrast, the gutta percha in this case was held at favorable temperatures for molding along its entire length while initial three-dimensional compaction occurred. Finally, while temperature was held constant, the delivery device was seamlessly removed, and final apical compaction was completed (Figure 6B). Good 44 Endodontic practice

Volume 6 Number 1

1. Hess W, Zürcher E, Dolamore WH. Anatomy of the Root Canals of the Teeth of the Permanent Dentition. New York, NY: William Wood; 1925:349.

2. De Deus QD. Frequency, location, and direction of the lateral, secondary, and accessory canals. J Endod. 1975;1:361-366. Reference note: Anatomical studies have shown that there are an increased frequency of lateral ramifications present at the apical region of canals.

Figure 8E: CORK Fit of the palatal canal. Note the Post CORK image of the MB system

Figure 8F: Backfill digital image

gutta percha, the first wave of compaction provided initial three-dimensional molding, followed by removal of the delivery device and final three-dimensional compaction.

Each canal was safely, accurately, and thoroughly corked with this technique, and the remaining canal was backfilled to desired levels.

lateral radiolucency or fistula that traces to a mid-root lesion excites us; it doesn’t concern us. This type of enthusiasm is what inspired the progressive development of the CORK system of obturation. The potential to fill all portals that feed our patient’s infection is thrilling. With the advances in shaping and disinfection, it is only logical to push forward on improvements and controls around our objective to threedimensionally seal disinfected root canal systems. Technological improvements in obturation will help in our pursuit to master our craft. Our commitment to continue to provide successful outcomes will enable us to stay at the front of the list when it comes to treatment options for our patients.

Future articles in this series will discuss the CORK technique in more detail with emphasis given to clinical examples of the benefits of this system of obturation.

The revolutionary 3D plugger, which conforms to individual canal anatomy as it moves within the canal, will be introduced.

Benefits of the new forces of compaction created and how they relate to molding will be discussed. EP

Closing comments: The endodontic profession has been the beneficiary of great leaders and monumental advances over the years.

From microscopes and CBCT imaging to revolutionary shaping files and disinfection systems, our ability to obtain many wellestablished objectives for success has increased exponentially. Breakthroughs in diagnosis, shaping, and disinfection have opened a new frontier in conservatively tackling the complexities of pulpal anatomy.

We are empowered to mindfully, and successfully shape and disinfect the vast array of anatomical possibilities present.

We respect the reality of pulpal anatomy and endodontic disease, yet we are exhilarated by the challenge that difficult pulpal anatomy poses. The preoperative

3. Plotino G, Grande NM, Pecci R, et al. Three-dimensional imaging using microcomputed tomography for studying tooth macromorphology. J Am Dent Assoc.

2006;137:1555-1561. Copyright 2006 American Dental Association. All rights reserved. Reprinted by permission.

4. Schilder H. Filling root canals in three dimensions, Dent Clin North Am. 1967:723-44.

5. Dow PR, Ingle JI. Isotope determination of root canal failure. Oral Surg Oral Med Oral Pathol.

1955;8:1100-1104.

6. West JD. The relationship between threedimensional endodontic seal and endodontic failure. [master’s thesis]. Boston, MA: Boston University; 1975.

7. Goodman A, Schilder H, Aldrich W. The thermomechanical properties of gutta-percha.

Part IV. A thermal profile of the warm guttapercha packing procedure. Oral Surg Oral Med Oral Pathol. 1981;51;544-51.

8. Miner MR, Berzins DW, Bahcall JK. A comparison of thermal properites between guttapercha and a synthetic polymer based root canal filling material (Resilon). J Endod. 2006;32:683-6.

9. Sweatman TL, Baumgartner JC, Sakaguchi RL. Radicular temperatures associated with thermoplasticized gutta-percha. J Endod.

2001;27:512-515.

10. Schilder H, Goodman A, Aldrich W. The thermomechanical propertiesof gutta-percha.

Part V. Volume changes in bulk gutta-percha as a function of temperature and its relationship to molecular phase transformation. Oral Surg Oral Med Oral Pathol. 1985;59(3);285-96.

Visit www.endopracticeus.com Email kmurphy@medmarkaz.com Call 1.866.579.9496

Volume 6 Number 1

Endodontic practice 45

TECHNOLOGY

References

ABSTRACTS

The latest in endodontic research Dr. Kishor Gulabivala presents the latest literature, keeping you up-to-date with the most relevant research Periodontal healing by periodontal ligament cell sheets in a teeth replantation model Zhou Y, LiY, Mao L, Peng H. Archives of Oral Biology (2012) 57(2): 169-76.

Abstract Aim: The aim of successful transplantation of avulsed teeth is to restore the attachment, and regenerate the periodontal support.

Different strategies have been applied in treatment from modification of tooth storage and antibiotic usage to peridontium tissue replacement. A novel periodontal ligament cell-sheet delivery system was developed to apply on delayed replanted teeth in promoting periodontal healing in a canine model.

Methodology: Autologous periodontal ligament (PDL) fibroblasts were isolated from extracted premolars of beagle dogs.

The cell sheets were fabricated using normal culture dishes after stimulation of extracellular matrix formation. Teeth were surgically extracted, and attached soft tissues were removed. After root canal treatment, the roots of teeth were wrapped by the PDL cell sheets and replanted back into prior sockets, while teeth without cell sheets were used as controls. Eight weeks after surgery, the animals were sacrificed, and decalcified specimens were prepared.

Regeneration of periodontal tissue was evaluated through a histology assay.

Results: Multilayered PDL cell sheets could be attached to tooth roots, and most cells on sheet-tooth constructs were viable before replantation. Minimum clinical signs of inflammation were observed in experiment. PDL cell-sheets group showed significantly higher occurrence of favorable healing (88.4%) than the control group with low healing (5.3%). Periodontal ligament and cementum tissue regeneration were observed in the experimental group, and the regenerated tissues showed high

Kishor Gulabivala, BDS, MSc, FDSRCS, PhD, FHEA, is professor and chairman of endodontology, and head of department of restorative dentistry at Eastman Dental Institute, University College London. He is also training program director for endodontics in London, England.

46 Endodontic practice

collagen type III, type I, and fibronectin expression.

Conclusions: The periodontal ligament cell sheets fabricated on normal cell culture dishes have a potential for regeneration of periodontal ligament and may become a novel therapy for avulsed teeth replantation.

in the regenerated tissues from all three cell sources. Expression of many angiogenic/ neurotrophic factors in the transplanted cells demonstrated trophic effects.

Conclusions: Bone marrow and adipose CD31-SP cells might be suitable alternative cell sources for pulp regeneration.

Regeneration of dental pulp following pulpectomy by fractionated stem/progenitor cells from bone marrow and adipose tissue

Responses of immature permanent teeth with infected necrotic pulp tissue and apical periodontitis/abscess to revascularization procedures

Ishizaka R, Iohara K, Murakami M, Fukuta O, Nakashima M. Biomaterials (2012) 33(7): 2109-18.

Chen MY, Chen KL, Chen CA, Tayebaty F, Rosenberg PA, Lin LM. International Endodontic Journal (2012) 45(3): 294-305.

Abstract Aim: Pulp stem/progenitor cells can induce complete pulp regeneration, but their limited availability from pulp tissue with age prompted a search for other sources for fractions of side population (SP) cells.

Methodology: In the present investigation, bone marrow and adipose tissues of the same individual were evaluated as alternate sources. Dental pulp cells were isolated and assessed for cell surface markers, phenotypic analysis by RT-PCR, induced differentiation, proliferation and migration assay, protein expression by twodimensional electrophoretic analyses, their use in an experimental pulp regeneration model, immunohistological, and in situ hybridization analyses of the transplanted cells, and gene expression analyses of the regenerated tissues.

Results: Pulp CD31-SP cells have higher migration activity and higher expression of angiogenic/neurotrophic factors than bone marrow and adipose CD31SP cells. Adipose tissue CD31-SP cell transplantation yielded the same amount of regenerated tissue as pulp derived cells. However, bone marrow CD31-SP cell transplantation yielded significantly less regenerated tissue in pulpectomized root canals in dogs. The rate of matrix formation was much higher in adipose CD31-SP cell transplantation compared to pulp CD31-SP cell transplantation on day 28. Microarray analysis demonstrated similar qualitative and quantitative patterns of mRNA expression characteristic of pulp

Abstract Aim: To report several types of response of immature permanent teeth with infected necrotic pulp tissue, and either apical periodontitis or abscess to revascularization procedures.

Methodology: Twenty immature permanent teeth from 20 patients were included; they were associated with infected necrotic pulp tissue, and either apical periodontitis or abscesses. The teeth were isolated with rubber dam, and pulp chambers were accessed through the crowns. The canals were gently irrigated with 5.25% sodium hypochlorite with minimal mechanical debridement. Calcium hydroxide was used as an interappointment intracanal medicament and placed into the coronal half of the canal space. After resolution of clinical signs and symptoms, bleeding was induced into the canal space from the periapical tissues using K-files. The coronal canal space was sealed with a mixture of mineral trioxide aggregate (MTA) and saline solution. The access cavity was filled with composite resin. These immature permanent teeth with infected necrotic pulp tissue, and apical periodontitis/abscesses were followed up from 6 to 26 months.

Results: Five types of responses of these immature permanent teeth with infected necrotic pulp tissue and apical periodontitis/ abscess to revascularization procedures were observed: type 1, increased thickening of the canal walls and continued root maturation; type 2, no significant continuation of root development with the Volume 6 Number 1

INVENTIONS

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Analysis of factors associated with cracked teeth Seo DG, Yi YA, Shin SJ, Park JW. Journal of Endodontics (2012) 38(3): 288-92.

Abstract Aim: The purpose of this study was to analyze the characteristics, distribution, and factors associated with longitudinally fractured teeth as defined by criteria recommended by the American Association of Endodontists (AAE).

Methodology: One hundred and seven teeth with longitudinal fractures from 103 patients were diagnosed and analyzed.

The patientsâ&#x20AC;&#x2122; signs, symptoms, age, and sex were noted as well as the tooth number, dental arch, filling materials, size/ classification of restoration, crack direction, pulp vitality, whether the patient had undergone endodontic treatment, bite test results, percussion test results, wear facet, and periodontal pocket depth.

Results: Eighty-seven teeth were diagnosed with a cracked tooth (81.3%); 814 were diagnosed with vertical root fracture (VRF, 13.1%); four had a split

ONLINE EDUCATION

Volume 6 Number 1

tooth (3.7%), and two had a fractured cusp (1.9%); 82.2% showed a sensitive reaction on the bite test. Longitudinal tooth fractures were observed most frequently in patients in their 40s. The upper first molar (28.0%) was most frequently cracked, followed by the lower first molar (25.2%), the lower second molar (20.6%), and the upper second molar (16.8%). Most longitudinal tooth fractures (72.0%) occurred mainly in restored teeth, whereas only 28.0% were found in intact teeth. Compared with resin (4.7%) or porcelain (0.9%), the use of non-bonded inlay restoration materials, such as gold (20.5%) or amalgam (18.7%), increased the occurrence of longitudinal tooth fractures. Out of 107 of longitudinally fractured teeth, 33 (30.8%) were treated endodontically, and 74 (69.2%) were not.

VRF was associated with endodontic treatment.

Conclusions: The bite test was the most reliable for reproducing symptoms. The combined use of various examination methods is recommended for detecting cracks and minutely inspecting all directions of a tooth. EP

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CONTACT

Endodontic practice 47

ABSTRACTS

root apex becoming blunt and closed; type 3, continued root development with the apical foramen remaining open; type 4, severe calcification (obliteration) of the canal space; type 5, a hard tissue barrier formed in the canal between the coronal MTA plug and the root apex.

Conclusions: Based on this case series, the outcome of continued root development was not as predictable as increased thickening of the canal walls in human immature permanent teeth with infected necrotic pulp tissue and apical periodontitis/abscess after revascularization procedures. Continued root development of revascularized immature permanent necrotic teeth depends on whether the Hertwigâ&#x20AC;&#x2122;s epithelial root sheath survives in case of apical periodontitis/abscess. Severe pulp canal calcification (obliteration) by hard tissue formation might be a complication of internal replacement resorption or union between the intracanal hard tissue and the apical bone (ankylosis) in revascularized immature permanent necrotic teeth.

PRACTICE MANAGEMENT

Know your liability as a business owner Dr. Robert M. Fleisher discusses how to mitigate general liability risks besides malpractice claims

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s small business owners, a category in which most of us as dentists fall, there are many rules and regulations we must follow. One area of importance that is rarely discussed has to do with our general liability to protect our patients, our staff, and our personal assets. Let’s explore other areas of risk aside from malpractice claims that may help keep you out of trouble.

Innocent chores – major risk Many practitioners find it convenient to have an employee run chores for them. These tasks range from making bank deposits to picking up supplies to transferring patient charts from one office to another. Some utilize the services of their assistants,

secretaries, and office managers rather often. If possible, it is best to avoid any and all of these types of requests.

Here is a scenario involving an auto accident that takes place every day in one city or another all around the country. Mary is riding to the bank to make your daily deposit when a dog runs into her path (hopefully she wasn’t texting). She veers off the street, onto the curb at the school bus stop where she kills three children, and four others are paralyzed to varying degrees; an unimaginable tragedy!

The families will sue Mary, and since she was acting as your agent when the accident occurred, they will sue you as well and win.

Robert Fleisher, DMD, graduated from Temple University School of Dental Medicine in 1974 and received his certificate in endodontics from The University of Pennsylvania in 1976. He taught at Temple University and The University of Pennsylvania and is now a member of the Affiliate Attending Staff – Albert Einstein Medical Center, Philadelphia, Department of Dental Medicine, Division of Endodontics, Philadelphia, Pennsylvania. Dr. Fleisher is the founding partner of Endodontics Limited, P.C., one of the larger endodontic practices in the United States. After retiring from practice, he now devotes his time to writing about practice management, aging and health issues, and fiction with a medical bent.

You can read about all of Dr. Fleisher’s methods to improve bedside manner in his book Bedside Manner - How to Gain Your Patients’ Respect, Love & Loyalty. www.bedsidemanner. info. Dr. Fleisher can be reached at: drfleisher@bedsidemanner.info.

48 Endodontic practice

There is much temptation to use others to run chores, but try to do them yourself if at all possible. If an employee does have to run errands, make sure he/she has a valid license and automobile insurance of his/her own. Make sure whoever runs chores for you is responsible, not driving under the influence or distracted by his/her cell phones. You must make sure you have liability insurance as well since, as noted, you will be sued, too.

Purchasing an umbrella liability policy provides a large amount of coverage for little cost. Your umbrella policy should be between 5 and 10 million dollars. Get as much coverage as you can reasonably afford to protect yourself as best as you can in an unreasonable climate. Your umbrella policy is usually applicable to your home and offices as well, giving you an extra boost of protection against a lawsuit.

Personal liability While your homeowner’s and automobile insurance policies protect you from most personal injury claims, the bigger worries are the catastrophic claims that require the umbrella policy noted above. People slip and fall all the time. They often try to find Volume 6 Number 1

Volume 6 Number 1

Vicarious liability Anyone who works for you can pose a threat by any and all of his/her actions. This is called vicarious liability – liability incurred due to the actions of others. These actions can include having your secretary or assistant making suggestions for managing postoperative pain to an associate who provides patient care.

The rationale for vicarious liability is based on the legal concept respondeat superior. This model was developed many years ago and means that the master is responsible for the acts or omissions of the servant. This states that you are responsible for the negligent actions of your staff members, including associates and possibly even independent contractors who offer services in your practice.

To reduce your liability, it is imperative to define and control all work-related procedures, and supervise all staff

contractor. However, remember you are going to be held responsible for any of your regular associates if the plaintiff can prove that you should have been aware of the poor quality of the associate’s work. How hard is it to subpoena several charts of patients your associate worked on to show a pattern of poor quality? Get rid of anyone who doesn’t practice quality care.

Make sure you have vicarious liability insurance coverage. Require a certificate of insurance from all professional employees, and make sure you check yearly that they have paid up policies. You should be listed as an additional insured on their policy just as your associates should be listed as an additional insured on your policy.

Examine all educational credentials of any employees requiring licensure, and make sure they have valid licenses.

Check references on job applications to make sure they are legitimate. Get

Make sure you have a protocol in place to manage emergencies, whether it’s from a slip and fall, or a medical emergency related to patient care. members. Make sure you script exactly what you want your staff to tell patients regarding postoperative care and sequelae as well as any instructions you have auxiliary staff provide to patients. Having written handout information is the best way to make sure you control instructions to patients, and it makes it much easier for your staff to learn the exact contents of the handouts. This allows them to offer the same instructions verbally when queried by the patient.

A patient who sees your associate, the independent contractor, will likely sue you as well if a claim of malpractice arises unless you inform the patient of the independent status. Without this notification, the patient has good reason to believe that the associate is an employee under the supervision of the owner of the practice, and therefore, making the owner liable for the actions of the associate.

A notification of the independent status of the associate, on the patient registration/ informed consent form that the patient signs, will help to reduce your vulnerability from the actions of the independent

written permission to contact an applicant’s references, and have the applicant sign a release form authorizing former employers to provide references. Call all the names on the reference list, not just the top ones.

Any question you ask a reference must abide by all nondiscrimination laws. It’s easy to be lazy about hiring, but the liability consequences can be enormous. Do your homework!

Protect yourself by employing these ideas. They will help make you bulletproof to lawsuits. Many people and lawyers are just waiting for the opportunity to file a claim. Don’t let yourself remain vulnerable.

Most of all, consult with your lawyer and insurance agent to help you properly institute the ideas contained herein.

This article is an excerpt from Dr. Fleisher’s soon to be published, From Waiting Room to Courtroom – How Doctors Can Avoid Being Sued. EP

Endodontic practice 49

PRACTICE MANAGEMENT

an excuse for their misfortune by blaming others and exaggerating the claim. There are some protective measures that will keep your personal and business properties less risk-prone, and reduce the chance for a fall in the first place.

Tour your properties periodically to look for potential problems like defective pavements, potholes, loose carpeting, defective waiting room chairs, sharp edges, heavy objects on flimsy shelving, and any potential threats to the safety of visitors to your home and practice. Parking lots should be well lit and properly paved with safe and easy access to your building.

Periodically have a serviceman check the stability of your overhead lights and X-ray equipment. Equipment falling onto your patient can result in considerable damage and grief for all involved.

If you practice in a colder climate, make sure that icy conditions are managed appropriately with application of salt or sand, snow is removed in a timely manner, and any water that may result in slippery surfaces is attended to. Assign someone on your staff to be in charge of safety, and make sure that he/she develops a list that documents that he/she is doing the inspections regularly. Discuss your accident prevention program with your staff, and stress the importance of safety.

Make sure you have a protocol in place to manage emergencies, whether it’s from a slip and fall, or a medical emergency related to patient care. Rather than running around in panic mode, each person should have a responsibility that allows for attending to the patient and a prompt call for emergency personnel.

During an emergency, it is not the time to run around looking for your emergency kit or checking the dates on the contents.

With a well-run emergency program in place, there should be no sign of panic, and most other patients in your office will not realize that an emergency has occurred until the ambulance pulls up to your door.

Having periodic emergency drills will allow you to handle most emergency problems in a professional and discreet manner.

The last thing you want is chaos, considering there will likely be several witnesses to what took place during an emergency. You don’t want the plaintiff to show the jury how you were not prepared, and the resultant panic delayed timely and appropriate care resulting in further injury.

ANATOMY MATTERS

Long-term case report Dr. John West continues his exploration of the Endodontic Seal and endodontic predictability Introduction In this installment of the series Anatomy Matters, my focus continues on the Endodontic Seal as the premier requisite for predictable and sustainable endodontic success. If the purpose of endodontics is to prevent or cure lesions of endodontic origin (LEOs) through either nonsurgically and/or surgically sealing the entire root canal system, including natural and/or iatrogenic radicular foramina (POEs) that includes the access cavity seal, then the repair of inadvertent furcal perforations becomes the domain of the endodontic clinician.1 While failure to seal the root canal system in endodontics does not mean failure to heal, failure to heal always is a result of failure to seal.2-4 An iatrogenic furcal portal of exit that is undersealed, if immediately repaired, and especially if the perforation location is below the epithelial attachment, is a good solution to a seemingly disastrous problem. In addition, the smaller the perforation, the better the prognosis becomes.5

The situation The patient presented with left side cellulitis, which had developed over a 3-day period subsequent to pin foundation build-up attempt by her restorative dentist (Figure 1A). Even though the buccal gingival crevice resisted gentle periodontal probing, the tissues were tender. After considering all options, including removal and replacement, the dentist and patient

Figure 1A: Pretreatment of left mandibular cellulitis that had been brewing for 3 days

Figure 1B: Bitewing of misplaced furcal TMS pin

Figure 1C: Clinical of profuse hemorrhage after TMS pin removal

Figure 1D: Microscope image of ravaged TMS furcal site demonstrating uneven perforation edges

wanted to attempt to save this now biologically compromised, important first molar. The endodontic treatment plan was to repair the perforation, clean the root canal system, and observe if swelling and patient symptoms subsided. The patient was placed on Penicillin VK 500 mg. four stat, and then one, four times per day until gone combined with Clindamycin 300 mg. two stat, then one, three times per day until gone. After mandibular block, rubber dam placement, access, and TMS pin removal,

profuse hemorrhaging occurred (Figures 1B-1C). After flushing access cavity with sodium hypochlorite, furcal tissue protruded through the damaged furca, and the outline of the TMS pin damage was easily observed (Figure 1D).

John West, DDS, MSD, the founder and director of the Center for Endodontics, continues to be recognized as one of the premier educators in clinical and interdisciplinary endodontics. Dr. West received his DDS from the University of Washington in 1971 where he is an affiliate associate professor. He then received his MSD in endodontics at Boston University Henry M. Goldman School of Dental Medicine in 1975 where he is a clinical instructor and has been awarded the Distinguished Alumni Award. Dr. West has presented more than 400 days of continuing education in North America, South America, and Europe while maintaining a private practice in Tacoma, Washington.

He co-authored “Obturation of the Radicular Space” with Dr. John Ingle in Ingle’s 1994 and 2002 editions of Endodontics and was senior author of “Cleaning and Shaping the Root Canal System” in Cohen and Burns 1994 and 1998 Pathways of the Pulp. He has authored “Endodontic Predictability” in Dr. Michael Cohen’s 2008 Quintessence text Interdisciplinary Treatment Planning: Principles, Design, Implementation, as well as Dr. Michael Cohen’s soon to be published Quintessence text Interdisciplinary Treatment Planning Volume II: Comprehensive Case Studies. Dr. West’s memberships include: 2009 president and fellow of the American Academy of Esthetic Dentistry, and 2010 president of the Academy of Microscope Enhanced Dentistry, the Northwest Network for Dental Excellence, and the International College of Dentists. He is a 2010 consultant for the ADA’s prestigious ADA Board of Trustees where he serves as a consultant to the ADA Council on Dental Practice. Dr. West further serves on the Henry M. Goldman School of Dental Medicine’s Boston University Alumni Board. He is a Thought Leader for Kodak Digital Dental Systems, and serves on the editorial advisory boards for: The Journal of Esthetic and Restorative Dentistry, Practical Procedures and Aesthetic Dentistry, and The Journal of Microscope Enhanced Dentistry. Visit www.centerforendodontics.com, or email: johnwest@ centerforendodontics.com, phone 1-800-900-7668 (ROOT), fax 253-473-6328.

50 Endodontic practice

The problem When a chamber is perforated with a parallel TMS pin or equivalent dental bur, the iatrogenic preparation essentially has parallel and ragged walls resulting in no resistance form to produce a seal. As with an open apex condition, a barrier must be placed beyond the iatrogenic tunnel in order to produce a wall to pack and seal against. Restoring a cavity preparation in dentistry without a matrix container is analogous to attempting to place an MOD restoration with only the wooden wedges in place (Figure 2A). Without a barrier, there is no clinical way to control the shape and contours of a restoration, and there is no way to create an hermetic seal at the tooth prep/restorative margins. In 1992, when this patient was treated, restorative resistance form was, as it is today, an essential element of predictable restorative success.

Using a universal endodontic carrier (Figure 2B), a nonresorbable hydroxyapatite bone Volume 6 Number 1

Figure 2C: While MTA is the standard of perforation material advised today, Calcitite® was a common material used in the early days of microscopic endodontics. The material was ground up into a fine powder using a mortar and pestle Figure 2A: Attempting to repair a furcal defect that has no “container” to obturate against is analogous to attempting this foundation without a matrix. Note restorative dentist has placed distal post that, by today’s knowledge about sufficient ferrule, which this tooth has, was contraindicated

Figure 2D: Animation of Schilder plugger used for compacting finely ground Calcitite against furcal matrix

Figure 2B: Standard microcarriers are useful to control the amount of furcal matrix material and placement precision

Figure 2E: Periapical radiograph of tooth No. 19 amalgam perforation repair. Note early furcal radiographic attachment apparatus disease

Figure 2F: Amalgam foundation is finished and ready for full crown preparation

Figures 3 A-C: Long-term posttreatment documentation

Figure 3A: Periapical radiograph validating 20-year perforation success. Note lamina dura and periodontal ligament have maintained health, and the tooth is fully functional and asymptomatic for the patient

Figure 3B: Occlusal view of structural crown integrity

Figure 3C: Buccal clinical view demonstrating buccal gingival crevice probing within 1.5 mm normal limits.

Blanching adjacent to probe confirms resistance of the epithelial attachment

grafting material (Calcitite®) [Figure 2C] matrix was carried into the TMS repair site, and compacted with a Schilder plugger (Figure 2D). Amalgam was condensed against the matrix, finished flush with the chamber floor; endodontics was completed after complete abatement of symptoms, followed by amalgam foundation. The restorative dentist then prepared the tooth for crown and cementation (Figures 2E-F).

Today, a more compatible material such as MTA would be the suggested material.6

(Figure 3A), the original crown remains fully functional (Figure 3B), and the gingival crevice is healthy and probes within normal limits (Figure 3B).

and their correction may not be examples of “herodontics” but rather simple biology and quality technique. EP

Long-term posttreatment Twenty-year posttreatment reveals long-term endodontic, restorative, and periodontal success. The lamina dura and periodontal ligament remain healthy Volume 6 Number 1

Summary and conclusions A 20-year long-term endodontic iatrogenic restorative furcal perforation is presented demonstrating that endodontic success is both possible and predictable if the components of endodontic healing are both understood and immediately fulfilled. Some dentists may see this same situation and quickly resort to recommending removal and replacement. It is the responsibility of endodontists everywhere to educate dentists and dentistry that underfilled root canal systems can come in many forms,

References 1. West J. Endodontic failure in the esthetic zone: Interdisciplinary decision making. In: Michael Cohen, ed. Interdisciplinary Treatment Planning, Volume II. Hanover Park, IL: Quintessence Publishing Co, Inc; 2012:233-248.

2. West J. Anatomy Matters. Endod Prac US. 2012;5(2):14-16.

3. West J. Anatomy Matters — part 2. Endod Pract US. 2012;5(4):26-27.

4. West J. Anatomy Matters — part 3. Endod Pract US. 2012;5(6):22-24.

5. Lemon RR. Nonsurgical repair of perforation defects. Dent Clin North Am.1992;36(2):439-457.

6. Torabinejad M, Chivian N. Clinical applications of mineral trioxide aggregate. J Endod. 1999; 25:3:197-203.

Endodontic practice 51

ANATOMY MATTERS

Figures 2A-F: Treatment documentation

PRODUCT PROFILE

TDO Practice Management Software Additional features provide endodontists with more tools and resources TDO is the most comprehensive endodontic practice management software available, and we listen to the needs of our users! By popular request, we have added new features to automatically confirm your patient appointments and allow you to chat online with your referring doctors. In addition, your referring doctors are also able to refer new patients via the web and access their patient case reports online 24/7. We are thrilled to announce these groundbreaking features!

Let TDO do all of the confirming for you!

Are you frustrated with tracking the patients down in order to confirm their appointment?

Tired of busy signals, voicemails, and out of service numbers?

Then let TDO text messaging and email do the confirming for you!

With just a click of the mouse, you can send a text message to all of your patients to confirm their appointment for the next day. You can also use this feature to send a single text message as needed to any patient or referring doctor. TDO Text Messaging will greatly improve the communication between you and your patients and your referring doctors.

In addition to text messaging, TDO also confirms patient appointments via email in just a couple of minutesâ&#x20AC;&#x2122; time.

Patients simply click a link in order to confirm their appointment, and after doing so, your office is immediately notified of that confirmation.

These latest features will save you and your staff a tremendous amount of time.

They will also keep your frustration at an all-time low and your productivity at an alltime high.

Chat live with your referring doctors online!

How many times have you wanted to discuss a case with the referring doctor, but are stuck in the operatory in treatment?

Well now with TDO Referral Chat, you can eliminate that obstacle and chat live with referring doctors while still at your computer.

With TDO Referral Chat, you can keep communication open at all times with your referring doctors, whether you are in 52 Endodontic practice

the operatory during treatment or in your private office working on case reports. Or if you are busy, they will see that you are currently offline and will be able to leave you a message.

You no longer need to worry about missing critical phone calls from your referrals or having to play phone tag backand-forth with them. Let TDO Referral Chat eliminate that headache today!

Receive new patient referrals via the web!

Your referring doctors may also refer new patients to you through the web, and you and your staff will be notified immediately of the new referral. This feature is very easy to use and is guaranteed to help increase

your referral base.

In addition to referring new patients online, your referring doctors may also access their patient case reports on the web 24 hours a day. No more worrying about case reports getting lost in the mail!

Please remember that from the clinical to the administrative, for the wellestablished practitioner or the clinician just starting out, TDO provides endodontists with all the tools and resources they need to build and maintain a successful practice.

For more information about TDO software and products, please call 858248-7757 or visit www.tdo4endo.com. EP This information was provided by TDO Software.

Volume 6 Number 1

DIARY

lllllllllllllllllllllll OF EVENTS llllllllllllllllllllllllllllllllllllllllllllllllllll

Endodontic Techniques for Safe & Predictable Results Dr. Barry Lee Musikant & Dr. Allan S. Deutsch January 11-12, 2013 March 1-2, 2013 South Hackensack, NJ www.essentialseminars.org

Southwest Dental Conference January 17-19, 2013 Dallas, TX www.swdentalconf.org

Ultradent Cancún 2013 Dr. John Flucke & Shannon Pace Brinker January 27-February 1, 2013 Cancún, Mexico www.ultradent.com

Yankee Dental Congress January 30-February 3, 2013 Boston, MA www.yankeedental.com

Current Scientific Evidence in Endodontic Therapy Troy McGrew February 8, 2013 Showshoe, WV www.tulsadentalspecialties.com

Volume 6 Number 1

Chicago Dental Society Midwinter Meeting February 21-23, 2013 Chicago, IL www.cds.org/mwm

The 81st Annual Nation’s Capital Dental Meeting March 7-9, 2013 Washington, DC www.dcdental.org/capmeet.asp

UDA Convention February 28-March 1, 2013 Salt Lake City, UT www.uda.org/convention.php

Big Apple Dental Meeting March 13-14, 2013 Mahwah, NJ bigappledentalmeeting.us

Current Scientific Evidence in Endodontic Therapy Dr. Sergio Kutter March 2, 2013 Portland, OR www.tulsadentalspecialties.com

ADEA Annual Session & Exhibition March 16-19, 2013 Seattle, WA www.adea.org/Secondary. aspx?id=13859

Pacific Dental Conference March 7-9, 2013 Vancouver, BC www.pdconf.com/cms2013

The 101st Thomas P. Hinman Dental Meeting March 21-23, 2013 Atlanta, GA www.hinman.org

Star of the South Dental Meeting March 7-9, 2013 Houston, TX www.starofthesouth.org

Endodontic practice 53

INDUSTRY NEWS

Aribex acquired by the KaVo Group Aribex, the leader in portable X-ray technology, joins the KaVo Group’s portfolio of dental brands

I

n November 2012, Aribex, a worldwide leader in portable and handheld X-ray products, was acquired by the KaVo Group, an affiliation of leading global dental equipment brands. Aribex, best known for the NOMAD™ handheld and portable X-ray systems, will continue to be the center of excellence for the portable X-ray business.

Handheld and portable X-ray systems are the fastest growing segment in intraoral Xray systems, and Aribex’s innovative products are supported by strong patents, intellectual property, and a robust new product pipeline. Aribex NOMAD X-ray systems are now used in clinical, remote, and mobile facilities throughout the world, from professional offices to humanitarian missions.

The NOMAD significantly decreases costs 54 Endodontic practice

and provides hundreds of safe, high-quality images on a single battery charge.

“We are thrilled to be joining forces with the KaVo Group, a world class dental organization that shares common values and a passion for future success. The KaVo Group combines over 500 years of dental experience with leading global brands and will certainly bolster Aribex’s ability to further accelerate the adoption of handheld X-ray technology,” says Ken Kaufman, President of Aribex.

The KaVo Group consists of marketleading brands such as KaVo, Gendex, DEXIS®, i-CAT®, Instrumentarium, SOREDEX, Pelton & Crane, and Marus.

With the acquisition of Aribex, the KaVo Group will reinforce its global imaging

footprint and commitment to marketleading innovation.

“We enthusiastically welcome the Aribex team and look forward to further acceleration and expansion of the portable X-ray market,” says Henk van Duijnhoven, Senior Vice President, Dental.

“The synergies across our platform are immense from integrated R&D, advances in workflow, technology integration, and a passion to advance the quality of care that our health care providers deliver. We also share a passion for serving our dealer partners with excellence.” EP This information was provided by the KaVo Group.

Volume 6 Number 1

DEXIS connects with the all-new Dentrix Developer Program and with Dentrix® users

MATERIALS lllllllllllll & lllllllllllll EQUIPMENT llllllllllllllllllllllllllllllllllllllllllllllllll EndoPoint The EndoPoint locator file makes Endodontic apex location a much simpler process. When working with an apex locator, EndoPoint’s new design is 26 mm in length so a 25 mm canal can be measured. This makes EndoPoint the only file that can measure a 25 mm canal. On other files, the clip area plus the stop take up 3 mm of space below the file handle allowing for only 22-mm canals to be measured accurately. EndoPoint is available in six sizes: 8, 10, 15, 20, 25 and 30. A kit of six (all one size or assortment) sells for $89.

For more information regarding EndoPoint, please visit www.commonsensedental.com.

J. Morita introduces TorqTech attachments J. Morita USA has announced the introduction of TorqTech geared straight and contra angle attachments. Compatible with both air and electric motors, the TorqTech attachment product line includes a 1:1 straight nose cone, 1:1 contra angle, and a 1:5 speed up contra angle. Designed with a new high-precision gear system, TorqTech offers reduced operational noise and excellent bur stability, which makes large preparations quicker and easier.

The chuck provides a strong grip on the bur and is also long lasting. A built-in water filter helps prevent clogging of the spray line and is easily removed for cleaning.

TorqTech is compatible with standard ISO connections including Morita’s Air Torx air motor, as well as other brands of air and electric motors. For more information, call 888-JMORITA (566-7482) or visit www.morita.com/usa/torqtech.

Volume 6 Number 1

DEXIS, LLC, whose premier product is the only digital X-ray system that fully integrates with Dentrix, is now a member of the Dentrix Developer Program, created for those companies that want to develop specific Dentrix G5 Connected applications. Both the DEXIS® Digital Imaging System and the DEXIS® Integrator™ for DENTRIX® have also been accepted into the Dentrix MarketPlace program. The Dentrix Market Place online portal provides a central location for users to easily review and select technologies that are associated with their Dentrix program and which ultimately enhance their practices.

The DEXIS Digital Imaging System with its award-winning Platinum Sensor and the feature rich DEXIS® Imaging Suite software provides clinicians with the best image quality, most comfortable sensor, and fastest workflow. For more information on DEXIS Imaging Suite and the DEXIS® Platinum Sensor, and to learn about DEXIS imaging solutions, visit www.dexis.com.

RGP signs license to produce Relax and Hydro armrests RGP has long been selling its articulating armrests, and under a newly signed license agreement, RGP owns the rights to manufacture the armrests. According to Sales Manager, Jason DeCosta, “The Relax arm is a two-dimensional armrest that moves with you to accept the weight of your arm off your back, neck and shoulder. It allows the user to hold a mirror or retract for long periods while alleviating the tension and strain usually associated with longer procedures. The Hydro arm is a three-dimensional armrest designed to provide ‘full rangeof-motion’ for the dominant-instrument arm.”

Visit RGP’s web site at: www.rgpdental.com; call: 800-5229695 x5534, or fax: 401-254-0157.

CareCreditSM announces free practice management CD featuring Dr. Rhonda Savage CareCredit is offering a complimentary educational audio CD, Accountability = Energized Teams and Satisfied Patients, featuring Dr. Rhonda Savage, chief operating officer of Miles Global, a practice management and consulting firm exclusively serving dentists. In this audio program, Dr. Rhonda Savage shares how accountability “done right” can improve communications, efficiency and help the practice run smoother.

Practices that currently accept CareCredit can request a copy of this complimentary audio CD by contacting their Practice Development Team at 800-859-9975. Practices that have yet to add CareCredit as a payment option can call 800-300-3046, ext.

4519 to request their complimentary copy.

Endodontic practice 55

Let’s redefine expertise

Imaging masterpieces that show every detail, in multiple dimensions

Workflow integration | Humanized technology | diagnostic excellence

2D/3D imaging systems

Your imaging solutions from a company with 2D and 3D roots Carestream dental’s imaging solutions allow you to see more from every angle. designed with the endodontist in mind, the Cs 9000 3d and rVG 6100 provide high quality images at a lower dose to meet your diagnostic needs. rVG 6100 • integrates seamlessly with current software & other Carestream imaging solutions • Crisp intraoral images with the same resolution as film Cs 9000 3d • focused field CBCt with 2d panoramic imaging • Highest resolution (76 μm) Visit www.carestreamdental.com/endoimaging or call 800.944.6365 and learn more about our imaging solutions © Carestream Health, inc. 2013.

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