Endodontic Practice US - January/February 2014 Issue - Vol7.1 by MedMark, LLC

clinical articles • management advice • practice profiles • technology reviews

Clinical management of teeth with incomplete root formation Dr. Siju Jacob

A conservative approach for internal bleaching of a vital anterior tooth with calcified pulp chamber Drs. David Keinan and Eugene A. Pantera Jr.

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The importance of a reproducible glide path Drs. Yosef Nahmias, Imran Cassim, and Gary Glassman

Feedback – lateral thinking Jacqui Goss

Corporate insight Sonendo®

So·nen·do:

EXCELLENCE

a revolutionary company that aims to redefine and transform traditional root canal therapy

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January/February 2014 – Vol 7 No 1

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

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he beginning of the New Year usually brings an examination of what we’ve learned from the past and a prediction of what lies ahead, and such examinations are critical to maintaining a standard of excellence in our discipline. With regard to our endodontic practices, it’s clear that the increasing pace of innovation is revolutionizing the way we practice, as it will change every form of healthcare practice. The areas of most rapid innovation within endodontics will include cone-beam computed tomography with new algorithms to improve assessments and facilitate surgical guidance, enhanced disinfection and shaping techniques, nanotechnology, innovative advances in obturation that promise safer treatment, improved workflow, and better outcomes and regenerative procedures. Stringent laboratory and clinical evaluations will be validating these innovations at an increasing pace, and more sophisticated studies will present clinicians with rigorously examined innovation opportunities that will provide very significant improvements to the practice of endodontics. As in most forms of medicine, it is not only the rate of change but the degree of difference that is increasing. The adoption of such innovations is becoming ever more compelling. Conversely, ignoring innovation is becoming an everincreasing professional risk. Over the past 50 years, change management has evolved as a recognized discipline. It was once a viable belief that specialists could achieve success by using the same treatments and business strategies for the greater part of their clinical career. For the current community of endodontists, such a notion is seriously flawed. Today, there are new products, technological developments, increased competition, and a changing workforce that require us to change course in order provide the most successful outcomes for our patients and to stay competitive. Most successful companies undergo moderate organizational change yearly and major changes every 4 to 5 years.1 But in spite of all this management attention, most studies show only moderate success for organizational change. This would suggest that Kotter’s classic eight success factors2 is also flawed. What is going on here? Perhaps two additional factors need to be considered, both of which may contradict other notions that served us in the past: • Change should not be episodic. Rather than considering change as a planned and defined part of our business plan, we should integrate change into the way we execute our business plan. This means that new approaches to treatment and business operations need to be examined on a continual basis and that we, as leaders of our practices, should adopt behavioral patterns that transform rather than maintain. This requires changing the fundamental values and principles of our organization and the individuals within it. Each member is continuously seeking better ways to operate as part of a team to improve results. But consider such a concept carefully, because this level of transformation does not require management. It requires leadership. • Change should not be hierarchical. Change from the top can never be adequate to the challenges of making the myriad of changes required to improve a complex organization. Rather than deciding and dictating change, the best practice leaders will inspire and coach change — structuring their organizations to actually breed ideas for improvement. In a recent case study, Kotter talks about the need to accelerate change by using a dual organizational structure. The problem is that most businesses have a hierarchical structure that maintains processes very well, but resists change. How many of our practices operate this way? Kotter proposes a parallel structure where employees at all levels are invited to contribute to change in a different, but complementary, way. He stated that creating a sense of urgency around a single opportunity (or problem) is a good way to start3 and to get people accustomed to contributing ideas independently of management roles and structure. Any size practice can benefit from such a parallel concept: Daily management of patient flow and procedures can be managed by a hierarchy of priorities and team member roles, but ideas for improvement should flow in parallel, unimpeded by hierarchy. So as the New Year begins, we must consider a qualitative review of our perspectives on treatment and the organizational culture of our practices. Most successful change efforts require creating a change-capable organization that is always ready to examine and adapt to new treatment protocols and office operational demands, all supported by the evidence and metrics, respectively. This means establishing a sense of urgency and creating a strategy that is supple and ready for modification as conditions change. At the Harvard Medical School 2013 Class Day address, Dr. Bruce Donoff, dean of the Harvard School of Dental Medicine, said, “We educated you in a way that does not simply repeat the lectures of the past but prepares you to understand and see new knowledge in the continuously changing field as well as in the wider world.”4 I would encourage us all to improve our individual, staff, and practice abilities to benefit from the ongoing stream of innovation that will enable us to continuously improve patient care. It is an exciting age in which to be practicing dental medicine. Best wishes for this New Year and years ahead. Martin D. Levin, DMD Diplomate, American Board of Endodontics Clinical Associate Professor of Endodontics, University of Pennsylvania www.endonet.com and www.endocc.com

$99 $239

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Volume 7 Number 1

1. Allen, SA. Organizational choices and general management influence networks in divisionalized companies. Academy of Management Journal. 1978;21(3):341365. 2. Kotter, JP. Leading change. Boston: Harvard Business Review Press; 1996. 3. Kotter, JP. Accelerate! Harvard Business Review. 2012;90(11): 44-58. 4. Harvard Medical School. Change in Medicine theme for new HMS grads. Harvard Medical School News, May 30, 2013. Http://hms.harvard.edu/news/changemedicine-theme-new-hms-grads-5-30-13. Accessed January 1, 2014.

Endodontic practice 1

INTRODUCTION

Dental medicine in an age of change January/February 2014 - Volume 7 Number 1

TABLE OF CONTENTS Clinical Clinical guidelines for the use of ProTaper Next™ instruments: part one Drs. Peet J. van der Vyver and Michael J. Scianamblo discuss the clinical guidelines for using ProTaper Next™ instruments........ 12 BT-Race — Biologic and conservative root canal instrumentation with the final

Corporate insight

Sonendo® — A new paradigm in endodontics At the 2014 AAE Annual Session, Sonendo is debuting its Multisonic Ultracleaning System that uses a mixture of irrigating fluids and sound waves to clean inside the roots of teeth.

restoration in mind Drs. Gilberto Debelian and Martin Trope explore the BT-Race system ......................... 22 A conservative approach for internal bleaching of a vital anterior tooth with calcified pulp chamber Drs. David Keinan and Eugene A. Pantera Jr. solve a common endodontic problem in a conservative way......................... 25

Clinical 7 Accuracy of a new apex locator in ex-vivo teeth using scanning electron microscopy Drs. Maria Bonilla, Taner Cem Sayin, Brenda Schobert, and Patrick Hardigan compare the accuracy of root canal working lengths in 200 ex-vivo teeth determined using a fourth-generation electronic apex locator and a new fifthgeneration electronic apex locator

2 Endodontic practice

ON THE COVER Cover photo courtesy of Drs. Peet J. van der Vyver and Michael J. Scianamblo. Article begins on page 12.

Volume 7 Number 1

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UltraCal® XS and Citric Acid 20% UltraCal XS, a uniquely formulated calcium hydroxide paste (pH 12.5), can be easily delivered with the NaviTip® tip exactly where it is needed in the canal. Calcium hydroxide offers strong antimicrobial effects and potentially stimulates the healing of bone to promote healing in infected canals.1 For two-appointment RCTs, no other medicament works better than UltraCal XS. When it comes time to remove UltraCal XS from the canal, look no further than Ultradent’s Citric Acid 20%, delivered with the NaviTip FX tip. Citric Acid 20% easily dissolves calcium hydroxide, and the small fibers attached to the NaviTip FX tip easily scrub the walls of the canal, which also helps remove the smear layer. So you know the canal is ready for obturation.

Use NaviTip® tip to place UltraCal® XS in the canal, and use Citric Acid with the NaviTip® FX® tip to easily remove it.

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800.552.5512 ultradent.com NaviTip tip delivers UltraCal XS where it is needed in the canal. 1. Gomes BP, Ferraz CC, Vianna ME, Rosalen PL, Zaia AA, Teixeira FB, et al. In vitro antimicrobial activity of calcium hydroxide pastes and their vehicles against selected microorganisms. Braz Dent J. 2002;13(3):155-61.

UltraCal XS ®

TABLE OF CONTENTS

Clinical management of teeth

Continuing education The importance of a reproducible glide path Drs. Yosef Nahmias, Imran Cassim, and Gary Glassman discuss how rotary and reciprocating instruments that follow a designated route will result in more successful outcomes and minimal iatrogenic mishaps ....28 Clinical management of teeth with incomplete root formation Dr. Siju Jacob discusses treatment techniques for teeth with incomplete root formation ...............................34

Abstracts The latest in endodontic research Dr. Kishor Gulabivala presents the latest literature, keeping you up-todate with the most relevant research .....................................................41 4 Endodontic practice

Anatomy matters Endodontic accountability: The “X” factor, part 9 Dr. John West discusses knowledge, skill, and willingness in endodontics .....................................................43

Endospective The cookbook’s not working — what’s next? Dr. Rich Mounce discusses a superior method for cleaning canals ...........48

34 Practice management Feedback – lateral thinking Jacqui Goss explains how to gather reliable patient feedback ...............52

Materials & equipment ......................54 Diary ......................................56

Product insight What is the ideal endodontic interappointment medicament, its most effective placement and removal technique? Drs. Carlos A.S. Ramos, Richard D. Tuttle, and Mr. Daniel C. White explain the benefits of UltraCal® XS...........50

Volume 7 Number 1

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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.

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â&#x20AC;&#x153;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.â&#x20AC;? ~ 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.

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CORPORATE INSIGHT

A new paradigm in endodontics So·nen·do: a revolutionary company that aims to redefine and transform traditional root canal therapy. Company History The mission of Sonendo® is to lead the transformation of endodontics through Sound Science®. At its core, Sound Science means that we are committed to ensuring that our product development is based on sound scientific research, and extensive proof source. Furthermore, we will continue to leverage our innovative approach to sound — and its use in endodontics — as we work to bring this disruptive new technology to the endodontic community.

“Our goal is to transform endodontics by improving the clinical quality and business performance of practices performing root canal therapy,” said Bjarne Bergheim, President and Chief Executive Officer of Sonendo. Sonendo is a privately held company located in Laguna Hills, California, and employs over 50 people. Sonendo was founded in 2006 with co-founders who include director Olav Bergheim; California Institute of Technology professor Morteza Ghari; retired dentist Erik Hars; and Bill Nieman. As President and CEO, Bjarne Bergheim collaborates with a scientific advisory board that includes Scott Arne, DDS, FAGD; Gerald Glickman, DDS; Markus Haapasalo, DDS, PhD; and Ove Peters, DMD, MS, PhD.

6 Endodontic practice

Multisonic Ultracleaning™ The Multisonic Ultracleaning System, currently scheduled to debut at the 2014 AAE Annual Session, is designed to be a disruptive technology that uses a mixture of irrigating fluids and sound waves to clean inside the roots of teeth. It quickly, easily, and safely loosens and removes all the pulp tissue, debris, decay, and bacteria from the entire root canal system within minutes. The system is designed to automatically and simultaneously clean all canals in about 5 minutes, as well as improve the clinical quality and business performance of root canal therapy.

SEM showing apical cleaning with Sonendo’s Ultracleaning™ System

New paradigm Sonendo’s design goals allow for little to no traditional instrumentation (endodontic file) required, with procedure time dramatically reduced. The Multisonic Ultracleaning System does not remove structural dentin, preserving the structural integrity of the tooth. Sonendo is focused to bring to market a device that will provide an endodontic treatment that is highly predictable for every procedure, more comfortable for the patient, faster and more efficient for the practice, offering a significant cleaner and disinfected treatment area compared to current standards. Sonendo’s system is not yet commercially available for sale or distribution. For more information, visit www.sonendo.com. EP

SEM showing dentin tubules cleaned with Sonendo’s Ultracleaning™ System

This information was provided by Sonendo.

Volume 7 Number 1

Drs. Maria Bonilla, Taner Cem Sayin, Brenda Schobert, and Patrick Hardigan compare the accuracy of root canal working lengths in 200 ex-vivo teeth determined using a fourth-generation electronic apex locator and a new fifth-generation electronic apex locator Introduction A key factor affecting the success of endodontic treatment is the establishment of an accurate root canal working length. The ideal cleaning, shaping, and disinfection of the root canal system depends on the accurate determination of the root canal anatomy from canal orifice to the canal-dentinal-cement (CDC) junction. The apical anatomy of root canals has been investigated in several research studies and review articles (Kuttler, 1955; Ricucci, 1998; Green, 1956; Pineda, Kuttler, 1972). The apical CDC junction, also defined as the minor diameter, is the anatomical landmark that segregates the pulp tissue from periodontal tissues. Dummer, et al., described the morphological variations of apical CDC junctions in 1984. Many of these variations cannot be determined radiographically. The distance between the major diameter and the minor diameter of the apex can vary, but usually it is between 0.5 mm to 1 mm (Ricucci, 1998; Green, 1956; Pineda, Kuttler 1972). To preserve the vitality of the periapical tissues, the ideal cleaning, shaping, and root canal filling materials have to be limited to the apical CDC junction. Therefore, it has become the preferred landmark for the apical endpoint for root canal therapy (Nekoofar, et al., 2002).

Maria Bonilla, DDS, CAGS, works at the Department of Endodontics, Nova Southeastern University, College of Dental Medicine, Fort Lauderdale, Florida. Taner Cem Sayin, DDS, PhD, is an associate professor at the Department of Endodontics, Nova Southeastern University, College of Dental Medicine, Fort Lauderdale, Florida. Brenda Schobert, DDS, CAGS, works at the Department of Endodontics, Nova Southeastern University, College of Dental Medicine, Fort Lauderdale, Florida. Patrick C. Hardigan, PhD, is a professor of public health at the Department of Endodontics, Nova Southeastern University, College of Dental Medicine, Fort Lauderdale, Florida.

Volume 7 Number 1

Procedural errors — such as overinstrumentation or under-instrumentation — can occur because of inaccurate estimates of root canal length. Over-instrumentation can damage the anatomy of the root end and also injure the periodontal tissues. On the other hand, under-instrumentation may create a suitable environment for bacteria that might cause a less favorable outcome of the endodontic treatment. Therefore, the accurate determination of the working length is an important goal for the success of the root canal treatment. Several methods can be used to measure the root canal working length. Radiographs can visualize the root canal but are limited to two dimensions and are technique-sensitive to operator inputs (Cox, et al., 1991). A study by Brunton, et al., (2002) showed that electronic apex locators (EALs) could be used to reduce the radiation exposure time to the patients by requiring less radiographs. Some studies found that there were no significant differences between the accuracy of EALs and radiographs (Hoer, Attin, 2004; Vieyra, Acosta, 2011). A study by Real, et al., (2011) found that EALs were significantly more accurate than digital sensors. The use of EALs for determining the root canal working length has become an indispensable part of endodontic treatment. More accurate EALs have evolved in recent years by improving the basic principles upon which the measurements are performed. In 1918, Custer proposed the development of electronic devices to determine the working length. In 1942, Suzuki presented the first generation of EAL to use the electrical resistance properties of the root canal to determine its working length. Sunada (1962) determined the electrical resistance value constantly at 6.5 ohms. This theory considered the electrical resistance between the oral tissues and the periodontal ligament to remain constant. The second generation of EAL had the peculiarity of working with impedance principles. An example of the third-

Figure 1: Apical portion of the specimen

generation EAL is the Root ZX® (J. Morita) which worked with a constant frequency principle. A fourth-generation EAL was created by Gordon and Chandler (2004), which worked with multiple frequencies. The first version of Root ZX EAL used the average measurements of two frequencies of 0.4kHz and 8kHz. Kobayashi and Suda (1994) described this method as the EAL frequency ratio. The most recent version of Root ZX uses multiple frequencies and can be classified as a fourth-generation EAL (Kobayashi, Suda, 1994). The fifth generation of EAL also uses multiple frequencies, in addition to calculating the root mean square (RMS) values of the electric signals. The RMS represents the energy of the electric signals, and therefore, it is claimed to be less affected by electrical noises affecting other physical parameters such as amplitude or phase of electrical signal that are used by other EALs. An example of a fifth-generation EAL is the Propex Pixi™, which is a newer version of recently designed EAL Propex (Dentsply Maillefer, Switzerland). Endodontic practice 7

CLINICAL

Accuracy of a new apex locator in ex-vivo teeth using scanning electron microscopy

CLINICAL

Figure 2: The mean distance from the final working length to the file tip

Aims and objectives The aim of this study was to compare the accuracy of root canal working lengths in 200 ex-vivo teeth determined using a fourth-generation EAL (the Root ZX II) with a fifth-generation EAL (the Propex Pixi). The Propex Pixi and Root ZX II use signals at two different frequencies to calculate the file tip position relatively to root apex. Furthermore, the technology utilized in Propex Pixi differs from the technology used in Root ZX II: Propex Pixi by measuring the RMS of the electric signal, which is further used for calculations. Because of these technology differences, there is a need to compare the accuracy of the Propex Pixi with the Root ZX II to determine root canal working lengths.

Materials and methods After IRB approval was obtained, an archive of 200 sound human permanent teeth with completely formed apices was used in this study. The teeth were disinfected by submerging them in a 6% sodium hypochlorite (NaOCl) solution for 15 minutes. They were then rinsed for 10 minutes with distilled water. This disinfection cycle was repeated 3 times for each tooth. The teeth were stored in 20ml sterile scintillation vials filled with distilled water in a refrigerator at 5ºC until use. Prior to inclusion in this study, the root surfaces and apices of each tooth were examined under x16 magnification using a surgical microscope (Global Surgical 8 Endodontic practice

Corp.) for a possible fracture or resorptive areas. If any defects were observed in a tooth, it was discarded from this study. The outer surfaces of the teeth were cleaned by removing tissues with a 15c scalpel (Aspen Surgical). Photographs were taken of each tooth in a buccolingual as well as a mesiodistal view (Figure 1). Digital radiographs (Schick Technologies) for each tooth in a buccolingual and a mesiodistal direction were also taken as pre-operatory procedure (Figure 2). Access cavities were prepared with a high-speed handpiece and a fissure bur (Maillefer, Switzerland) with water coolant, under the surgical operating microscope. Pre-flaring of the root canals was not performed. The root canals were irrigated with 6% NaOCl before the introduction of any file. Patency was established by introducing a No. 6 or No. 8 hand file (Maillefer, Switzerland) until it emerged in the apical foramen, and this was corroborated by visualization using the surgical microscope. Each of the teeth was embedded in a dental device for training purposes with alginate. The 200 teeth were randomly assigned to the Propex Pixi (n = 100) group or the Root ZX II (J. Morita) (n = 100) group. The root canal working length measurements were carried out according to the manufacturers’ instructions. The lip clip electrode was attached to the device, and the other electrode was attached to a file that fit snugly in the apical portion of

the root canal. Digital radiographs for each tooth in a buccolingual and a mesiodistal direction were taken to corroborate radiographically that the working length had been established. The files were then withdrawn from the canals to measure them with an endodontic ruler (Maillefer, Switzerland). The reference points were marked with silicone stoppers. All the working lengths were measured using the same endodontic ruler. The working lengths were recorded on a spreadsheet. The files were reinserted into the root canal and cemented with a flowable composite resin to avoid any movements from within the root canal. The apical 4-mm portion of the root canals was carefully shaved in a longitudinal direction using a fine diamond bur (Maillefer, Switzerland) and a scalpel under a Olympus SZX7® stereomicroscope at x8 magnification to prevent touching the files with the diamond bur. The apical portion of the teeth and files were observed in micrographs at x40 magnification using an FEI Quanta 200 FEG Environmental Scanning Electron Microscope in the low-vacuum mode, and the distance from the file tip to the CDC junction was measured with Scandium image software (FEI Company) (Figure 3). A Welch’s t-test test was used to compare the accuracy of the working lengths determined by the two EALs at a significance level of P<.05.

Results The mean distance from the final working length to the file tip was 0.21 ± 0.25 mm for the Propex Pixi EAL while it was 0.08 ± 0.22 mm for the Root ZX II EAL (Table 1, Figure 2). A difference of 0.13 mm (95%: 0.23 to 0.47) was found between the Propex Pixi and Root ZX II EALs. The Propex Pixi was accurate 88% of the time to ± 0.5 mm and 98% accurate within ± 1.00 mm (Table 2). The Root ZX II was accurate 97% of the time to ±0.50 mm and 99% accurate within ±1.00 mm (Table 2). There was no significant difference in the accuracy of the working lengths determined by the two EALs (P > 0.05).

Discussion This study is the first to investigate the accuracy of the root canal working length measurements of a new fifth-generation EAL called the Propex Pixi. Given the importance of accurate root canal working length measurements to the outcome of Volume 7 Number 1

Group

M (mm)

SD (mm)

Min (mm)

Max (mm)

PIXI

100

0.21

0.25

-0.40

1.27

Root ZX

100

0.08

0.22

-0.87

1.04

Difference

0.13

0.03

0.23

0.47

Table 2: Frequency of distance from working length per locater device

PIXI (N=100) Distance from actual WL

Count

Root ZX (N=100)

Percent

Count

Percent

-0.49 to 0.00

13%

0.01 to 0.50

80%

84%

0.50 to 1.00

10%

Greater then 1.00

endodontic treatment, it is essential that all new EALs be evaluated for their accuracy. The multiple frequency processing technology, and use of RMS incorporated into the Propex Pixi may have theoretical advantages for increasing the accuracy of the working length measurements, by reducing the electrical noises affecting other physical parameters like amplitude or phase of electrical signal that are used by other EALs. But the technology improvements were not enough to make the Propex Pixi significantly more accurate than the Root ZX II (P > 0.05), which appears to be an extremely accurate fourth-generation EAL. The Propex Pixi and Root ZX II gave root canal working lengths of 0.21 and 0.08 mm, which were accurate 88% and Volume 7 Number 1

97% of the time within 0.5 mm of the actual root canal length. These high levels of accuracy appear to be beneficial to the practice of endodontics, and since both EALs had similar levels of accuracy, both the Propex Pixi and Root ZX II EALs can be recommended for use in endodontics. Traditionally, a radiographic evaluation has been the primary technique to determine the vertical limit of instrumentation, irrigation, and obturation in endodontic therapy (Fouad, Rivera, Krell, 1993). However, El Ayouti, et al., (2005) concluded that radiographic evaluation was not accurate enough and causes over-instrumentation, especially in 56% of premolars. Williams, et al., (2006) concluded that the files that seem to be beyond the apex were longer by an average of 1.2 mm. In contrast, files

that seemed to be short of the apex on the radiographs were 0.47 mm closer to the apical foramen. The new technologies in EALs appear to make them more accurate; they are more accurate than radiographs, which are only useful to corroborate the EAL readings. Radiographs are useful for visualizing the existence of pathology, the amount of root to treat, and the direction of curvatures in the root canal system (Ricucci, 1998; Dummer, McGinn, Rees, 1984; Gordon, Chandler, 2004). The use of EAL reference points has been controversial. The major diameter reference point has been claimed as the more reliable and accurate reference point than minor diameter because the minor reference point is more difficult to locate (Martinez-Lozano, et al., 2001; Lee, et al., 2002). Lee, et al., (2002) recommended using the major foramen as reference point to determine the accuracy of EALs. The anecdotal evidence suggests it is extremely important to follow manufacturers’ EAL instructions without any deviation and to always have a high battery charge. Some previous studies discovered that EALs can only detect the major foramen (Mayeda, et al., 1993; Ounsi, Naaman, 1999). Therefore, the present study used the CDC junction as the measuring point for both EALs. The Propex Pixi is a new EAL, and no literature is available to compare its working length accuracy with the present study. The results of the present study did demonstrate that it has a similar accuracy to the Root ZX II. The accuracy of the Root ZX II has been successful to determine the root canal working length within 1 mm in 96.5% of the cases observed by Shabahang, et al., (1996). The accuracy of the Root ZX II was confirmed in a study by Pagavino (1998), which had an 82.75% success in locating the root canal working length with a 0.5 mm tolerance. In a study by El Ayouti (2005), the Root ZX II also showed 90% accuracy within a 1 mm range when compared to Raypex® (VDW) (74%) and Apex Pointer™ (Micro-Mega) (71%). Welt, et al., (2003) also found that Root ZX II was 90.7% accurate within 0.5 mm at the apical constriction. An in-vivo study by Silveira, et al., (2011) found that the Root ZX II was 91.7% accurate in locating the apical constriction. On the other hand, percentages for accuracy in Tselnik’s 2005 study were around 75% for Root ZX. The first generation of Propex also showed Endodontic practice 9

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Table 1: Descriptive statistics per locator device

CLINICAL similar accuracy for determining the apical constriction with Root ZX II in Plotino’s (2006) study. The accuracy of the Root ZX II measurement to within 0.50 mm of the root canal working length 97% of time, and within 1 mm 99% of the time in the present study, appears consistent with previous research. Some of the accuracy variations may be due to differences in operator technique sensitivity, handling of the EALs, placement of files, and radiographic angulation visualization of the file inside the root canal. Stainless-steel hand files were used in the present study. The file sizes were different in each root canal because of differences in root canal sizes. According to Herrera (2007), the Root ZX II EAL is more accurate if the diameter size of the file is less than a No. 60 (0.6 mm). The largest apical file diameter used in the present study was 0.30 mm. Shaving the apical portion of the canal also gave a clear visibility of the CDC junction, and it seemed to allow more accurate measurements from radiographs using the SEM.

References Brunton PA, Abdeen D, MacFarlane TV. The effect of an apex locator on exposure to radiation during endodontic therapy. J Endod. 2002;28(7):524-526. Cox VS, Brown CE Jr, Bricker SL, Newton CW. Radiographic interpretation of endodontic file length. Oral Surg Oral Med Oral Pathol. 1991;72(3):340-344. Custer LE. Exact methods of locating the apical foramen. J Natl Dent Assoc. 1918;5:815-819. Dummer PM, McGinn JH, Rees DG. The position and topography of the apical canal constriction and apical foramen. Int Endod J. 1984;17(4):192-198. ElAyouti A, Kimionis I, Chu AL, Löst C. Determining the apical terminus of root-end resected teeth using three modern apex locators: a comparative ex vivo study. Int Endod J. 2005;38(11):827-833. Fouad AF, Rivera EM, Krell KV. Accuracy of the Endex with variations in canal irrigants and foramen size. J Endod. 1993;19(2):63-67.

The results of the present study suggest that our improvements to the methodology for measuring working length accuracy can help improve the reliability of EALs — in the case of the Root ZX II, up to 99% of the time within 1 mm. Root canal irrigation with 6% NaOCl was used in the present study to dissolve the necrotic pulp around the orifice and the coronal portion of the canals before determining the working lengths. The antimicrobial activity and the removal of the organic remnants by irrigants are very important for the success of endodontic treatment. Previous studies showed that some EALs had inaccurate measurements when used with other irrigation solutions (Kaufman, Keila, Yoshpe, 2002; Haffner, et al., 2005). The present study confirmed that both EALs can provide accurate measurements in the presence of 6% NaOCl. We recommend further modification of EALs to select the type and dilution of irrigation solutions to avoid this problem, and to help improve the accuracy of EALs under all types of operating conditions. While using the

Kaufman AY, Keila, S, Yoshpe M. Accuracy of a new apex locator: an in vitro study. Int Endod J. 2002;35(2):186-192. Kobayashi C, Suda H. New electronic canal measuring device based on the ratio method. J Endod. 1994;20(3):111-114. Kuttler Y. Microscopic investigation of root apexes. J Am Dent Assoc. 1955;50(5):544-562. Lee SJ, Nam KC, Kim YJ, Kim DW. Clinical accuracy of a new apex locator with an automatic compensation circuit. J Endod. 2002;28(10):706-709. Martínez-Lozano MA, Forner-Navarro L, SánchezCortés JL, Llena-Puy C. Methodological considerations in the determination of working length. Int Endod J. 2001;34(5):371-376. Mayeda DL, Simon JH, Aimar DF, Finley K. In vivo measurement accuracy in vital and necrotic canals with the Endex apex locator. J Endod. 1993;19(11):545-548.

Gordon MP, Chandler NP. Electronic apex locators. Int Endod J. 2004;37(7):425-437.

Nekoofar MH, Sadeghi K, Sadighi Akha E, Namazikhah MS. The accuracy of the Neosono Ultima EZ apex locator using files of different alloys: an in vitro study. J Calif Dent Assoc. 2002;30(9):681-684.

Green D. A stereomicroscopic study of the root apices of 400 maxillary and mandibular anterior teeth. Oral Surg Oral Med Oral Pathol. 1956;9(11):1224-1232.

Ounsi HF, Naaman A. In vitro evaluation of the reliability of the Root ZX electronic apex locator. Int Endod J. 1999;32(2):120-123.

Haffner C, Folwaczny M, Galler K, Hickel R. Accuracy of electronic apex locators in comparison to actual length – an in vivo study. J Dent. 2005;33(8):619-625.

Pagavino G, Pace R, Baccetti T. A SEM study of in vivo accuracy of the Root ZX electronic apex locator. J Endod. 1998;24(6):438-441

Herrera M, Abalos C, Planas AJ, Llamas R. Influence of apical constriction diameter on Root ZX apex locator precision. J Endod. 2007;33(8):995-998.

Plotino G, Grande NM, Brigante L, Lesti B, Somma F. Ex vivo accuracy of three electronic apex locators: Root ZX, Elements Diagnostic Unit and Apex Locator and ProPex. Int Endod J. 2006;39(5):408-414.

Hoer D, Attin T. The accuracy of electronic working length determination. Int Endod J. 2004;37(2):125-131

10 Endodontic practice

Propex Pixi, we did appreciate its smaller size compared to traditional sized EALs; this gave a little more space in the clinical setup.

Conclusions The multiple frequency processing technology and the use of RMS incorporated into the Propex Pixi may have theoretical advantages for increasing the accuracy of the working length measurements. But the technology improvements were not enough to make the Propex Pixi significantly more accurate than the Root ZX II (P > 0.05), which appears to be an extremely accurate fourth-generation EAL. These high levels of accuracy appear to be beneficial to the practice of endodontics, and since both EALs had similar levels of accuracy, both the Propex Pixi and Root ZX II EALs can be recommend for use in endodontics.

Acknowledgments The authors thank Dr. Armando Lara from University of Tlaxcala, Mexico. EP

Real DG, Davidowicz H, Moura-Netto C, Zenkner Cde L, Pagliarin CM, Barletta FB, de Moura AA. Accuracy of working length determination using 3 electronic apex locators and direct digital radiography. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2011;111(3):e44-49 Ricucci D. Apical limit of root canal instrumentation and obturation, part I. Literature-review. Int Endod J. 1998;31(6):384-393. Shabahang S, Goon WW, Gluskin AH. An in vivo evaluation of Root ZX electronic apex locator. J Endod. 1996;22(11):616-618. Silveira LF, Petry FV, Martos J, Neto JB. In vivo comparison of the accuracy of two electronic apex locators. Aust Endod J. 2011;37(2):70-72. Sunada I. New method for measuring the length of the root canal. J Dent Res. 1962;41:375-387. Suzuki K. Experimental study on iontophoresia. J Jap Stomatol. 1942;16:411. Tselnik M, Baumgartner JC, Marshall JG. An evaluation of Root ZX and elements diagnostic apex locators. J Endod. 2005;31(7):507-509. Vieyra JP, Acosta J. Comparison of working length determination with radiographs and four electronic apex locators. Int Endod J. 2011;44(6):510-518. Welk AR, Baumgartner JC, Marshall JG. An in vivo comparison of two frequency-based electronic apex locators. J Endod. 2003;29(8):497-500. Williams CB, Joyce AP, Roberts S. A comparison between in vivo radiographic working length determination and measurement after extraction. J Endod. 2006;32(7):624-627.

Pineda F, Kuttler Y. Mesiodistal and buccolingual roentgenographic investigation of 7,275 root canals. Oral Surg Oral Med Oral Pathol. 1972;33(1):101-110.

Volume 7 Number 1

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Clinical guidelines for the use of ProTaper Next™ instruments: part one Drs. Peet J. van der Vyver and Michael J. Scianamblo discuss the clinical guidelines for using Protaper Next instruments Introduction According to Bird, Chambers, and Peters (2009), rotary nickel-titanium (NiTi) instruments have become a standard tool for shaping root canal systems. These instruments provide the clinician with several advantages compared to conventional stainless steel instruments. They are more flexible, have increased cutting efficiency (Kim, et al., 2012; Peters, 2004; Walia, Brantley, Gerstein, 1988), can create centered preparations more rapidly (Short, Morgan, Baumgartner, 1997; Glossen, et al., 1995), and can produce tapered root canal preparations with a reduced tendency of canal transportation (Chen, Messer, 2002; Kim, et al., 2012). However, nickel-titanium instruments appear to have a high risk of fracture (Arens, et al., 2003; Sattapan, et al., 2000) mainly because of flexural and torsional stresses during rotation in the root canal system (Berutti, et al., 2003; Parashos, Messer, 2006). When there is a wide area of contact between the cutting edge of the instrument and the canal wall during rotation, the instrument will be subjected to an increase in torsional stress (Peters, et al., 2004; Blum, et al., 1999). The preparation of a reproducible glide path can reduce the torsional stress on root canal instruments. A glide path is a smooth passage that extends from the canal orifice in the pulp chamber to its opening at the apex of the root (West, 2006). This will provide a continuous, uninterrupted pathway for the rotary nickel-titanium instrument to enter and to move freely to the root canal terminus.

Dr. Peet J. van der Vyver is extraordinary professor at the Department of Odontology, School of Dentistry, University of Pretoria and Private Practice, Sandton, South Africa (see www.studio4endo.com for more). Michael J Scianamblo, DDS, is an endodontist and the developer of Critical Path Technology. He is a postgraduate and fellow of the Harvard School of Dental Medicine and has served as a faculty member of the University of the Pacific and the University of California, Schools of Dentistry in San Francisco.

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The main purpose of a glide path is to create a root canal diameter the same size as, or ideally a size bigger than, the first rotary instrument introduced (Berutti, et al., 2004; Varela-Patio, et al., 2005; Berutti, et al., 2009). Another way to reduce torsional stress is to incorporate multiple progressive tapers to the instrument design, for example, the ProTaper® universal system (Dentsply/Maillefer). According to West (2001), the progressive taper allows for only small areas of dentin to be engaged. This design concept also contributes to maintaining the original canal curvature (Yun, Kim, 2003).

ProTaper Next Recently, the ProTaper Next system (Dentsply/Maillefer) was launched into the dental market. (ProTaper NEXT® is only available in North America through DENTSPLY Tulsa Dental Specialties.) There are five instruments in the system, but most canals can be prepared by using only the first two instruments. This system also makes use of the multiple progressive taper concept. Each file presents with an increasing and decreasing percentage tapered design on a single file concept (Ruddle, Machtou, West, 2013). The design ensures that there is reduced contact between the cutting flutes of the instrument and the dentin wall, thus reducing the chance for taper lock (screw-in effect). At the same time, it also increases flexibility and cutting efficiency (Ruddle, 2001). The first instrument in the system is ProTaper Next X1 (Figure 1), with a tip size of 0.17 mm and a 4% taper. This instrument is used after creation of a reproducible glide path by means of hand instruments or rotary PathFile™ instruments. This instrument is always followed by the second instrument, the ProTaper Next X2 (0.25 mm tip and 6% taper) (Figure 2). ProTaper Next X2 can be regarded as the first finishing file in the system, as it leaves the prepared root canal with adequate shape and taper for optimal irrigation and root canal obturation. ProTaper Next X1 and X2 have an increasing and decreasing

Figure 1: ProTaper Next X1 (17/04) instrument

Figure 2: ProTaper Next X2 (25/06) instrument

Figure 3: ProTaper Next X3 (30/07) instrument

Figure 4: ProTaper Next X4 (40/06) instrument

Figure 5: ProTaper Next X5 (50/06) instrument

percentage tapered design over the active portion of the instruments. The last three finishing instruments are ProTaper Next X3 (0.30 mm tip with 7% taper) (Figure 4), ProTaper Next X4 (0.40 mm tip with 6% taper) (Figure 5) and ProTaper Next X5 (0.5 mm tip with 6% taper) (Figure 6). These instruments have a decreasing percentage taper from the tip to the shank. ProTaper Next X3, X4, and X5 can be used to either create more taper in a root canal or to prepare larger root canal systems. Another benefit of this system is the fact that the instruments are manufactured from M-Wire and not traditional nickeltitanium alloy. Research by Johnson, et al., (2008) demonstrated that the M-Wire alloy could reduce cyclic fatigue by 400% compared to similar instruments manufactured from conventional nickeltitanium alloys. The added metallurgical benefit contributes toward more flexible instruments, increased safety, and Volume 7 Number 1

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Figure 6: ProTaper Next instruments have a bilateral symmetrical rectangular cross section (except for the last 3 mm of X1) with an offset from the central axis of rotation (except in the last 3 mm of all the instruments, D0-D3). This design characteristic allows the instrument to experience a rotational phenomenon known as precession or swagger. The swaggering movement enables the instrument to cut a larger envelope of motion (red line) compared to a similarly sized instrument with a symmetrical mass and axis of rotation

Figure 7: ProTaper Next instrument after canal preparation to full working length. Note the absence of debris on the cutting flutes in the last 2-3 mm of the instrument. In the presence of irrigation solution, the cutting debris is moved coronally, away from the tip of the instruments because of the swaggering effect allowing more space for fluid movement in the root canal system

Figure 8: Preoperative radiograph of maxillary left first premolar with three roots, showing a large periapical radiolucency

• There is a smooth transition between the different sizes of instruments because the design ensures that the instrument sequence itself expands exponentially. Figures 9A-9B: Extended access cavity preparation to allow straight-line access into the buccal and palatal root canals. Arrows indicate dentin triangle obscuring the orifice of the distobuccal root canal

protection against instrument fracture (Gutmann, Gao, 2012). The last major advantage towards root canal preparation with the ProTaper Next system is the fact that most of the instruments present with a bilateral symmetrical rectangular cross section (Figure 6) with an offset from the central axis of rotation (except in the last 3 mm of the instrument, D0-D3). The exception is ProTaper X1 that has a square cross section in last 3 mm to give the instruments a bit more core strength in the narrow apical part. This design characteristic allows the instrument to experience a rotational phenomenon known as precession or swagger (Scianamblo, 2011). The benefits of this design characteristic include: • It further reduces (in addition to the progressive tapered design) the engagement between the instrument and the dentin walls. This will contribute to a reduction in taper lock, screw-in effect, and stress on the file. Volume 7 Number 1

• Removal of debris in a coronal direction (Figure 7) because the off-center cross section allows for more space around the flutes of the instrument. This will lead to improved cutting efficiency, as the blades will stay in contact with the surrounding dentin walls. Root canal preparation is done in a very fast and effortless manner. • The swaggering motion of the instrument initiates activation of the irrigation solution during canal preparation, improving debris removal. • It reduces the risk of instrument fracture because there is less stress on the file and more efficient debris removal. • Every instrument is capable of cutting a larger envelope of motion (larger canal preparation size) (Figure 6) compared to a similarly sized instrument with a symmetrical mass and axis of rotation. This allows the clinician to use fewer instruments to prepare a root canal to adequate shape and taper to allow for optimal irrigation and obturation.

Clinical guidelines for ProTaper Next instruments The clinical technique for ProTaper Next will be discussed by means of case reports. The first case report will outline the basic guidelines for the use of ProTaper Next instruments. The patient, a 46-year-old male, presented with a previous emergency root canal treatment on his upper-left first premolar. A periapical radiograph showed evidence of three separate roots and large periapical lesion (Figure 8). According to the patient, the tooth was left open by his previous dentists that performed the emergency root canal treatment to allow for drainage.

Guideline one: Create straightline access and remove triangles of dentin It is very important to prepare an adequate access cavity that will ensure straightline access into each root canal system. However, in the present clinical case there was still a dentin triangle obscuring direct access into the distobucaal root canal system (Figures 9A and 9B). The Start-X tip No. 3 (Dentsply/Maillefer) was used to remove some of this dentin on the pulp floor Endodontic practice 13

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Figure 10: Start-X tip No.3 (Dentsply/Maillefer) is used to remove some of the restrictive dentin obscuring the distobuccal canal

Figure 11: Micro-opener (Dentsply/Maillefer), size 10, taper 6% is used to locate the distobuccal canal orifice

Figure 13A: Distobuccal root canal negotiated to patency (arrow) with a size 10 K-file (Dentsply/Maillefer)

Figure 13B: Periapical radiograph showing the position of the files during length determination â&#x20AC;&#x201D; two size 10 K-files (25 mm length) in mesiobuccal and distobuccal root canals and a size 20 K-file (25 mm length) in palatal root canal

(Figure 10), allowing more direct access to the distobuccal root canal orifice. A Micro-opener (Dentsply/Maillefer), size 10, 06% taper instrument was used to locate and enlarge the distobuccal and mesiobuccal canal orifices (Figure 11). For improved radicular access, the SX instrument (Dentsply/Maillefer) from the ProTaper Universal system was used (Figure 12A). The recommended method of use is to introduce the file into the coronal portion of the root canal, ensuring that the file is able to freely rotate. Restrictive dentin is then removed by using a backstroke, outward brushing motion. This step will also relocate the canal orifices more mesial or distal (away from furcal danger) and preflare the canal orifices, ensuring complete staight-line access into the root canal system (Figure 12b).

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Figure 12A: ProTaper SX instrument (Dentsply/Maillefer) instrument is used to create more straightline radicular access

Figure 12B: Direct, straight-line access (arrows) into all three canals after removal of coronal restrictive dentin

Figure 14: Reproducible glide path confirmation. 14A: Size 10 K-File file is taken to full working length 14B: The size 10 K-file is withdrawn 4 mm to 5 mm and slide back to working length using light finger pressure

Guideline two: Negotiate canal to patency and create a reproducible glide path The authors prefer to negotiate the root canal with size 08 or 10 K-files until apical patency is established (Figure 13A). Apical patency is the ability to pass small K-files 0.5 mm - 1 mm passively through the apical constriction, beyond the minor diameter without widening it (Buchanan, 1989). Length determination was done using a Propex Pixi Apex Locator (Dentsply/ Maillefer). Predictable readings were achieved by using two size 10 K-files in the mesiobuccal and distobuccal root canals and a size 20 K-file in the larger palatal root canal and confirmed radiographically (Figure 13B). After working length determination, a reproducible glide path should be established. According to West (2010),

a glide path is a smooth passage that extends from the canal orifice in the pulp chamber to its opening at the root apex. Most authors recommend that the glide path should be the same size as, or ideally a size bigger, than the first rotary instrument that will be introduced into the root canal system (Berutti, et al., 2004; Varela-Patino, et al., 2005; Berutti, et al., 2009). It is recommended to use the stainless steel K-files in vertical in and out motion with an amplitude of 1 mm and gradually increasing the amplitude as the dentin wall wears away and the file advances apically (West, 2006). West (2010) recommends a â&#x20AC;&#x153;super looseâ&#x20AC;? size 10 K-file as the minimum requirement. To confirm that a reproducible glide path is present, the size 10 file is taken to full working length (Figure 14B). The file is then withdrawn 1 mm and should be able to slide back to working Volume 7 Number 1

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Figure 15A: PathFile No. 1 is taken to full working length

Figure 15B: PathFile No. 2 is taken to full working length

length by using light finger pressure. Thereafter, the file is withdrawn 2 mm and should be able to slide back to working length, using the same protocol. When the file can be withdrawn 4 mm to 5 mm and slide back to working length (Figure 14B), a reproducible glide path is confirmed (Van der Vyver, 2011). The reproducible glide path is then enlarged using rotary PathFiles (Dentsply/ Maillefer). (PathFiles™ are only available in North America through DENTSPLY Tulsa Dental Specialties.) PathFile No. 1 (0.13 mm tip size) is taken to full working length operating at 300 rpm and 5 N/cm torque (Figure 15A). As soon as the file reaches working length, the authors recommend to brush lightly outwards against one side of the canal wall. The file is pushed back to working length and brushed outward against another part of the canal wall. This procedure is repeated four times (touching the canal wall in a mesial, distal, buccal, and lingual direction). PathFile No. 2 (0.16 mm tip size) is used following the same protocol (Figure 15B). When using ProTaper Next, it is only necessary (in most cases) to enlarge the glide path to the second PathFile (0.16 mm) as the first preparation instrument, the X1 of the ProTaper Next system has a tip size of ISO 17. However, it is recommended to use PathFile No. 3 (0.19 mm tip size) when dealing with challenging root canal systems.

Guideline three: ProTaper Next preparation sequence ProTaper Next X1 (shaping instrument only) Introduce sodium hypochlorite and the 16 Endodontic practice

Figures 16A-16C: Preparation sequence for easy canals. 16A: ProTaper Next X1 (operating at 300 rpm and torque of 2.8N/cm) is slid down the glide path, and it is able to reach working length 16B: The instrument is pulled back to approximately 2 to 3 mm short of working length and a deliberate backstroke, outward brushing motion is incorporated (away from any external root concavities) to create more space in the coronal aspect of the root canal. 16C: Finally, the instrument is taken to full working length and a “touch-and-brush” sequence is done up to 3 to 4 times in order to complete canal preparation

Figures 17A-17C: Preparation sequence for more difficult or longer canals. 17A: Allow the ProTaper Next X1 to slide down the glide path until resistance is met. Incorporate a deliberate backstroke, outward brushing motion in order to remove restrictive dentin at this level. 17B: Increased lateral space will enable the file to slide a few more mm down the root canal toward working length and the brushing cycle is repeated. 17C: When the file reaches full working length, the “touch-and-brush” sequence is done 3 to 4 times to complete canal preparation

ProTaper Next X1 instrument into the root canal. The authors found that four scenarios can present itself when using ProTaper Next X1 instrument: 1. Easy root canals 2. More difficult and longer root canals 3. Very long/severely curved root canals 4. Larger diameter root canals and retreatment cases root canals where the use of ProTaper Next X1 is not necessary and canal preparation can be initiated with ProTaper Next X2, X3, X4, or X5. The last two scenarios will be discussed later in this article. For easy canals (mesiobuccal root canal in this case report), allow the ProTaper Next X1 instrument (operating at 300 rpm and torque of 2.8N/cm) to slide down the glide

path up to working length (Figure 16A). If this is possible, pull the instrument back to approximately 2-3 mm short of working length and incorporate a deliberate backstroke, outward brushing motion (away from any external root concavities) to create more space in the coronal aspect of the root canal (Figure 16B). Finally, take the file to full working length and “touch” the apex and brush outwards (coronally) with the file in the apical third of the root canal. This “touch-and-brush” sequence can be repeated up to 3 or 4 times (Figure 16C). For more difficult and longer canals (distobuccal root canal in this case report), allow the ProTaper Next X1 to slide down the glide path until resistance is met (Figure 17A). Incorporate a deliberate backstroke, outward brushing motion in order to remove Volume 7 Number 1

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Figure 18: Irrigation solution is deposited into the root canal before a patency file is used to dislodge any debris inside the root canal. Finally, the dislodged debris is flushed out with fresh irrigation solution

Figure 21A: Size 25/02 NiTi hand file is used to gauge the apical foramen of the prepared palatal root canal. In this case it was found that the 25/02 file was loose at length, and it could be pushed past working length (arrow)

Figure 21B: A size 30/02 NiTi hand file that fit snug at working length, confirmed that the shape is complete

restrictive dentin at this level (away from any external root concavities). This motion will create more lateral space, enabling the file to slide a few more millimeters down the root canal towards working length (Figure 17B) (if the file ceases to progress apically, remove the file, clean the flutes, irrigate, recapitulate, and re-irrigate the canal before you progress with the shaping procedure). The above procedure is repeated until the file reaches full working length. Finally, take the file to full working length (Figure 17C) and the “touch-and-brush” sequence is done 3 to 4 times in order to complete canal preparation. After the use of ProTaper Next X1, it is recommended to irrigate with sodium hypochlorite, recapitulate with a small patency file to dislodge cutting debris, and to re-irrigate to flush out all the dislodged Volume 7 Number 1

Figure 19: ProTaper Next X2 is taken to full working length. The apical part of the root canal is prepared by using the “touch-and-brush” sequence only 2 to 3 times with this instrument

Figure 22A: A 30/02 NiTi hand instrument fit tight and short of the full working length (arrow)

Figure 20: Size 25/02 NiTi hand file (Dentsply/Maillefer) is used to gauge the apical foramen of the prepared distobuccal root canal. Note that the file fits snug up to the full working length

Figure 22B: Continue shaping with a ProTaper Next X3 (30/07) to full working length

debris from the root canal (Figure 18).

ProTaper Next X2 (first finishing instrument) Use ProTaper Next X2 (25/06) to full working length, using the same protocol as previously described. However, it is recommended to use the “touch-andbrush” sequence in the apical part of the root canal only 2 to 3 times as a final step (Figure 19). Excessive “touch-and-brush” sequences in the apical part of the root canal can lead to transportation of the root canal. The root canal is again irrigated, recapitulated, and re-irrigated.

Gauging of apical foramen to determine if the preparation is complete Introduce a size 25/02 NiTi hand file

Figure 22C: Gauge again with a 30/02 NiTi hand instrument. If the instrument fits tight and at full working length, the shape is complete

(Dentsply/Maillefer) to full working length (Figure 20). If the file is snug at working length, it means that the apical foramen is prepared to a size ISO 25, and the canal is adequately shaped. The palatal root canal in the present case report was prepared with the ProTaper Next X1 and X2 according to the protocol previously outlined. In this case it was found that the 25/02 NiTi hand file was fitting loose at length, and it could be pushed past working length (Figure 21A) after canal preparation with the X2 instrument. This indicated that the apical foramen was still larger than 0.25 mm. In these situations, it is recommended to gauge the foramen with a size 30/02 NiTi hand file (Figure 21B). If the 30/02 file is snug at length, the shape is complete. If it is found that the 30/02 instrument fits tight, Endodontic practice 17

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Figure 23: Final result after obturation using the Calamus Dual Obturation Unit (Dentsply/Maillefer)

Figure 24: Preoperative radiograph of mandibular right first molar. Note the dentin triangle (arrow) preventing straight-line access into the mesial root canals

Figure 27A: ProTaper Next X1 (with outstroke brushing motion) is used to secure the coronal twothirds of the canal length

but short of the full working length (Figure 22A), it is recommended to continue canal preparation with the ProTaper Next X3 (30/07) (Figure 22B) and gauge again with the 30/02 NiTi hand instrument (Figure 22C).

Guideline four: Shaping recommendations for ProTaper Next X3, X4, and X5 ProTaper Next X3 (and X4 and X5 if necessary) is used in the same manner as ProTaper X1 or X2 with the exception that the apical preparation is done by using the “touch-and-brush” sequence only once or twice in the apical third of the root canal. Apical gauging is done according to the previously mentioned protocol using a size 30/02, 40/02, or 50/02 NiTi instruments. The 30/02 instrument was fitting snugly at working length in the palatal 18 Endodontic practice

Figure 25: Access cavity preparation after the tooth was restored with composite. Note the evidence of the dentin triangles on the mesial aspect of the canal orifices

Figure 27B: After irrigation, recapitulation and reirrigation sequence with sodium hypochlorite the ProTaper Next X2 is then used in the same manner to secure the canal to the same length

Figure 27C: ProTaper Next X1 is then used until the file can progress to full working length

root canal in the present case report. The canals were obturated with ProTaper Next X2 gutta-percha points in the mesiobuccal and distobuccal root canals and a ProTaper Next X3 gutta-percha point (Dentsply/Maillefer) in the palatal root canal as master cones using the Calamus® Dual Obturation Unit (Dentsply/Maillefer). Figure 23 demonstrates the final result after canal obturation.

Preparation sequence for very long and curved root canals In selected clinical cases, the clinician might find that ProTaper Next X1 does not progress to full working length even after a few coronal circumferential brushing motions. The authors then recommend to create more coronal shape by using ProTaper Next X1 followed by ProTaper Next X2 up to two-thirds of the canal

Figure 26: Length determination radiograph showing straight-line access of the K-files into all the root canal systems

Figure 27D: After irrigation, recapitulation and reirrigation, ProTaper Next X2 is thereafter taken to full working length

length. This preparation sequence will create enough lateral space in the coronal two-thirds of the root canal to ensure that ProTaper Next X1 can now be taken to full working length without any difficulty.

Case report The patient, a 50-year-old female, presents with pain on her mandibular rigth first molar with a history of a previous emergency root canal treatment. Clinical examination revealed a broken down and leaking temporary restoration possibly resulting in coronal leakage. A periapical radiograph revealed very long and curved mesial roots. Also visible on the radiograph was evidence of dentin triangles preventing straight-line access into the mesial root canals (Figure 24). The defective temporary restoration and caries were removed before the tooth Volume 7 Number 1

CLINICAL

Figure 28A: GuttaCore Figure 28B: Postoperative result verifiers are fitted to working after the canals were obturated length to confirm the size with GuttaCore obturators of obturators that will be used for obturation after the canals were prepared with ProTaper Next

was restored with composite and a new access cavity prepared. Note the evidence of dentin triangles on the mesial aspect of the canal orifices (Figure 25, arrows). The dentin triangles were removed with a ProTaper SX instrument, ensuring straightline access into all the root canals. Figure 26 shows the radiographic view of the length determination confirming straightline access into the root canals. As mentioned before, the clinical protocol for cases with very long and curved root canals would be to allow ProTaper Next X1 to progress to about two-thirds of the canal length (Figure 27A). This is followed by irrigation, recapitulation, and re-irrigation sequence with sodium hypochlorite. ProTaper Next X2 is then used in the same manner (with circumferential outstroke brushing motions) to the same length (Figure 27B). ProTaper Next X1 is then used again to progress with canal preparation to full working length (Figure 27C) using the â&#x20AC;&#x153;touch-and-brushâ&#x20AC;? sequence as described before. ProTaper Next X2 is then taken to full working length (using the same protocol as described before) (Figure 27D) after irrigation, recapitulation, and re-irrigation of the root canal. Canals were gauged according to the technique described before, and final preparation was done up to ProTaper Next X2 in the mesial root canals and up to ProTaper Next X3 in the distal root canal. GuttaCoreâ&#x201E;˘ verifiers were fitted (Figure 28A) to working length to confirm the size Volume 7 Number 1

Figure 29A: Preoperative radiograph of the maxillary right central incisor revealed a previously underfilled root canal treatment, and there was evidence of a large periapical area

Figure 30A: ProTaper Next X4 instrument taken to full working length

Figure 29B: Length determination, using a size 35 K-file

Figure 30B: Apical gauging with a 40/02 NiTi hand file revealed that the tip of the file was loose at length and able to travel past the predetermined working length

of obturators for each canal before the canals were obturated with corresponding GuttaCore obturators. Figure 28B shows the postoperative result after obturation.

Shaping recommendations for large diameter root canals or retreatment of root canals If the first file to working length is a size 20 K-file and it is loose up to working length, the shaping procedure can be initiated by using ProTaper Next X2 (25/06). If the first files to length are a size 25/30, 30/35, or 40/45, and they are found to be loose in the canal up to working length, the shaping procedure can be initiated with ProTaper Next X3 (30/07), X4 (40/06), and X5 (50/06) respectively.

Figure 30C: Apical gauging with a size 50/02 NiTi hand file was unable to reach full working length, penetrating to about 2 mm short of working length

Case report The patient, a 44-year-old female, presented with pain and discomfort on her maxillary right-central incisor. Radiographic examination revealed that the tooth was poorly root treated, and there was evidence of a large periapical area (Figure 29A). After removal of the previous gutta percha, it was possible to take a size 35 K-file to working length (Figure 29B). Root canal preparation was initiated by preparing the root canal to working length with the ProTaper Next X4 (40/06) instrument (Figure 30A). Apical gauging with a 40/02 NiTi hand file revealed that the tip of the file was loose at length and able to travel past the predetermined working length (Figure 30B) and that a size Endodontic practice 19

CLINICAL

Figure 31A: After irrigation, recapitulation, and re-irrigation, a ProTaper Next X5 was taken to full working length

50/02 NiTi hand file was unable to reach full working length, penetrating to about 2 mm short of working length (Figure 30C). This indicated that the apical foramen size was between 0.40 mm and 0.50 mm. The root canal preparation was enlarged with a ProTaper Next X5 (50/06) (Figure 31A) and gauged again with a 50/02 hand NiTi file (Figure 5F). It was found that the 50/02

References Arens FC, Hoen MM, Steiman HR, Dietz GC Jr. Evaluation of single-use rotary nickel-titanium instruments. J Endod. 2003;29(6):664-666. Berutti E, Cantatore G, Castellucci A, Chiandussi G, Pera F, Migliaretti G, Pasqualini D. Use of nickeltitanium rotary PathFile to create the glide path: comparison with manual preflaring in simulated root canals. J Endod. 2009;35(3):408-412. Berutti E, Chiandussi G, Gaviglio I, Abba A. Comparative analyses of torsional and bending stresses in two mathematical models of nickel-titanium rotary instruments: ProTaper vesus Profile. J Endod. 2003;29(1):15-19. Berutti E, Negro AR, Lendini M, Pasqualini D. Influence of manual preflaring and torque on the failure rate of ProTaper rotary instruments. J Endod. 2004;30(4):228230. Bird DC, Chambers D, Peters OA. Usage parameters of nickel-titanium rotary instruments: a survey of endodontics in the United States. J Endod. 2009;35(9):1193-1197. Blum JY, Cohen A, Machtou P, Micallef JP. Analysis of forces developed during mechanical preparation of extracted teeth using Profile NiTi rotary instruments. Int Endod J. 1999;32(1):24-31. Chen JL, Messer HH. A comparison of stainless steel hand and rotary nickel-titanium instrumentation using a silicone impression technique. Aust Dent J. 2002;47(1):12-20. Glossen CR, Haller RH, Dove SB, del Rio CE. A comparison of root canal preparations using Ni-Ti

20 Endodontic practice

Figure 31B: Apical gauging with a size 50/02 nickel-titanium hand file. The file was snug at working length

Figure 31C: Postoperative result after the root canal obturation

instrument fitted snug at working length (Figure 31B) indicated that the shape was complete. The prepared canal was obturated with a ProTaper Next X5 guttapercha point (Dentsply/Maillefer) using Calamus Dual Obturation Unit (Dentsply/ Maillefer). Figure 31C shows the final result after obturation.

hand, Ni-Ti engine-driven, and K-Flex endodontic instruments. J Endod. 1995;21(3):146-151. Gutmann JL, Gao Y. Alteration in the inherent metallic and surface properties of nickel-titanium root canal instruments to enhance performance, durability and safety: a focused review. Int Endod J. 2012;45(2):113128. 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 rotary instruments. J Endod. 2008;34(11):1406-1409. Kim HC, Kwak SW, Cheung GS, Ko DH, Chung SM, Lee W. Cyclic fatigue and torsional resistance of two new nickel-titanium instruments used in reciprocation motion: Reciproc versus WaveOne. J Endod. 2012;38(4):541-544. Parashos P, Messer HH. Rotary NiTi instrument fracture and its consequences. J Endod. 2006;32(11):10311043. Peters OA. Current challenges and concepts in the preparation of root canal systems: a review. J Endod. 2004;30(8):559-567. Ruddle CJ. The ProTaper endodontic system: geometries, features, and guidelines for use. Dent Today. 2001;20(10):60-67. Ruddle CJ, Machtou P, West JD. The shaping movement: fifth-generation technology. Dent Today. 2013;32(4):94, 96-99.

Part 2 of this series will discuss the management of complex root canal systems with the ProTaper Next system (Dentsply/Maillefer). EP

Scianamblo MJ, inventor. Endodontic instruments for preparing endodontic cavity spaces. US patent 6942484, 7094056, 7955078 and 20060228669. May 20, 2011. Short JA, Morgan LA, Baumgartner JC. A comparison of canal centering ability of four instrumentation techniques. J Endod. 1997;23(8):503-507. Van der Vyver PJ. Creating a glide path for rotary NiTi instruments: Part one. Endodontic Practice. 2011;14(1)40-43. Patiño PV, Biedma BM, Liébana CR, Cantatore G, Bahillo J. The influence of a manual glide path on the separation rate of NiTi rotary instruments. J Endod. 2005;31(2):114-116. Walia HM, Brantley WA, Gerstein H. An initial investigation of the bending and torsional properties of Nitinol root canal files. J Endod. 1988;14(7):346-351. West JD. Introduction of a new rotary endodontic system: progressively tapering files. Dent Today. 2001;20(5):50-52, 54-57. West J. Endodontic update 2006. J Esthet Restor Dent. 2006;18(5):280-300. West JD. The endodontic Glidepath: “Secret to rotary safety”. Dent Today. 2010;29(9):86, 88, 90-93. Yun HH, Kim SK. A comparison of the shaping abilities of 4 nickel-titanium rotary instruments in simulated root canals. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2003;95(2):228-233.

Sattapan B, Nervo GJ, Palamara JF, Messer HH. Defects in rotary nickel-titanium files after clinical use. J Endod. 2000;26(3):161-165.

Volume 7 Number 1

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WHAT IF I had hundreds of world-class endodontists mentoring me daily, helping me to become more successful? WHAT IF my patients recognized immediately that my practice was centered around quality?

CLINICAL

BT-Race — Biologic and conservative root canal instrumentation with the final restoration in mind Drs. Gilberto Debelian and Martin Trope explore the BT-Race system

ntracanal microbes are the cause of endodontic disease.1-3 The prevention or removal of microbes from the root canal system during treatment is the factor that determines if the treatment will be successful or not.4-5 Root canal instrumentation is one of the major tools to ensure the long-term success of root canal therapy.6-7 The aim is to mechanically disrupt as much biofilm as possible so that with the addition of irrigants and/or intra-canal medicaments, a very low microbial count can consistently be achieved before root canal filling. Another aim/challenge of root canal instrumentation is to achieve the microbial reduction goals previously mentioned without unnecessarily weakening the root by over-instrumentation, i.e., reduction of the dentin wall thickness. Preservation of native tooth structure, especially in the cervical region of the tooth, has been demonstrated to correspond to better long-term survivability from a loading and

restorative standpoint. It is well established that as the remaining dentin thickness decreases, so the root decreases in its resistance to fracture.8

What is the ideal root canal instrumentation size? The axiom: The file alone does not remove the maximum amount of biofilm but works with irrigation in a synergistic effect with the file. The key question is, What is the ideal instrumentation size to achieve the desired goal of biofilm elimination? In order to answer this question, we need to analyze anatomical studies and evaluate whether and how it is possible to remove biofilm from these canals. When evaluating the anatomical studies, it is interesting to note how consistent they are! (Figure 1) best summarizes the anatomical aims for a mandibular molar. First, let’s look at the mesio-buccal and mesio-lingual canals at the 1 mm

Gilberto Debelian, DMD, PhD, received his DMD degree from the University of Sao Paulo, Brazil, in 1987. He completed his specialization in Endodontics from the University of Pennsylvania, School of Dental Medicine, in 1991.He has taught as a clinical instructor and associate professor at the post-doctoral endodontic program at the Department of Endodontics, University of Oslo, Norway, from 1991 to 2001, and from 2006 to 2010. He concluded his PhD studies at the University of Oslo, Norway, in 1997 on endodontic microbiology. He is an adjunct visiting professor at the post-graduate program in endodontics, University of North Carolina in Chapel Hill, and University of Pennsylvania in Philadelphia. Dr. Debelian maintains a private practice limited to endodontics as well as an advanced endodontic microscopy center, EndoInn, in Bekkestua, Norway. He is an author of books and 50 scientific and clinical papers and is currently a member of the scientific advisory panel for the Journal of Endodontics and Endodontic Practice Today, director of the Oslo Endodontic Study Club, and the vice-president of the Norwegian Endodontic Society. Martin Trope, BDS, was born in Johannesburg, South Africa, where he received his BDS degree in dentistry in 1976. From 1976 to 1980, he practiced general dentistry and endodontics. In 1980, he moved to Philadelphia to specialize in endodontics at the University of Pennsylvania. After graduating as an endodontist, he continued at the University of Pennsylvania as a faculty member until 1989 when he became Chair of Endodontology at Temple University, School of Dentistry. In 1993, he accepted the JB Freedland Professorship in the Department of Endodontics at the University of North Carolina at Chapel Hill, School of Dentistry. Dr. Trope is now Clinical Professor, Department of Endodontics, School of Dental Medicine, University of Pennsylvania. He is also in private practice in Philadelphia, PA. He has served as a Director of the American Board of Endodontics. Before entering full-time private practice, he was editor-in-chief of two journals, Dental Traumatology and Endodontic Topics. He also serves on the Editorial Board of Oral Surgery, Oral Medicine, Oral Pathology and on the Advisory Board of Esthetic Dentistry. His work has been published in numerous journals and book chapters. In April 2002, he was awarded The Louis I. Grossman Award for cumulative publication of significant research by the American Association of Endodontists. Both authors maintain full-time private endodontic specialty practices while serving as consultants to various manufactures, including the manufacturer of the BT Race file system.

22 Endodontic practice

Figure 1

measurement from the apical foramen, which corresponds most closely to the dentino-cemental junction. In the mesialdistal direction, the diameters are 0.21 and 0.28, respectively. Thus, finishing at a No. 25 file would appear to be sufficient when viewed with a periapical radiograph since the mesio-distal direction is what we see on the radiograph. However, if we look at the bucco-lingual direction, the correct sizes are between No. 35 and No. 40! For the distal canal, a No. 35 would look adequate on the radiograph (mesio-distal view), but the correct size would be No. 50. Thus, we might take a popular saying from our colleagues who advocate thermoplastic obturation: “If we want to clean in three dimensions, we need to instrument in the bucco/lingual dimension also.” Just as important, if we look at the measurements at 2 mm and 5 mm from the end of the root, it is apparent that if we in fact do instrument to the apical sizes required (No. 35 or No. 40 mesial and No. 50 distal), then a 0.04 taper is all that is needed to contact the walls in these areas farther from the apex. Using tapers larger than 0.04 is not required to remove microbes and unnecessarily weakens the root. Anatomical studies of all roots follow this basic biological rule; i.e., No. 35 or No. 40 for the “smaller” canals and No. 50 for the “larger” canals.9-11 Volume 7 Number 1

CLINICAL

Figure 2

Figure 5

Ideal shape for an instrumented canal? Adequate biological sizes with minimal taper with the least number of files Thus, in order to achieve the aims stated above, i.e., maximal biofilm disruption with minimal weakening of the root, we should aim for No. 35, No. 40, or No. 50 apical sizes with no more that 0.04 taper.9-11 These biological sizes with the addition of an adequate irrigation protocol will ensure a consistently low microbial count to ensure maximal success.

BT-Race system â&#x20AC;&#x201D; biologic and conservative BT-Race files (Brasseler USA) are sterilized in individual blisters so that sterility is ensured for every file. (Figure 2) The biologic sizes mentioned previously can be achieved in three files every time after a glide path is achieved. The system is designed so that these sizes are attained with minimal removal of unnecessary dentin coronally so as to maintain the strength of the root. The BT-Race file has a non-screw-in design, triangular cross section to increase Volume 7 Number 1

Figure 3

Figure 6: BT1 - 10/0.06, BT2 - 35/0.00, and BT3 35/0.04

flexibility and cutting efficiency and is electro-polished to decrease the effects of torsional and cyclic fatigue. (Figure 3) Booster Tip (BT) The booster tip is the key feature of these files that allows them to follow curvatures in canals without undue stress on the file or the root. The Booster Tip files start as a non-cutting tip from 0 mm to 0.17 mm diameter, and the cutting edges start from 0.17 mm and upward on the file. This allows these files to safely follow a canal even with a very narrow diameter. The final size of the file is achieved within 0.5 mm of the tip. Thus, for example, the BT2 (see Figure 4), which is a non-tapered file with a cutting size of 0.35 mm, can still easily advance into the canal prepared by the glide path file, which is 0.15mm in diameter. The booster tip allows a file of any diameter to follow the shape of a canal that has been prepared with a No. 15 glide path stainless-steel file. However, the protocol of three files (see Figure 5) is designed to relieve undue stress on the root and files while instrumenting the canal to biologically accepted sizes.

Figure 4

Figure 7: BT-Race XL - BT40/0.04 and BT 50/0.04 (600800 RPM). These two instruments enable finishes at ISO No. 40 and No. 50 when adequate apical sizes require larger sizes. If even larger apical preparations than ISO No. 50 are required, use the Race range of instruments to the required sizes, preferable with small taper 0.02.

Essentials for successful use of the BT-Race sequence 1. Glide path. In order to guarantee a minimal number of file breakages, a glide path to No. 15/0.02 taper is essential. Hand files can usually achieve this aim. However if a No. 6 or No. 10 is extremely difficult to get to working length, then ScoutRace files (Brasseler USA) allow endodontists to achieve this requirement more quickly. 2. Speed of 800â&#x20AC;&#x201C;1000 RPM A high speed reduces the risk of breakage due to torsional fatigue, and since these files are for single-patient use only, the chances of breakage from cyclic fatigue is also reduced. Thus, by using high speed and limiting the number of usages to one, we are limiting the chances of breakage of these files. BT1 â&#x20AC;&#x201C; 10/0.06 This file establishes the final glide path and determines the coronal diameter. In any canal in which a No. 15/0.02 glide path has been achieved, the file will contact mainly the coronal third of the canal. At 12 mm Endodontic practice 23

CLINICAL

Figure 8

Figure 9

Figure 10

Figure 11

from the working length, the diameter will be 0.82 mm. These files have no booster tip since the tip diameter is already 0.10 mm and smaller than the glide path established with a K-File No. 15/0.02. BT2 – parallel No. 35 file with Booster Tip The BT2 file is used to prepare the apical third of the canal. The file is extremely flexible due to its non-tapered design and yet easily and efficiently penetrates into the narrow canal due to the BT Tip. BT3 - No. 35/0.04 with Booster Tip This file is used to join the coronal and apical preparations created by the BT1 and

References 1. Kakehashi S, Stanley HR, Fitzgerald RJ. The effects of surgical exposures of dental pulps in germ-free and conventional laboratory rats. Oral Surg Oral Med Oral Pathol. 1965;20:340-349. 2. Bergenholtz G. Micro-organisms from necrotic pulp of traumatized teeth. Odontol Revy. 1974;25(4):347358. 3. Möller AJ, Fabricius L, Dahlén G, Ohman AE, Heyden G. Influence on periapical tissues of indigenous oral bacteria and necrotic pulp tissue in monkeys. Scand J Dent Res. 1981;89(6):475-484. 4. Sjögren U, Figdor D, Persson S, Sundqvist G. Influence of infection at the time of root filling on the

24 Endodontic practice

BT2 and thus create a No. 35/0.04 final shape that allows maximal irrigation and a tight-fitting cone fit. The file is able to get to working length with minimal stress since the coronal has been cleared by BT1 and the apical cleared with BT2 file. Importantly, in this canal the maximum diameter at the 12 mm level is 0.83 mm. Thus, the removal of coronal dentin is minimal allowing for the strongest root possible after restoration.

Conclusion With this unique file system, all canals can be conservatively instrumented to the correct biological sizes while maintaining maximum cervical tooth structure that

remains following instrumentation. The booster tip ensures that the original canal shape is maintained, thus, keeping even the larger files centered in the canal. With this centering advantage, in addition to the minimal taper required to achieve these biologic sizes, the canal is maximally cleaned without weakening or stressing the root. Case studies Note that these cases fulfill the objective of biologic apical sizes with conservative coronal removal of dentin. Thus, they have a high probability of endodontic success and survivability. EP

outcome of endodontic treatment of teeth with apical periodontitis. Int Endod J. 1997;30(5):297-306.

fracture of restored endodontically treated teeth. Endod Dent Traumatol. 1985;1(3):108-111.

5. Waltimo T, Trope M, Haapasalo M, Ørstavik D. Clinical efficacy of treatment procedures in endodontic infection control and one year follow-up of periapical healing. J Endod. 2005;31(12):863-866.

9. Vertucci FJ. Root canal morphology and its relationship to endodontic procedures. Endod Topics. 2005;89(6):3-29.

6. Dalton BC, Orstavik D, Phillips C, Pettiette M, Trope M. Bacterial reduction with nickel titanium rotary instrumentation. J Endod. 1998;24(11):763-767. 7. Shuping GB, Orstavik D, Sigurdsson A, Trope M. Reduction of intracanal bacteria using nickel-titanium rotary instrumentation and various medications. J Endod. 2000;26(12):751-755. 8. Trope M, Maltz DO, Tronstad L. Resistance to

10. Wu MK, R’oris A, Barkis D, Wesselink PR. Prevalence and extent of long oval canals in the apical third. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2000;89(6):739-743. 11. Villas-Bôas MH, Bernardineli N, Cavenago BC, Marciano M, Del Carpio-Perochena A, de Moraes IG, Duarte MH, Bramante CM, Ordinola-Zapata R. Microcomputed tomography study of the internal anatomy of mesial roots of mandibular molars. J Endod. 2011;37(12):1682-1686.

Volume 7 Number 1

Drs. David Keinan and Eugene A. Pantera Jr. solve a common endodontic problem in a conservative way Abstract This article presents a case demonstrating a new and conservative approach for bleaching anterior teeth with yellowishbrown discoloration secondary to pulp chamber calcification. There was also no response to cold stimulation, and the periodontal ligament was radiographically continuous and normal in width. The patient preferred to avoid the option of external bleaching or tooth preparation for laminate veneer. The presented technique offers a comparatively conservative approach in the treatment of anterior tooth discoloration associated with pulp chamber obliteration. The esthetic results are consistent with non-vital tooth internal bleaching; yet pre-bleaching root canal treatment is not requested.

Introduction Internal bleaching is a well-known commonly used clinical procedure for the treatment of discoloration of endodontically treated anterior teeth (Rotstein, Zalkind, et al., 1991; Amato, Scaravilli, et al., 2006). However, it is not uncommon to have a discolored vital anterior tooth due to pulp chamber calcification (Abbott and Heah, 2009). This pulp chamber calcification is caused by excessive dentin apposition by the odontoblasts that may be accelerated because of trauma to the tooth (Abbott and Heah, 2009). Consequently, there is a decrease in the translucency of the tooth resulting in a yellowing to dark discoloration (Abbott, 1997). There are several approaches to deal with this esthetic problem. The common and often most predictable technique involves tooth preparation for a laminate

David Keinan, DMD, PhD, is in the Department of Endodontics, Medical Corps, Tel Hashomer Hospital, Ramat-Gan, Israel. Eugene A. Pantera Jr., DDS, MS, is in the Department of Periodontics and Endodontics, School of Dental Medicine, University at Buffalo, the State University of New York, Buffalo, New York.

Volume 7 Number 1

Figures 1A and 1B: Pre-treatment radiograph (1A) of the maxillary left central incisor with an obliterated pulp chamber, and 1-year recall radiograph (1B) following conservative coronal bleaching treatment

veneer or full porcelain crown (Chen and Raigrodski, 2008; Jun and Wilson, 2008; Sadighpour, Geramipanah, et al., 2009; Freire and Archegas 2010; Alghazzawi, Lemons, et al., 2012; Beier, Kapferer, et al., 2012). However, these options result in irreversible removal of tooth structure and may present barriers in expense and esthetics. Using external vital tooth bleaching procedure for color change secondary to a calcified pulp chamber has limited efficacy. External bleaching techniques involve the use of a customized mouth tray with carbamide peroxide gels as the bleaching medium (Fasanaro 1992; Haywood 1992; Haywood 1992; Kielbassa, Attin, et al., 1995; Attin, Paque, et al., 2003). External bleaching of a single tooth is carried out by using 20% carbamide peroxide gel for a period of 4 to 6 weeks or until the single tooth matches all the adjacent teeth. The technique requires modifying the bleaching tray in order to make space for the bleaching agent and limit its action to the discolored tooth. The high success rate and simplicity of non-vital tooth bleaching technique requires endodontic treatment prior to

initiating internal bleaching (Rotstein, Zalkind, et al., 1991; Amato, Scaravilli, et al., 2006). This approach is also used to reduce tetracycline and other sources of discoloration (Abou-Rass 1982). However, this method for bleaching of a tooth with a calcified pulp chamber has two main disadvantages. First, the endodontic treatment can be a costly procedure as well as being irreversible. Second, since there is calcific metamorphosis, there is a risk for crown or root perforation while trying to find or negotiate the calcified canal space. The presented case report offers a conservative approach for treating discoloration due to pulp chamber obliteration. This approach may reduce the amount of unnecessary laminate veneers or root canal treatments performed before internal bleaching in refractory cases to external bleaching.

Case report A 35-year-old man complained about discoloration of his maxillary left central incisor (Figure 1A). The patient did not report pain or sensitivity to temperature changes or percussion. Radiographic examination Endodontic practice 25

CLINICAL

A conservative approach for internal bleaching of a vital anterior tooth with calcified pulp chamber

CLINICAL

Figures 2A and 2B: Pre- (2A) and post- (2B) coronal bleaching photographs of the maxillary left central incisor

Figures 3A and 3B: Three-year follow-up photo (3A) and radiograph (3B) showing clinically and radiographically satisfying results.

revealed complete calcification of the pulp chamber and the root canal space. The periodontal ligament was continuous with no widening, and the lamina dura appeared normal (Figure 2A). At the first visit, the tooth was isolated by using a rubber dam (Hygenic®, Coltène®/Whaledent) and an access cavity was designed similar to a normal pulp chamber to the level of the cementalenamel junction. This step was performed without anesthesia in order to get feedback from the patient for the possibility of neural fibers within a microscopic canal. A resin modified glass ionomer (RMGI) liner (3M™ ESPE™ Vitrebond™ Light Cure Glass Ionomer Liner/Base, VB) was lined over the calcified canal orifice. A mixture of sodium perborate (SP) was inserted as the common protocol for internal bleaching. A week later, on the second visit, there was major color change, and the bleaching process was repeated again. In the final visit, the color change satisfied the patient (Figure 2B), the SP was flushed out, and a temporary restoration with a zinc oxide-calcium sulfate premixed material (Coltosol®, Colten, Langenau, Germany) was placed. The patient was referred to his dentist for placement of a permanent restoration. The patient presented after 1 year to a follow-up examination with no symptoms, and the recall radiograph revealed a continuous PDL (Figure 1B). The last follow-up examination, 3 years after treatment, also revealed no symptoms, color satisfaction (Figure 3A), and the same conical root with continuous PDL (Figure 3B). 26 Endodontic practice

Discussion The presented technique recommends a relatively conservative approach in cases with vital tooth discoloration due to pulp chamber obliteration that did not respond to external bleaching. Clinically, as in the presented cases, it is not uncommon to see some color improvement after the first step of making an access cavity. This may be attributed to improving some of the tooth transparency that was reduced by the dentin apposition (Abbott, 1997). We recommend offering the patient trying external bleaching first since it does not involve any tooth preparation. The patient should also be informed about the limited possibility to predict the effect of external bleaching in those cases. The presented bleaching option should be carefully selected for asymptomatic cases with pulp chamber calcification. When using the technique previously described, the patient should be informed about the risk of irritating the remaining pulp tissue in the canal, yet it is minimal for several reasons. First, H2O2 is synthesized by the human body itself as a mean of defense (McKenna and Davies, 1988); second, the GIC lining on the access cavity floor prevents H2O2 penetrating the canal. Furthermore, even during external bleaching, a small amount of H2O2 penetrates into the pulp chamber (Bowles and Ugwuneri, 1987). Third, when the favorable prognosis of external vital tooth bleaching is weighed against minimal risk of irritating the pulp, it can be assumed that even if small amount of H2O2 penetrates the GIC barrier, it would have minimal influence; and finally, if there are signs of pulpal dis-

ease, then endodontic treatment should be performed as is done with the less conservative non-vital bleaching technique. Sodium perborate (SP) has been widely used to bleach non-vital teeth with predictable results (Amato, Scaravilli, et al., 2006). The bleaching agent releases active oxygen radicals inside the pulp chamber where it diffuses into the dentinal tubules (Kawamoto and Tsujimoto, 2004). It oxidizes and bleaches the iron sulfide and other pigments present in the dentinal tubules (Attin, Paque, et al., 2003). Free radicals can cause oxidative effects to lipids, proteins, and nucleic acids (Floyd 1997; Park and Floyd, 1997; Kwon, Lee, et al., 1998). Although free radicals are suspected of being mutagenic and carcinogenic (Attin, Paque, et al., 2003), this risk is mitigated with appropriate use of H2O2 during (Rotstein, Zyskind, et al., 1992; Steiner and West, 1994) and after (Li, Sole, et al., 1998) bleaching therapy. Yet, since sensitivity increases with age, high concentrations of H2O2 or extended contact of H2O2 with tissues (Floyd and Carney, 1992; Smith, Carney, et al., 1992; Stadtman, Starke-Reed, et al., 1992; Li, Yan, et al., 1998) should be avoided. Care should be taken to minimize the number of times SP is refreshed as well in order to decrease risk of coronal fracture (Tam, Kuo, et al., 2007; Azevedo, Silva-Sousa, et al., 2011). The recommended clinical steps for our modified technique include: 1. Access cavity preparation in the pulp chamber without entering the canal. 2. Sealing the floor of the access cavity with glass ionomer cement. 3. Applying sodium perborate mixed with saline. 4. Placing an intermediate restoration for 4-7 days. This procedure may be repeated several times (2-5), while laminate veneers should be considered for refractory cases. Additionally, this treatment may be followed by external bleaching with carbamide peroxide, especially in cases of persistent discoloration due to external layer stain (West, 1997). Included in any informed consent regarding bleaching procedures is the need to inform the patient of possibility of requiring endodontic treatment if symptoms of pulpal disease develop. EP

Volume 7 Number 1

Esthet Dent. 1992;4(3):71-78.

Abbott P, Heah SY. Internal bleaching of teeth: an analysis of 255 teeth. Aust Dent J. 2009;54(4)326-333.

Floyd RA. The effect of peroxides and free radicals on body tissues. J Am Dent Assoc. 1997;128(suppl):37S40S.

Abbott PV. Aesthetic considerations in endodontics: internal bleaching. Pract Periodontics Aesthet Dent. 1997;9(7):833-840, 842.

Floyd RA, Carney JM. Free radical damage to protein and DNA: mechanisms involved and relevant observations on brain undergoing oxidative stress. Ann Neurol. 1992;32(suppl):S22-27.

Abou-Rass M. The elimination of tetracycline discoloration by intentional endodontics and internal bleaching. J Endod. 1982;8(3):101-106.

Freire A, Archegas LR (2010) Porcelain laminate veneer on a highly discoloured tooth: a case report. J Can Dent Assoc. 2010;76:a126.

Alghazzawi TF, Lemons J, Liu PR, Essig ME, Janowski GM. Evaluation of the optical properties of CAD-CAM generated yttria-stabilized zirconia and glass-ceramic laminate veneers. J Prosthet Dent. 2012;107(5)300308.

Haywood VB. Bleaching of vital and nonvital teeth. Curr Opin Dent. 1992;2:142-149. Haywood VB. History, safety, and effectiveness of current bleaching techniques and applications of the nightguard vital bleaching technique. Quintessence Int. 1992;23(7):471-488.

Amato M, Scaravilli MS, Farella M, Riccitiello F. Bleaching teeth treated endodontically: long-term evaluation of a case series. J Endod. 2006;32(4):376378.

Jun SK, Wilson S. Restoration of severely discolored maxillary anterior teeth with porcelain laminate veneers. Pract Proced Aesthet Dent. 2008;20(5):285287.

Attin T, PaquĂŠ F, Ajam F, Lennon AM. Review of the current status of tooth whitening with the walking bleach technique. Int Endod J. 2003;36(5):313-329. Azevedo RA, Silva-Sousa YT, Souza-Gabriel AE, Messias DC, Alfredo E, Silva RG. Fracture resistance of teeth subjected to internal bleaching and restored with different procedures. Braz Dent J. 2011;22(2):117121.

Kawamoto K, Tsujimoto Y. Effects of the hydroxyl radical and hydrogen peroxide on tooth bleaching. J Endod. 2004;30(1):45-50. Kielbassa AM, Attin T, Schaller HG, Hellwig E. Endodontic therapy in a postirradiated child: review of the literature and report of a case. Quintessence Int. 1995;26(6):405-411.

Beier US, Kapferer I, Burtscher D, Dumfahrt H. Clinical performance of porcelain laminate veneers for up to 20 years. Int J Prosthodont. 2012;25(1):79-85. Bowles WH, Ugwuneri Z. Pulp chamber penetration by hydrogen peroxide following vital bleaching procedures. J Endod. 1987;13(8):375-377.

Kwon OJ, Lee SM, Floyd RA, Park JW. Thioldependent metal-catalyzed oxidation of copper, zinc superoxide dismutase. Biochim Biophys Acta. 1998;1387(1-2):249-256.

Chen YW, Raigrodski AJ. A conservative approach for treating young adult patients with porcelain laminate veneers. J Esthet Restor Dent. 2008;20(4):223-236, 237-228.

Li RK, Sole MJ, Mickle DA, Schimmer J, Goldstein D. Vitamin E and oxidative stress in the heart of the cardiomyopathic syrian hamster. Free Radic Biol Med. 1998;24(2):252-258.

Fasanaro TS. Bleaching teeth: history, chemicals, and methods used for common tooth discolorations. J

Li Y, Yan Q, Pendergrass WR, Wolf NS. Response of lens epithelial cells to hydrogen peroxide stress and

the protective effect of caloric restriction. Exp Cell Res. 1998;239(2):254-263. McKenna SM, Davies KJ. Bacterial killing by phagocytes: potential role(s) of hypochlorous acid and hydrogen peroxide in protein turnover, DNA synthesis, and RNA synthesis. Basic Life Sci. 1988;49:829-832. Park JW, Floyd RA. Glutathione/Fe3+/O2-mediated DNA strand breaks and 8-hydroxydeoxyguanosine formation. Enhancement by copper, zinc superoxide dismutase. Biochim Biophys Acta. 1997;1336(2):263268. Rotstein I, Zalkind M, Mor C, Tarabeah A, Friedman S. In vitro efficacy of sodium perborate preparations used for intracoronal bleaching of discolored non-vital teeth. Endod Dent Traumatol. 1991;7(4):177-180. Rotstein I, Zyskind D, Lewinstein I, Bamberger N. Effect of different protective base materials on hydrogen peroxide leakage during intracoronal bleaching in vitro. J Endod. 1992;18(3):114-117. Sadighpour L, Geramipanah F, Nikzad S. Fixed rehabilitation of an ACP PDI class III patient with amelogenesis imperfecta. J Prosthodont. 2009;18(1):64-70. Smith CD, Carney JM, Tatsumo T, Stadtman ER, Floyd RA, Markesbery WR. Protein oxidation in aging brain. Ann N Y Acad Sci. 1992;663:110-119. Stadtman ER, Starke-Reed PE, Oliver CN, Carney JM, Floyd RA. Protein modification in aging. EXS. 1992;62:64-72. Steiner DR, West JD. A method to determine the location and shape of an intracoronal bleach barrier. J Endod. 1994;20(6):304-306. Tam LE, Kuo VY, Noroozi A. Effect of prolonged direct and indirect peroxide bleaching on fracture toughness of human dentin. J Esthet Restor Dent. 2007;19(2):100-109, 110. West JD. The aesthetic and endodontic dilemmas of calcific metamorphosis. Pract Periodontics Aesthet Dent. 1997;9(3):289-293, 294.

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Endodontic practice 27

CLINICAL

References

CONTINUING EDUCATION

The importance of a reproducible glide path Drs. Yosef Nahmias, Imran Cassim, and Gary Glassman discuss how rotary and reciprocating instruments that follow a designated route will result in more successful outcomes and minimal iatrogenic mishaps

he principles of three-dimensional cleaning, shaping, and obturation of the root canal system, which are the foundations for predictable endodontic success, were outlined by Schilder over 4 decades ago and remain pertinent even with all the technological advances that have been made since the turn of the 21st century (Schilder, 1967; Schilder, 1974). The preparation of the root canal system remains one of the most difficult tasks in endodontic treatment (Hülsmann, Peters, Dummer, 2005) due to the complex anatomy of root canals, with their irregular, non-circular cross sections, multiplanar curves, bifurcations, trifurcations, fins, vagaries, and cul-de-sacs (Figures 1 and 2). They often present extreme challenges to clinicians who aim to create a conservative, predictable shape conducive to three-dimensional obturation and a sound restoration. It does not take much to lose control of the root canal space with subsequent iatrogenic mishaps, such as apical ledges or the packing of dentinal debris; both of which may jeopardize apical patency. Additionally, canal transportation can undesirably alter the diameter and special position of the apical foramen, as well as the working length, thereby adversely affecting the apical seal (Wu, Fan, Wesselink, 2000) and potentially

Educational aims and objectives This clinical article aims to explain how a reproducible glide path can reduce iatrogenic mishaps and achieve more successful outcomes. Expected outcomes Correctly answering the questions on page 33, worth 2 hours of CE, will demonstrate you can: • Identify “glide path” as explained by various clinicians. • Realize that the incorporation of modern mechanized files into the instrumentation protocol will help achieve a reproducible glide path.

Figure 1: Complex root canal anatomy

Figure 2: Maxillary first molar anatomy

Yosef Nahmias, DDS, MSc, was born and raised in Mexico City. After he had graduated from the Universidad Tecnologica de Mexico, School of Dentistry, in 1980 with a degree in dentistry, he decided to advance his education and chose endodontics as his specialty. He earned his Master of Science degree in 1983. Dr. Nahmias has authored and published many articles. He lectures in Canada, Mexico, and across South America. Dr. Nahmias resides in Toronto, Ontario, and has maintained a private practice specializing in endodontics in Oakville, Ontario, since 1983. Imran Cassim, BDS, WITS, PG Dip Dent Endo (Cum Laude), qualified with a BDS degree from University Of Witwatersrand in South Africa in 1999. He attained distinctions in physiology, pharmacology, and anesthetics during his undergraduate study. In 2009, he completed his postgraduate diploma in endodontics at University of Pretoria in South Africa, with distinctions in oral biology and endodontics. Dr. Cassim is currently studying part-time toward an MSc in Endodontics at University of Pretoria, and in private practice focusing mainly on endodontics and restorative dentistry in Durban, South Africa. Gary Glassman, DDS, FRCD(C), graduated from the University of Toronto, Faculty of Dentistry in 1984 and was awarded the James B Willmott Scholarship, the Mosby Scholarship, and the George Hare Endodontic Scholarship for proficiency in Endodontics. A graduate of the endodontology program at Temple University in 1987, he received the Louis I. Grossman Study Club Award for academic and clinical proficiency in Endodontics. Dr. Glassman lectures globally on endodontics and has authored numerous publications. He maintains a private practice, Endodontic Specialists in Toronto, Ontario, Canada.

28 Endodontic practice

causing irritation to the periapical tissues by extruded irrigants and irritants (Schäfer, Dammaschke, 2009). Mounce (2004) outlined certain “sound principles” that must be adhered to before treatment. These include a comprehensive appraisal of the tooth being treated, canal numbers, location, length, curvatures at all levels, the presence of calcifications, anomalous anatomy, access difficulties, and so on. Superior illumination and magnification, an adequate well-designed access, good irrigation techniques, and re-capitulation are all essential ingredients to gaining control over the canal being treated. Volume 7 Number 1

One guiding strategy that has also emerged as a critical part of endodontic success, especially when using rotary nickel-titanium files, is the creation and maintenance of a glide path. This is necessary because many available nickel-titanium rotary instruments for shaping canals have non-end cutting tips (Peters, Paqué, 2010) and because of their extreme flexibility are not designed for initial negotiation of the root canal (Young, Parashos, Messer, 2007). It has been demonstrated that the risk of instrument fracture can be reduced by first performing coronal enlargement of the root canal (Roland, et al., 2002; Peters, et al., 2003). Blum, et al., (2003) suggested that a glide path be initially created with small flexible stainless steel hand files to create or verify that within any portion of

instruments must “follow,” not create, the pathway of the canal. John West (2006) defined the glide path as a smooth, though possibly narrow, tunnel or passage from the orifice of the canal to the radiographic terminus or electronic portal of exit, and noted that a glide path is achieved when the file forming it can enter from the orifice and follow the smooth canal walls uninterrupted to the terminus. Once this is achieved, that “path” is much more likely to be maintained with the larger rotary nickel-titanium instruments. However, it has also been observed that the use of stainless-steel instruments to create this glide path can be problematic (Berutti, et al., 2009; Pasqualini, et al., 2012). Because of the relative stiffness of stainless steel, there is the risk of canal transportation, which may lead to perforation, ledging, or

handpiece. It must be emphasized that these instruments should not be taken into the canal, until a No. 10 stainless-steel hand file goes easily to length. To get to that point, stainless-steel hand files should be used to initially negotiate the canal space to achieve working length with the No. 6, No. 8, and No. 10 K-files. These files should be stiff, cut well, and be used only once, ideally. This part of the procedure can be made more efficient with the use of the M4 Saftey® Handpiece (SybronEndo) (Figure 4) (Kinsey, Mounce, 2008). This is a contra-angle that fits onto any E-type slow speed handpiece, as well as in the new TF™ Adaptive motor (SybronEndo), M4 handpiece setting, and mimics the watchwinding motion normally used in hand filing, with a reciprocating motion, 30° in each direction. This contra-angle will also fit on

Figure 4: Reciprocating handpiece Figure 3: X-Plorer series 15-01; 20-01; 20-02

the root canal there will be sufficient space for the rotary instrument to follow. Berutti, et al., (2004) recommended manual pre-flaring of the root canal to create a glide path before using nickeltitanium rotary instrumentation and found that this reduced torsional stress and increased the life span of rotary nickeltitanium instruments. The separation of nickel-titanium rotaryshaping files is a matter of concern for clinicians, and Patino, et al., (2005) also found that the separation rate of three different rotary nickel-titanium instruments was significantly reduced when their use was preceded by glide path preparation. Recently, Berrutti, et al., (2011) reported that the preparation of a glide path allowed for better maintenance of canal curvature with a new nickel-titanium reciprocating file. The term “glide path” is very apropos, as it describes what rotary files should do in the canal: glide. Rotary shaping Volume 7 Number 1

apical zipping. These may complicate the entire cleaning and shaping procedure, and change the anatomical shape of the apex, which may create other challenges. In these cases, the canal now owns the practitioner, transforming the procedure into a negative and frustrating experience with success very much in jeopardy. So while it is acknowledged that creating a reproducible glide path is essential, the appropriate instrumentation is necessary to achieve the desired result.

Mechanized glide path A few manufacturers have introduced “glide path” instruments, which are used with rotary endodontic motors. They are designed to be used to complete the glide path phase of instrumentation. One such series of files are the X-Plorer™ files (Clinician’s Choice) (Figure 3). Initially, there was some hesitation on the part of clinicians to take such a small instrument to working length in a rotary

some endodontic motors. (Check with the manufacturer to see if it is compatible and what revolutions per minute and reduction settings should be used.) This handpiece is ideally used with the No. 6, No. 8, and No. 10 files. Some clinicians report that negotiating these files by hand, leaving them in place in the canal, and then securing the M4 to the file while still in the canal are very efficient. As Kinsey, et al., (2008) stated: “Reciprocation is inherently safe in that if it is performed correctly, it is very unlikely that an iatrogenic event (instrument fracture, ledging, etc.) might occur.” Having accomplished getting a No. 10 hand file easily to length, whether by hand or using the M4 handpiece, the glide path may be completed with the X-Plorer instruments rotating in an electric handpiece at 400 rpm. The sizes have been well thought out, as the first is a size 15 with a .01 taper. This is a unique file size and makes a great deal of sense, in that the Endodontic practice 29

CONTINUING EDUCATION

Glide path defined

CONTINUING EDUCATION

Figure 5: X-Plorer size 20-02 entering canal.

Figure 7A: EndoVac setup

transition from a No. 10 file to a No. 15 is often very difficult, as this is a 50% jump in diameter. However, the X-Plorer 15/.01 is half the taper of a No. 15 hand file and has a triangular cross section for added flexibility so will glide down a canal even with severe curvature with relative ease, if the No. 10 file has gone to length easily. Of course, as with any nickel-titanium instrument, if any resistance is encountered, the file should be withdrawn, and patency should be reestablished with a No. 10 file. The next file is a size 20, also with a .01 taper with a square cross section, followed by a size 20 with a .02 taper (Figure 5), also with a square cross section. One additional design feature is that there is a limited 10-mm cutting zone. This obviously limits canal engagement, reducing instrument fatigue, which is a must with this small an instrument. The use of a chelator/file lubricant, such as File-Eze® (Ultradent Products, Inc.) (Figure 6) or SlickGel ES® (SybronEndo), is optional. If they are used, the aforementioned are preferable as they are water-based and easily rinsed out of the canal. In some cases, these products help keep debris and tissue in suspension, allowing it to be easily flushed out of the canal. 30 Endodontic practice

Figure 6: File-Eze syringe

Figure 7B: EndoVac components

Figure 8A: TF File

The use of abundant irrigation with sodium hypochlorite is a must, as this cleans, disinfects, transports, and digests tissue, as well as effectively lubricating the instruments. Since tissue digestion is not limited to the root canal space, if sodium hypochlorite is forced beyond confines of the canal system, sequelae ranging from postoperative sensitivity (Gondim, et al., 2010) to life-threatening events (Bowden, Ethunandan, Brennan, 2006) are not uncommon. Accordingly, this is best accomplished with apical negative pressure via the EndoVac® system (SybronEndo) (Figures 7A and 7B). Not only has the EndoVac been demonstrated to be significantly safer than positive pressure irrigation (Desai, Himel, 2009; Mitchell, Yang, Baumgartner, 2010; Mitchell, Baumgartner, Sedgley, 2011), but it also produces cleaner canal walls (Nielsen, Baumgartner, 2007) and intracanal irregularities (Susin, et al., 2010). Most importantly, in a recent success/ failure clinical study, the EndoVac system produced 96.57% long-term healing in nonvital teeth treated in a single visit (ParedesVieyra, Enriquez, 2012), compared to a 80.1% healing rate in teeth treated with traditional positive pressure (Su, Wang, Ye, 2011).

Figure 8B: Typhoon Infinite Flex files

The previous sequence results in an efficient, predictable glide path to a size 20. At this point, you are much more apt to “own the canal,” proceeding in a crowndown fashion with your rotary system into the beautiful true path you have just created. While any system can be used, TF Twisted Files (SybronEndo) (Figure 8A) and Typhoon™ Infinite Flex files (Clinician’s Choice) (Figure 8B), dovetail nicely with this predictable glide path. As the glide path created with flexible nickel-titanium results in much less canal transportation, Typhoon files, made with CM nickel-titanium, have virtually no memory, so will obediently follow the canal path you have just created with maximum cutting efficiency, as well with little or no canal transportation and drastically reduced instrument fatigue (Shen, et al., 2011; Shen et al., 2012).

Case report 1 A 62-year-old male patient presented with irreversible pulpitis in tooth UL7. He reported that the restoration on the tooth fell out 3 months previously. A preoperative radiograph revealed a large carious lesion into the pulp, sharp mid-canal curvature of the mesial root, and calcified canals (Figure 9). After pre-endodontic build-up and access cavity preparation, ultrasonic Volume 7 Number 1

Figure 10: Ultrasonic Troughing for MB2

Figure 13A

troughing with a CT4 diamond-coated tip (SybronEndo) was carried out to locate the orifice of the MB2 canal (Figure 10). Root canal patency and working length were established using size 10 K-files (Figure 11). Figure 12 shows the impression of the MB2 canal on a size 10 K-file after removing it from the canal, demonstrating the extent of the tortuous mid-root canal curvature. Glide path preparation was undertaken using the M4 handpiece with No. 8 and No. 10 hand files, and then X-Plorer 15/0.1, 20 0.1 and 20/0.2 files. The canals were further prepared using the Wave•One™ Primary (25/0.8) (Dentsply), and the palatal canal was finished up to a 35/0.6 using a FlexMaster® file (VDW) after apical gauging. A size 10 K-file was used to ensure patency between file insertions and copious irrigation with 3% sodium hypochlorite in a 31-gauge NaviTip® side port needle (Ultradent). Once final shaping was completed, the canals were irrigated with 17% EDTA (smear clear) to remove the smear layer, and then a final rinse with 3% sodium hypochlorite was done. The canals were obturated with gutta percha and AH Plus® sealer (Dentsply), and MicroSeal condensers (SybronEndo) were used to thermomechanically condense the root filling. Figures 13A and 13B show the postoperative radiographs. Note the Volume 7 Number 1

Figure 11

Figure 13B

Figure 12

Figure 14: Pre-op

Figure 15

maintenance of the natural curvature of the canals and minimal coronal enlargement required for preparation of the curved anatomy.

Case report 2 A 63-year-old man was referred for consultation of tooth UL6. The patient’s medical history was non-contributory. The chief complaint was extreme temperature and bite sensitivity localized to the first upper-left molar. Testing confirmed that tooth UL6 was extremely sensitive to percussion and cold testing. A radiograph taken (Figure 14) revealed a large composite

that appeared to be very close to the pulp chamber. No significant radiolucencies could be noted. A diagnosis of acute pulpitis with acute apical periodontitis was made. Options were discussed, and the patient opted to proceed with endodontic therapy, as recommended. Access opening was made, and four separate canals were located with the use of the operating dental microscope (Global Surgical Corporation Microscopes). The preoperative radiograph was used to determine an approximate length of the canals (Figure 15). A No. .08 hand file was introduced in all the canals. This file was Endodontic practice 31

CONTINUING EDUCATION

Figure 9

CONTINUING EDUCATION

Figure 16A

Figure 16B

taken to two-thirds of the predetermined length with a watch-winding motion. Care was taken to make sure that this length could be reproduced. A No. 10 hand file followed and was carefully taken to the same length as the previous file in all the canals. At this point, a No. 10 file with the aid of the M4 handpiece was introduced into all the canals. This file was followed by the No. 15 and the No. 20 file to as close as possible to the predetermined length. None of these files were forced apically into the canals. Copious irrigation with 5% sodium hypochlorite was done in between files. A reciprocating nickel-titanium instru-

ment (Wave•One Primary file, Dentsply) was introduced into the canals, trying to get as close to the predetermined length as possible. No apical pressure was used. This file was used in a brushing motion. The canals were irrigated and dried with paper points. Working lengths for all four canals were determined with the use of an apex locator (Bingo) and a No. 10 25-mm hand file. A No. 10 hand file with the M4 handpiece (SybronEndo) was taken to length, and the presence of a reproducible glide path to this point was confirmed. This file was followed by an X-Plorer rotary nickeltitanium file (Clinician’s Choice) No. 15/.01

taper to length. A No. 20/.01 and a No. 20/.02 taper file followed. An electric motor with torque control was used for these files. Copious irrigation and patency files were used in between instruments. Once the reproducible mechanical glide path was created and confirmed, a No. 25/.08 taper Wave•One file was taken to length. Deep shape was achieved by using larger hand files with the M4 handpiece. Gutta-percha cones were selected, and the canals were obturated with a warm single-wave technique. Postoperative radiographs confirm proper three-dimensional obturation of all four canals (Figures 16A and 16B).

Conclusion Scientific literature and clinical experience clearly show that successful outcomes are more likely and iatrogenic mishaps will be minimal when rotary and reciprocating instruments follow a designated route, a reproducible glide path. The incorporation of modern mechanized files into the instrumentation protocol will help achieve this important step in the endodontic procedure. EP

References Berutti E, Cantatore G, Castellucci A, Chiandussi G, Pera F, Migliaretti G, Pasqualini D. Use of nickel titanium rotary PathFile to create the glide path: comparison with manual preflaring in simulated root canals. J Endod. 2009; 35(3):408-412. Berutti E, Negro AR, Lendini M, Pasqualini D. Influence of manual preflaring and torque on the failure rate of ProTaper instruments. J Endod. 2004;30(4):228-230. Berutti E, Paolino DS, Chiandussi G, Alovisi M, Cantatore G, Castellucci A, Pasqualini D. Root canal anatomy preservation of WaveOne reciprocating files with or without glide path. J Endod. 2012;38(1):101104. Blum JY, Machtou P, Ruddle CJ, Micallef JP. Analysis of mechanical preparations in extracted teeth using ProTaper rotary instruments: value of the safety quotient. J Endod. 2003;29(9):567-575. Bowden J, Ethunandan M, Brennan P. Life-threatening airway obstruction secondary to hypochlorite extrusion during root canal treatment. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006;101(3):402-404. Desai P, Himel V. Comparative safety of various intracanal irrigation systems. J Endod. 2009;35(4):545549. Gondim E Jr, Setzer FC, Dos Carmo CB, Kim S. Postoperative pain after the application of two different irrigation devices in a prospective randomized clinical trial irrigation devices in a prospective randomized clinical trial. J Endod. 2010;36(8):1295-1301. Hülsmann M, Peters OA, Dummer PMH. Mechanical preparation of root canals: shaping goals, techniques and means. Endod Topics. 2005;10(1):30-76. Kinsey B, Mounce R. Safe and efficient use of M4 safety handpiece in endodontics. Roots. 2008;4(2):3640.

32 Endodontic practice

Mitchell RP, Baumgartner JC, Sedgley CM. Apical extrusion of sodium hypochlorite using different root canal irrigation systems. J Endod. 2011;37(12):16771681. Mitchell RP, Yang SE, Baumgartner JC. Comparison of apical extrusion of NaOCl using the EndoVac or needle irrigation of root canals. J Endod. 2010;36(2):338-341. Mounce R. An excellent glide path, the road to smoother endodontics. Oral Health. 2004;94:51-68. Nielsen BA, Baumgartner CJ. Comparison of the EndoVac system to needle irrigation of root canals. J Endod. 2007;33(5):611-615. Paredes-Vieyra J, Enriquez FJ. Success rate of singleversus two-visit root canal treatment of teeth with apical periodontitis: a randomized controlled trial. J Endod. 2012;38(9):1164-1169. Pasqualini D, Mollo L, Scotti N, Cantatore G, Castellucci A, Migliaretti G, Berutti E. Postoperative pain after manual and mechanical glide path: a randomized clinical trial. J Endod. 2012;38(1):32-36. Patiño PV, Biedma BM, Liébana CR, Cantatore G, Bahillo JG. The influence of a manual glide path on the separation rate of NiTi rotary instruments. J Endod. 2005;31(2):114-116. Peters OA, Paque F. Current developments in rotary root canal instrument technology and clinical use: a review. Quintessence Int. 2010;41(6):479-488. Peters OA, Peters CI, Schönenberger K, Barbakow F. ProTaper rotary root canal preparation: assessment of torque and force in relation to canal anatomy. Int Endod J. 2003;36(2):93-99. Roland DD, Andelin WE, Browning DF, Hsu GH, Torabinejad M. The effect of preflaring on the rates of separation for 0.04 taper nickel titanium rotary instruments. J Endod. 2002;28(7):543-545.

Schäfer E, Dammaschke T. Development and sequelae of canal transportation. Endod Topics. 2006;15(1):7590. Schilder H. Filling root canals in three dimensions. Dent Clin North Am. 1967;11:723-744. Schilder H. Cleaning and shaping the root canal. Dent Clin North Am. 1974;18(2):269-296. Shen Y, Qian W, Abtin H, Gao Y, Haapasalo M. Fatigue testing of controlled memory wire nickel-titanium rotary instruments. J Endod. 2011;37(7):997-1001. Shen Y, Qian W, Abtin H, Gao Y, Haapasalo M. Effect of environment on fatigue failure of controlled memory wire nickel-titanium rotary instruments. J Endod. 2012;38(3):376-380. Su Y, Wang C, Ye L. Healing rate and post-obturation pain of singleversus multiple-visit endodontic treatment for infected root canals: a systematic review. J Endod. 2011;37(2):125-132. Susin L, Liu Y, Yoon JC, Parente JM, Loushine RJ, Ricucci D, Bryan T, Weller RN, Pashley DH, Tay FR. Canal and isthmus debridement efficacies of two irrigant agitation techniques in a closed system. Int Endod J. 2010;43(12):1077-1090. West J. Endodontic update 2006. J Esthet Restor Dent. 2006;18(5):280-300. Wu MK, Fan B, Wesselink PR. Leakage along apical root fillings in curved root canals. Part I: effects of apical transportation on seal of root fillings. J Endod. 2000;26(4):210-216. Young GR, Parashos P, Messer HH. The principles of techniques for cleaning root canals. Aust Dent J. 2007;52(suppl 1):S52-S63.

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The importance of a reproducible glide path 1. The principles of three-dimensional cleaning, shaping, and obturation of the root canal system, which are the foundations for predictable endodontic success, were outlined by _____ over 4 decades ago and remain pertinent even with all the technological advances that have been made since the turn of the 21st century. a. West b. Mounce c. Schilder d. Hülsmann 2. It does not take much to lose control of the root canal space with subsequent iatrogenic mishaps, such as apical ledges or the packing of dentinal debris; both of which may jeopardize _____. a. apical patency b. canal curvature c. proper calcification d. re-capitulation 3. One guiding strategy that has also emerged as a critical part of endodontic success, especially when using rotary nickel-titanium files, is the ______ of a glide path. a. creation b. maintenance c. length d. both a and b 4. It has been demonstrated that the _______ can be reduced by first performing coronal

Volume 7 Number 1

enlargement of the root canal. a. size of the contra angle b. potential for infection c. risk of instrument fracture d. apical negative pressure 5. Blum, et al., (2003) suggested that a glide path be initially created with _____ stainlesssteel hand files to create or verify that within any portion of the root canal, there would be sufficient space for the rotary instrument to follow. a. small b. flexible c. large d. both a and b 6. The separation of nickel-titanium rotary shaping files is a matter of concern for clinicians, and Patino, et al., (2005) also found that the separation rate of three different rotary nickeltitanium instruments _____ when their use was preceded by glide path preparation. a. was significantly reduced b. was increased c. remained the same d. was inherent 7. Because of the relative stiffness of stainless steel, there is the risk of canal transportation, which may lead to ___________. a. perforation b. ledging

c. apical zipping d. all of the above 8. As Kinsey, et al., (2008) stated: “________ is inherently safe in that if it is performed correctly, it is very unlikely that an iatrogenic event (instrument fracture, ledging, etc.) might occur.” a. Flaring b. Reciprocation c. Apexification d. Resistance 9. Of course, as with any nickel-titanium instrument, if any resistance is encountered, the file should be withdrawn, and patency should be re-established with a _____ file. a. No. 10 b. No. 20 c. No. 30 d. No. 40 10. The use of abundant irrigation with _____ is a must, as this cleans, disinfects, transports, and digests tissue, as well as effectively lubricating the instruments. a. water b. sodium hypochlorite c. chlorhexidine d. saline

Endodontic practice 33

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Clinical management of teeth with incomplete root formation Dr. Siju Jacob discusses treatment techniques for teeth with incomplete root formation Introduction Teeth with incomplete root formation, commonly referred to as “open apices,” pose several clinical challenges and require altered clinical protocols compared to routine endodontic cases. When revascularization techniques are not practical, are not essential, or have failed, these teeth can be managed in three different ways: 1. Orthograde mineral trioxide aggregate (MTA) placement without surgery 2. Surgery with orthograde/retrograde MTA placement 3. Traditional apexification. This article illustrates each of these techniques using clinical cases with recalls.

Case 1 Orthograde MTA placement A 28-year-old male patient reported to the clinic with a history of intermittent pain, swelling, and discoloration in the left upper front teeth. He gave a history of previous endodontic therapy followed by surgery on these teeth. Clinical examination revealed discolored left maxillary central and lateral incisor teeth. Both teeth were tender to percussion, and probing depths were within normal limits. Radiographs showed previously endodontically treated left maxillary central and left lateral incisors (Figures 1A and 1B). The previous endodontic therapy appeared poorly done, and there seemed to be evidence of previous root resection. The treatment options were discussed with the patient, and a decision was made to perform non-surgical retreatment endodontics in both teeth. Since the

Siju Jacob, BDS, MDS, completed his BDS from Bangalore University, Bangalore, India, and MDS in conservative dentistry and endodontics from MGR Medical University, Chennai, India. Since 2001, Dr. Jacob has had a full-time private practice limited to endodontics. He currently divides his time between his two practices in Dubai and Bangalore. He can be contacted through his website www.rootcanalclinic. com.

34 Endodontic practice

Educational aims and objectives This clinical article aims to present three case studies illustrating different treatment methods for teeth with incomplete root formation, commonly referred to as “open apices.” Expected outcomes Correctly answering the questions on page 40, worth 2 hours of CE, will demonstrate you can: • Recognize treatment techniques for teeth with incomplete root formation. • Visualize a case that includes orthograde MTA placement. • Visualize a case that includes orthograde MTA placement and immediate surgery. • Visualize a case that includes traditional apexification. • Realize that certain clinical conditions and situational factors affect the treatment protocol.

apex appeared resected, the option of using MTA as an obturating material was included in the treatment plan. After local anesthesia and rubber dam application, the old restoration and gutta percha were removed in both teeth (Figure 2). Both canals were cleaned and shaped using hand and rotary nickel-titanium files. Gauging of the apex revealed that that the lateral incisor, despite the previous root resection, was no larger than ISO size 40 at the apex, and adequate resistance form and cone fit had been achieved. The central incisor, however, had an open apex through which a size 80 file passed through easily. There was also profuse bleeding at the apex of the central incisor (Figure 3). It was decided to eventually obturate the lateral incisor with gutta percha and the central incisor with MTA. The canals were irrigated with 5.2% sodium hypochlorite, 17% EDTA, and 2% chlorhexidine. Care was taken to keep sodium hypochlorite and EDTA irrigation restricted only to the coronal portion in the tooth with the open apex. The canals were dried using paper points, and a calcium hydroxide paste (UltraCal® XS, Ultradent) was placed in the canals (Figure 4). The access cavity was sealed with a layer of Cavit™ (3M™ ESPE™) followed by glass ionomer cement (Fuji VII, GC). The patient was recalled 2 weeks later. Both teeth were asymptomatic. It was

decided to obturate the lateral incisor with gutta percha and the central incisor with MTA. The calcium hydroxide was removed from the central incisor. Inspection of the apical area through a surgical microscope showed absence of any bleeding (Figure 5), and an environment conducive to placing MTA. MTA (ProRoot® MTA, Dentsply) was placed at the apical area with the help of Dovagan’s MTA carrier (Figure 6) and condensed using pluggers. Indirect ultrasonics was applied to improve the density of packed MTA. The apical MTA pack was verified through the microscope as well as radiographically (Figures 7A and 7B). The remainder of the canal was backfilled with MTA (Figure 8), and a composite core build-up was done (Figure 9). The lateral incisor was obturated using gutta percha and AH Plus® sealer (Dentsply) in warm vertical condensation. The access cavity was sealed using a dual-cured resin (LuxaCore®, DMG) (Figures 10A and 10B). The patient was recalled after 2 years, and a recall radiograph taken to verify healing (Figures 11A and 11B).

Case 2 Orthograde MTA placement and immediate surgery A 27-year-old male patient reported to the clinic with a history of persistent swelling Volume 7 Number 1

Figures 1A and 1B: Preoperative radiographs show poorly done endodontic therapy with evidence of root resection

Figure 2: Old restoration and gutta percha removed

Figure 3: Bleeding seen at the open apex

Figure 4: Calcium hydroxide placed

Figure 5: Two weeks later, bleeding and inflammation under control in the open apex area

Figure 6: MTA placement using Dovgan carrier

Figures 7A and 7B: MTA placed at the apex and verified both through the scope as well as radiograph

Figure 8: Canal back-filled with MTA

Figure 9: Core build-up done with composite resin

Figures 10A and 10B: Postoperative radiographs. Lateral incisor obturated with gutta percha and central incisor with MTA

Figures 11A and 11B: Two-year recall radiograph

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Case 1

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Figure 12: Left and right maxillary central incisor teeth with crowns and a labial swelling

Figure 13: Preoperative radiograph

Figures 15A-15C: Original canal located

Figures 16A and 16B: Perforation repaired with MTA

Figure 16D: Core build-up done with composite resin

Figure 16E: Postoperative radiograph after treatment of the left central incisor

Figure 18A: Canal filled with MTA

Figure 18B: Core build-up done with composite resin

Figures 14A and 14B: Removal of old gutta percha in the left central incisor reveals perforation

Figure 16C: Original canal obturated with gutta percha

Figures 17A and 17B: Old gutta percha removed from the right central incisor

Figure 18C: Postoperative (presurgical) radiograph showing slight over-filling of MTA

Figure 17C: Open apex seen through the surgical microscope

Figures 19A and 19B: Apical portion of the root visualized under the microscope. Rough margins smoothened. Uniformity and hardness of MTA checked

Case 2 Figure 20A: Preoperative radiograph

36 Endodontic practice

Figure 20B: Post-surgical radiograph

Figure 20C: Two-year recall shows complete healing

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the periapical lesion (Figures 20A-20C).

Case 3 Traditional apexification A 22-year-old female patient reported to the clinic with a history of intermittent pain and swelling in the upper front teeth. She gave a history of previous endodontic therapy and crown on one of these teeth when she was 10 years old. Clinical examination revealed a crowned right maxillary central incisor. The right maxillary central incisor and right lateral incisor were tender on percussion. Probing depths were within normal limits. Intraoral periapical radiographs revealed a large lesion involving the right maxillary central and lateral incisor and the left maxillary central incisor (Figures 21A and 21B). The endodontically treated maxillary incisor appeared to have an open apex. In addition to the previously endodontically treated right maxillary central incisor, the right lateral incisor also tested non-vital. All

on the right central incisor through the existing crown. A decision was made to temporarily retain the existing crown for esthetic reasons. The old gutta-percha filling was removed and the canals rinsed with 2% chlorhexidine. A part of the old gutta percha was inadvertently extruded periapically. Efforts to retrieve the extruded fragment were not successful. The canal was packed with calcium hydroxide and the access closed with Cavit, followed by pink glass ionomer (Fuji VII) (Figures 23A-23G). A small amount of calcium hydroxide was unintentionally extruded periapically because of the open apex. This was expected to be resorbed. The patient was recalled after 2 weeks. The extruded calcium hydroxide was found to be resorbed completely. A second round of calcium hydroxide was placed in the canals and the access closed with Cavit followed by glass ionomer (Figures 24A-24C).

An open apex can pose numerous treatment challenges to a clinician. A correct diagnosis, followed by a suitable treatment plan, taking into account the various factors discussed in this article can help improve treatment outcomes

other anterior teeth were vital. Treatment options were discussed with the patient, and a decision was made to perform endodontic therapy on the right lateral incisor and non-surgical retreatment endodontics on the right maxillary central incisor. Because of the size of the lesion and the additional problem of the open apex, a decision was made to treat this tooth conservatively with long-term placement of calcium hydroxide. The two main objectives of long-term calcium hydroxide placement follow: 1. To promote healing and repair, thereby reducing the size of the lesion 2. To induce apexification to facilitate obturation. The right lateral incisor was treated first. Endodontic therapy was done in a single session. The canal was filled with gutta percha and the access sealed with composite resin (Figures 22A-22D). Retreatment endodontics was initiated

Calcium hydroxide medication was replaced twice at 2-week intervals after which the patient failed to turn up for subsequent appointments. She eventually reported to the clinic 2 years later because the incisal edge of the right maxillary right lateral incisor had chipped off. A radiograph taken during this visit showed complete healing of the apical lesion, resorption of the extruded gutta percha, and evidence of a dense apical barrier in the right maxillary central incisor (Figures 25A and 25B). A decision was made to re-access the canal in the central incisor, remove the calcium hydroxide, evaluate the apical barrier under the scope, and complete treatment, if possible. The old glass ionomer filling and Cavit were removed to reveal calcium hydroxide (Figures 26A and 26B). Removal of the calcium hydroxide and observation of the apical area under the microscope revealed a dense, uniform apical barrier (Figures 27A and 27B). Endodontic practice 37

CONTINUING EDUCATION

and pain in the upper front teeth. He gave a history of previous endodontic therapy and crowns followed by surgery on these teeth performed 3 years ago. Clinical examination revealed crowned left and right maxillary central incisor teeth with a labial swelling (Figure 12). Both teeth were tender to percussion, and probing depths were within normal limits. Radiographic examination revealed previously endodontically treated left and right maxillary central incisors (Figure 13). The right maxillary central incisor showed evidence of previous root resection. The left central incisor appeared calcified and showed what looked like a previous unsuccessful attempt to locate the canal. The treatment options were discussed with the patient. The patient had traveled from abroad and wanted the entire treatment to be completed in 9 days. Considering the limited time available, it was decided to perform retreatment endodontics followed by immediate surgery. The left maxillary central incisor was treated first. Removal of the old guttapercha filling revealed a perforation (Figures 14A and 14B). The original canal was located distal to the previous attempt (Figures 15A-15C). Once the canal was located, it was cleaned, shaped, and obturated with gutta percha in warm vertical condensation. The perforation was repaired with MTA, and the coronal build-up was completed using dual-cured composite resin (Figures 16A-16E). The left maxillary central incisor was treated next. Removal of previous gutta percha revealed an open apex (Figures 17A-17C). The canals were cleaned using 2% chlorhexidine. Sodium hypochlorite was not used because of the danger of apical extrusion. The entire canal was then obturated with MTA delivered through a Dovgan syringe and condensed using wet microbrush and pluggers assisted by indirect ultrasonics. The coronal buildup was completed using a fiber-post and composite resin (Figures 18A-18C). The patient was scheduled for surgery 2 days later. A papilla preservation flap was raised, the periapical lesion curetted, the excess MTA removed, and the remaining MTA in the canal checked for hardness and uniform seal (Figures 19A and 19B). The entire surgery was done using a surgical microscope. Healing was uneventful, and the sutures were removed 6 days later. A 2-year recall showed complete healing of

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Case 3

Figures 21A and 21B: Preoperative radiographs

Figures 22A-22D: Endodontic therapy of the right lateral incisor completed

Figures 23A-23C: Re-treatment of the right central incisor started. Access made through existing crown. Old gutta percha removed

Figure 23G: Postoperative radiograph after first visit. Note minimal extrusion of calcium hydroxide

Figure 24A: Two weeks later, extruded calcium hydroxide is completely resorbed

Figures 26A and 26B: Pink-colored glass ionomer makes re-accessing the canal easier. Removal of glass ionomer and Cavit shows canal filled with calcium hydroxide

38 Endodontic practice

Figures 23D and 23E: Intra-operative radiographs taken at periodic intervals to verify gutta percha removal

Figures 24B and 24C: Calcium hydroxide re-packed. Access closed with Cavit and glass ionomer

Figure 27A: Uniform apical barrier visualized through the surgical microscope

Figure 27B: Radiographic picture of the apical barrier

Figure 23F: Gutta percha unintentionally extruded periapically

Figures 25A and 25B: Two-year recall radiographs showing complete healing of periapical lesion, resorption of extruded gutta percha, and evidence of apical barrier formation in the right central incisor

Figures 28A and 28B: Physical verification of the apical barrier using a gutta-percha cone

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Figures 29A and 29B: Apical barrier resists vertical condensation forces during obturation by thermoplasticized gutta percha

Figures 30A-30D: Large fiber-post inverted and cemented with dual core composite resin to strengthen the root

Physical verification of the barrier was done using a gutta-percha cone (Figures 28A and 28B). The canal was obturated using thermoplasticized gutta percha injected from the Obtura® (SybronEndo) gun and condensed using large pluggers. The barrier was found to be firm and withstood condensation forces without any apical extrusion (Figures 29A and 29B). A large fiberglass post was placed to strengthen the root. The fiberglass post was placed inverted to fit the large width of the canal. The core build-up was done using dualcured composite resin (Figures 30A-D). The patient was referred to her general dentist for a new crown.

Discussion Management of the open apex requires variations from conventional endodontic therapy. The treatment protocol depends on the size of the periapical lesion, time factor, and patient cooperation. In the first case described in this article, the periapical destruction of bone was minimal. The aim was to control apical periodontitis and obturate the canal predictably. Therefore, short-term placement of calcium hydroxide followed by obturation with MTA at the root apex was a predictable procedure. Surgery is rarely required in these cases. In the second case described in this article, the time available for the patient was a very important factor to consider. For patients who live in remote places and have to travel to access quality endodontic care, immediate surgery combined with orthograde/retrograde MTA placement can be a very predictable alternative. Today, with improved magnification and special microsurgical techniques, the success rate of surgical endodontics is fairly high. The disadvantage is that in large lesions, surgery might be a radical option and Volume 7 Number 1

might require additional procedures on adjacent teeth and surrounding hard and soft tissues. In the third case described in this article, considering the large size of the lesion and incomplete root formation, long-term calcium hydroxide therapy was the most conservative treatment. Patient follow-up is the most difficult part in apexification cases, as the waiting period is long, and some patients have a tendency to miss appointments once the symptoms subside. However, all other factors being uniform, it is a good rule to keep surgery as the last alternative and limited to cases that do not respond to non-surgical retreatment endodontics. Apexification is a fairly predictable procedure. However, there have been studies concerning the reduced fracture resistance of teeth treated with long-term calcium hydroxide. These cases should, therefore, be evaluated on a risk versus benefit basis. There needs to be modification of irrigation protocol for open apex cases. It is virtually impossible to control the apical extrusion of any irrigant in open apex cases. Therefore, caution is advised when using solutions that can cause severe periapical tissue damage and irritation. Apical extrusion of sodium hypochlorite can cause severe complications, and it is probably best to irrigate these cases with 2% chlorhexidine. MTA is a proven material for management of open apex cases. The ability to set in the presence of moisture makes it the material of choice for open apex cases. There have been numerous studies that affirm MTA as an excellent root-end filling material.

Conclusion

Figures 31A and 31B: Comparison of preand postoperative radiographs

treatment challenges to a clinician. A correct diagnosis, followed by a suitable treatment plan, taking into account the various factors discussed in this article can help improve treatment outcomes. EP

References Bernabé PF, Gomes-Filho JE, Bernabé DG, Nery MJ, Otoboni-Filho JA, Dezan-Jr E, Cintra LT. Sealing ability of MTA used as a root end filling material: effect of the sonic and ultrasonic condensation. Braz Dent J. 2013;24(2):107-110. Carr GB, Murgel CA. The use of the operating microscope in endodontics. Dent Clin North Am. 2010;54(2):191-214. Chala S, Abouqal R, Rida S. Apexification of immature teeth with calcium hydroxide or mineral trioxide aggregate: systematic review and metaanalysis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2011;112(4):36-42. Costa GM, Soares SM, Marques LS, Gloria JC, Soares JA. Strategy for apexification of wide-open apex associated with extensive periapical lesion in a weakened root. Gen Dent. 2013;61(3):e2-4. Katsamakis S, Slot DE, Van der Sluis LW, Van der Weijden F. Histological responses of the periodontium to MTA: a systematic review. J Clin Periodontol. 2013;40(4):334-344. Malhotra N, Agarwal A, Mala K. Mineral trioxide aggregate: a review of physical properties. Compend Contin Educ Dent. 2013;34(2):e25-32. Malhotra N, Agarwal A, Mala K. Mineral trioxide aggregate: part 2 – a review of the material aspects. Compend Contin Educ Dent. 2013;34(3):e38-43. Ray JJ, Kirkpatrick TC. Healing of apical periodontitis through modern endodontic retreatment techniques. Gen Dent. 2013;61(2):19-23. Shabahang S. Treatment options: apexogenesis and apexification. Pediatr Dent. 2013;35(2):125128. Tang Y, Li X, Yin S. Outcomes of MTA as root-end filling in endodontic surgery: a systematic review. Quintessence Int. 2010;41(7):557-566. Taschieri S, Del Fabbro M, Weinstein T, Rosen E, Tsesis I. Magnification in modern endodontic practice. Refuat Hapeh Vehashinayim. 2010;27(3):18-22, 61.

An open apex can pose numerous Endodontic practice 39

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Case 3 continued

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Clinical management of teeth with incomplete root formation 1. When revascularization techniques ______, these teeth can be managed in three different ways: 1. Orthograde mineral trioxide aggregate (MTA) placement without surgery. 2. Surgery with orthograde/retrograde MTA placement 3. Traditional apexification. a. are not practical b. are not essential c. have failed d. all of the above 2. (In case No. 1) Care was taken to keep sodium hypochlorite and EDTA irrigation restricted only to the _______in the tooth with the open apex. a. coronal portion b. lingual portion c. dental follicle d. root sheath 3. (For case No. 2) Once the canal was located, it was cleaned, shaped, and obturated with gutta percha in ____. a. calcium hydroxide b. warm vertical condensation c. 3% chlorhexidine d. sodium hypochlorite 4. (For case No. 3) Because of ______, a decision was made to treat this tooth conservatively with long-term placement of

40 Endodontic practice

calcium hydroxide. a. the size of the lesion b. the additional problem of the open apex c. profuse bleeding at the apex of the central incisor d. both a and b 5. Calcium hydroxide medication was replaced twice at _____after which the patient failed to turn up for subsequent appointments. a. a 1-week interval b. 2-week intervals c. 3-week intervals d. a 1-month interval 6. (When the patient returned to the clinic 2 years later) A radiograph taken during this visit showed ______. a. complete healing of the apical lesion b. resorption of the extruded gutta percha c. evidence of a dense apical barrier in the right maxillary central incisor d. all of the above 7. (For case No. 3) The fiberglass post was _____ to fit the large width of the canal. a. ordered in a larger size b. covered with additional liquid fiberglass c. placed inverted d. placed at an angle

8. Management of the open apex requires variations from conventional endodontic therapy. The treatment protocol depends on _______. a. the size of the periapical lesion b. the time factor c. patient cooperation d. all of the above 9. For patients who live in remote places and have to travel to access quality endodontic care, immediate surgery combined with orthograde/retrograde MTA placement can ______. a. be a very predictable alternative b. lead to development of a large lesion c. result in poor postoperative care d. lead to bone destruction 10. (For open apex cases) Apical extrusion of sodium hypochlorite can cause severe complications, and it is probably best to irrigate these cases with ______. a. sodium hypochlorite b. 2% chlorhexidine c. a Dovgan syringe d. cooled vertical condensation

Volume 7 Number 1

Dr. Kishor Gulabivala presents the latest literature, keeping you up-to-date with the most relevant research Histologic examination of condensing osteitis in cadaver specimens Green TL, Walton RE, Clark JM, Maixner D Journal of Dental Research (2013) 39(8): 977-9 Abstract Aim: Condensing osteitis is a radiographic finding, but with no reported histologic investigations in humans. The objectives of this study were to evaluate and describe histologically condensing osteitis in human cadaver jaws. Patterns of bone formation and presence/absence and nature of inflammation were examined. Methodology: Specimens of mandibles and maxillas were obtained from cadavers and examined radiographically. Those periapical areas with characteristics of condensing osteitis were removed en bloc, decalcified, and processed for light microscopy. For comparison, specimens that showed normal apical radiographic anatomy were also removed for examination. Results: Normal apical regions showed an intact periodontal ligament and a thin layer of alveolar bone proper surrounded by cancellous bone with fatty marrow. In contrast, areas of condensing osteitis exhibited areas of inflammation or no inflammation, occupied by connective tissue. This area was bordered by a rim of varying widths of dense lamellar-type bone replacing the cancellous bone and marrow. Conclusions: The histologic changes of condensing osteitis consisted of the replacement of cancellous bone with compact bone. Areas of fibrosis and an

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

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inflammatory infiltrate were seen in some but not all specimens. All teeth exhibiting condensing osteitis had an identifiable etiology that likely resulted in degenerative pulp disease.

(IBUg) and 36% (PLAg). Conclusions: Preoperative oral administration of IBU significantly improved the efficacy of IANB in patients with symptomatic irreversible pulpitis.

Efficacy of preoperative ibuprofen on the success of inferior alveolar nerve block in patients with symptomatic irreversible pulpitis: a randomized clinical trial

Radiographic healing after a root canal treatment performed in single-rooted teeth with and without ultrasonic activation of the irrigant: a randomized controlled trial

Noguera-Gonzalez D, Cerda-Cristerna BI, Chavarria-Bolanos D, Flores-Reyes H, Pozos-Guillen A International Endodontic Journal (2013) 46(11): 1056-62 Abstract Aim: To evaluate the effect of preoperative oral ibuprofen (IBU) on the success of inferior alveolar nerve blocks (IANBs) with mepivacaine containing 1:100000 epinephrine for patients with symptomatic irreversible pulpitis (SIP). Methodology: The present study was a double-blind, randomized, placebocontrolled clinical trial. The study included two study groups each consisting of 25 patients who exhibited symptomatic irreversible pulpitis of a mandibular posterior tooth. The patients presented prolonged moderate or severe pain (>10s) after cold testing and indicated their pain scores on a Heft-Parker visual analogue scale. The patients received outwardly identical capsules containing either 600 mg IBU (IBUg) or gelatin (placebo, PLAg) 1 hour before administration of IANB with 2% mepivacaine containing 1:100000 epinephrine. After 15 minutes, the anesthetic blockade was assessed by a three-step examination (lip numbness, positive/ negative response to cold testing, and clinical discomfort during endodontic access). IANB success was defined as the absence of pain during any of these evaluations. The data were analyzed using the chi-square test. Results: All of the patients reported moderate or severe pain before the preoperative procedure. Statistically significant differences were observed between the IBUg and PLAg (P < 0.05); the success rates for the IANB were 72%

Liang YH, Jiang LM, Jiang L, Chen XB, Liu YY, Tian FC, Bao XD, Gao XJ, Versluis M, Wu MK, van der Sluis L Journal of Endodontics (2013) 39(10): 1218-25 Abstract Aim: The aim of this study was to compare the outcome of a root canal treatment with and without additional ultrasonic activation of the irrigant. Methodology: Single-rooted teeth with radiographic evidence of periapical bone loss were randomly assigned to two treatment groups. In both groups, syringe irrigation was performed, and in one group, the irrigant was also activated by ultrasound. Ten to 19 months after treatment, the teeth were examined by using periapical radiography (PA) and cone-beam computed tomography (CBCT). The area and volume of the periapical lesions were measured, and the outcome was presented in four categories: absence, reduction, or enlargement of the radiolucency, or uncertain. Lesions were classified as reduced or enlarged when the radiolucency changed in size by 20% or more. Results: The recall rate was 82%, and 84 teeth were analyzed. CBCT detected significantly more postoperative lesions than PA (P = .038), but the percentages of absence and reduction of the radiolucency together revealed by CBCT and PA were similar (P = .383). The CBCT results showed that absence of the radiolucency was observed in 16 of 84 teeth (19%) and reduction of the radiolucency in 61 of 84 teeth (72.6%), but there was no significant difference between the results of the two groups (P = .470). Absence and reduction Endodontic practice 41

ABSTRACTS

The latest in endodontic research

ABSTRACTS of the radiolucency together were observed in the ultrasonic group in 39 of 41 teeth (95.1%) and in the syringe group in 38 of 43 teeth (88.4%). Conclusions: Root canal treatments with and without additional ultrasonic activation of the irrigant contributed equally to periapical healing.

Retrospective follow-up assessment of prognostic variables associated with the outcome of periradicular surgery Villa-Machado PA, Botero-Ramirez X, Tobon-Arroyave SI International Endodontic Journal (2013) 46(11): 106376 Abstract Aim: To investigate, retrospectively over a 1- to 16-year follow-up period, the strength and independence of the association of different patient-, tooth- and surgeryrelated prognostic variables with the outcome of periradicular surgery. Methodology: The study cohort included 171 teeth in 154 subjects. Clinical and radiographic measures along with the follow-up period were used to determine the healing outcome. For statistical analysis, results were dichotomized into healed/healing versus asymptomatic function/persistent disease cases. The association between candidate prognostic variables and asymptomatic function/ persistent disease was analyzed individually and adjusted for confounding using a multivariate binary logistic regression model. Results: The percentage of success (healed/healing cases) was found to be 83.6%, whereas the percentage of failure (asymptomatic function/persistent disease cases) was found to be 16.4%. While univariate analysis revealed a positive association of the presence of preoperative signs/symptoms, unsatisfactory quality of the coronal restoration, pronounced root-end resection bevel, and inadequate quality of root-end filling with asymptomatic function/persistent disease, after multivariate binary logistic regression analysis only the unsatisfactory quality of the coronal restoration and inadequate quality of root-end filling were strongly and independently associated with disease status. Confounding and interaction effects between candidate prognostic variables were noted. Conclusion: The findings of this study 42 Endodontic practice

suggest that while the quality of both the coronal restoration and the root-end filling might be the foremost prognostic variables in periradicular surgery, there are synergistic biological interactive and mutually confounding effects with respect to root-end resection bevel and preoperative signs and/or symptoms that may be also associated with an increased proportion of failures after periradicular surgery.

Outcomes of hospitalizations attributed to periapical abscess from 2000 to 2008: a longitudinal trend analysis Shah AC, Leong KK, Lee MK, Allareddy V Journal of Endodontics (2013) 39(9): 1104-10 Abstract Aim: Root canal therapy is a highly successful in-surgery treatment and preventive measure against periapical abscesses. Left untreated, periapical abscesses can have serious consequences that can lead to hospitalization. This study observes the trends of hospitalizations attributed to periapical abscesses. Methodology: A retrospective analysis of the Nationwide Inpatient Sample (years 2000-2008) was used; we selected cases with a primary diagnosis of a periapical abscess with/without sinus involvement. The demographic characteristics and outcomes were examined. Each individual hospitalization was the unit of analysis. Results: During the 9-year study period, a total of 61,439 hospitalizations were primarily attributed to periapical abscesses in the United States. The average age was 37 years, and 89% of all hospitalizations occurred on an emergency/urgent basis. The mean length of stay was 2.96 days, and a total of 66 patients died in hospitals. Medicare, Medicaid, and private insurance plans paid for 18.7%, 25.2%, and 33.4% of hospitalizations, respectively. Uninsured patients accounted for 18.5% of hospitalizations. Significant predictors that influenced both hospital charges and length of stay included age, race, insurance status, a periapical abscess with sinus involvement, geographic region of country, the Charlson comorbidity index, and the year of study (P < .05). Conclusion: The current study highlights the increasing burden of hospitalization of patients with periapical abscesses over a 9-year study period from 2000 to 2008. The

high-risk groups likely to seek a hospital setting for the treatment of periapical abscesses were identified as were groups associated with higher hospital charges and a longer length of stay.

The influence of bone tissue deficiency on the outcome of endodontic microsurgery: a prospective study Song M, Kim SG, Shin SJ, Kim HC, Kim E Journal of Endodontics (2013) 39(11): 1341-5 Abstract Aim: This study assessed the influence of deficiencies of the periapical and marginal bone tissue on clinical outcomes after endodontic microsurgery. Methodology: Data were collected from the Microscope Center of the Department of Conservative Dentistry at the Dental College of Yonsei University, Seoul, South Korea, between August 2004 and March 2011. In total, 199 teeth that required endodontic surgery were included in the study. During the surgical procedure, deficiencies of the periapical and marginal bone tissue were measured immediately before the flap was repositioned. The patients were recalled 6 months and 1 year after the surgical procedure to assess the clinical and radiographic signs of healing. The Studentâ&#x20AC;&#x2122;s t-test or the Mann-Whitney U test and logistic regression were performed to evaluate the parameters. Significant associations between the outcome and all the evaluation parameters were analyzed using the Pearson chi-square test or the Fisherâ&#x20AC;&#x2122;s exact test with a significance level of 0.05. Results: A recall rate of 67.8% (135/199 teeth) was obtained. The height of the buccal bone plate was the only significant predictor (P = .040) of the healing outcome, suggesting that teeth with a buccal bone plate > 3 mm presented a higher success rate than teeth with a buccal bone plate that was â&#x2030;¤ 3 mm high (94.3% versus 68.8%, P < .001) Conclusion: These data suggest that a favorable prognosis can be expected when teeth are covered with a buccal bone plate that is > 3mm in height regardless of the amount of marginal bone loss. EP

Volume 7 Number 1

Dr. John West discusses knowledge, skill, and willingness in endodontics Introduction I have an agreement with Alaska Airlines. If I arrive late, they leave without me! I also have an agreement with Mother Nature. She has the same agreement with you. If we clean, shape, and seal her root canal system, Mother Nature has the capacity and agreement to heal with a 100% success rate minus some number. Call it “X.” As endodontic clinicians, we have come to learn that “X” is not the size of the lesion of endodontic origin (LEO) or the histology of the LEO. The presence or absence of a sinus tract is not an “X” factor. In fact, as endodontic clinicians, we know that LEOs heal whether pulps are vital or non-vital. Mother Nature just does not care. She only cares that our endodontic shapes “follow” her original root canal system anatomy and that we produce what I have come to know as, and prefer to call, the Endodontic Seal. The “X” factor is really our knowledge of what to do, our skill in doing it, and lastly, and perhaps the most differentiating factor of all, is our willingness to do it. The “X” factor is us: the clinician and the endodontic anatomy. This ninth article of Anatomy Matters chronicles six examples of the “X” factor and my experience of its role in endodontic success or failure. The purpose of this

Figures 1A-1K: Portals of Exit (POEs) significance from “coast to coast.” 1A. Periapical image of underfilled apical POEs and underfilled iatrogenic furcal POE (chamber access perforation)

Figure 1B: Deep distobuccal precipitous sinus tract through the gingival crevice

series has been to archive in one place examples of clinical cases that give evidence that anatomy does matter and what we can biologically, structurally, and mechanically do about it in order to optimize our endodontic performance.1-8

mid-root, and sometimes furcally. Patient No. 1 presents with duplicable percussion and palpation pain. The pretreatment image suggests a furcal and apical LEO (Figure 1A). The distobuccal gingival crevice has an 8-mm narrow precipitous periodontal pocket probing (Figure 1B). Diagnosis: Underfilled root canal system resulting in an endo-perio periodontal vector. Treatment plan — options: Remove/replace or attempt to restore. Patient chose to attempt furcal repair, measure subsequent furcal healing and, if successful, proceed with nonsurgical endodontic retreatment in order to produce a radicular Endodontic Seal. On endodontic access, considerable hemorrhage occurred due to previous furcal perforation (Figure 1C). Mineral trioxide aggregate (MTA) repair better demonstrated accurate radiographic furcal condition. Modified periapical and periapical images are shown after MTA repair (Figures 1D and 1E). Figure 1F showed satisfactory furcal radiographic healing, and clinically gingival crevice resisted gentle probing, suggesting an improved predictability of success if the Endodontic Seal could be technically finished (Figures 1G-1I). Nonsurgical retreatment became justifiable and finished (Figure 1J). Subsequent 10-month posttreatment resulted in good osseous repair (furcal and apical), as well as gingival repair (Figure 1K).

Patient Case Reports Patient No. 1: Portal of exit significance from “coast to coast.” (Figures 1A-1K) Underfilled endodontic portals of exit (POEs) have potential biologic significance at any location along the three-dimensional walls of the radicular root structure. An endodontic failure may have underfilled or unfilled POEs located apical, sometimes

John West, DDS, MSD, the founder and director of the Center for Endodontics, British-born Dr. John West continues to be recognized as one of world’s premier educators in clinical and interdisciplinary endodontics. John West received his DDS from the University of Washington in 1971 where he is an Affiliate Associate Professor. He then earned 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 unmatched endodontic continuing education in North America, South America, and Europe while maintaining a private practice in Tacoma, Washington. Dr. West is a clinical visionary, an inventor, a teacher, and a coach for any dentist that wants to experience the possibilities of endodontics in his/her practice. He coauthored 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, and Michael Cohen’s 2010 Quintessence text Interdisciplinary Treatment Planning Volume II: Comprehensive Case Studies and is lead author of Esthetic Management of Endodontically Treated Teeth in Ronald Goldstein’s “in print” third edition of Esthetics in Dentistry. 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. Web www.centerforendodontics.com Phone 1-800-900-7668 (ROOT)

Volume 7 Number 1

E-mail johnwest@centerforendodontics.com Fax 253-473-6328

Patient No. 2: The “silent tooth killer.” (Figures 2A-2C) There are five kinds of endodontic resorptions.9 None of them are good. Endodontic practice 43

ANATOMY MATTERS

Endodontic accountability: The “X” factor, part 9

ANATOMY MATTERS However, internal resorption has the capacity for repair if nonsurgical endodontics is successfully completed before the internal resorption reaches the root surface. Lateral radicular resorption perforations often produce an asymmetric portal of exit that is challenging to seal. Usual funnel-shape obturation hydraulics was not possible, and resorptive lateral POE seal requires a skillful approach. Patient No. 2 presented with apical LEO coupled with previous post placement surrounded by internal root resorption (Figure 2A). The

could not be easily removed even with CORONAflex crown and bridge remover from KaVo. A surgical treatment plan was discouraged due to possible existing coronal leakage and therefore need for improved coronal seal after nonsurgical retreatment. In addition, surgical seal of mid-root perforation presented an access and technical challenge (deemed probable mid-root POE) and esthetic challenge due to risk of possible gingival black triangle with full surgical flap, especially if patient were to have a high smile line. Anatomy

Patient No. 4 presented with a 10-year previous endodontic procedure and palpation sensitivity. The periapical image implied apical and lateral underfilled POEs. While nonsurgical retreatment was successful, insufficient care was taken to preserve the mesial and distal ferrule (Figures 4A-4F). While the tooth benefits from a healthy attachment apparatus and new crown 10 years later, endodontic clinicians must be mindful and skillful to protect the tooth’s ferrule, particularly the lingual ferrule of maxillary anterior teeth, the

Figure 1C: Severe hemorrhage from furcal perforation after removal of previous access cavity temporary material

Figure 1D: Modified bitewing in order to accurately measure radiographic damage and to evaluate twodimensional placement of MTA furcal repair

Figure 1E: Periapical image of MTA furcal repair

Figure 1F: Two-month periapical image of MTA furcal repair

Figure 1G: Clinical of healthy MB periodontal probing

Figure 1H: Clinical image of healthy buccal gingival crevice

post was successfully removed using the Ruddle post extractor after first loosening with ultrasonics (Figure 2B). Endodontic nonsurgical retreatment was finished, and 16-month posttreatment confirmed successful healing of the periodontal ligament and lamina dura and no apparent progression of internal resorption (Figure 2C).

matters at any time and in any place. For this patient at least four needed POE seals were anticipated: maxillary right lateral incisor apical endodontic underfilling and lateral root perforation. For the maxillary left central incisor, apical POE and lateral POE were suggested by location of guttapercha cone tracing sinus tract to lateral mesial border of root. Accesses were safely made through both FPD abutments. Nonsurgical retreatment of the maxillary right lateral incisor and nonsurgical treatment of the maxillary left central incisor resulted in complete endodontic healing validated at 2-year posttreatment records (Figures 3A-3L).

facial ferrule of mandibular anterior teeth, and the buccal-lingual ferrule of posterior teeth.

Patient No. 3: “Iatrogenic and natural underfilled portals of exit” in the same fixed bridge abutments. (Figures 3A-3L) Patient No. 3 presented with post perforation, apical underfilling of FPD maxillary right lateral incisor and simultaneous lesion of endodontic origin of central incisor abutment due to necrotic and gangrene pulp. Bridge 44 Endodontic practice

Patient No. 4. “Biology vs. structure vs. time.” (Figures 4A-4F)

Patient No. 5: “We never know for sure.” (Figures 5A-5D) Patient No. 5 presents with sinus tract tracing to mandibular right first molar coronal third of furca. Pulp tested nonvital. Location of offending POE(s) was unclear, but proper shaping and cleaning enabled 3D seal of culprit anatomy with subsequent osseous and clinical healing (Figures 5A-5D). We will never know what endodontic anatomy was responsible for this patient’s LEOs. Was it the so-called main canals or the almost entire canal that I missed clinically but was picked up with SybronEndo (previously Kerr Endo) Pulp Volume 7 Number 1

Figure 1I: Healthy DB probing after 2-month MTA furcal repair

Figure 1J: Posttreatment image of nonsurgical endodontic retreatment

Figure 1K: Ten-month posttreatment suggesting healing of the furcal and apical LEOs

Figures 2A-2C: The “silent tooth killer.” 2A. Pretreatment image of mandibular left second premolar with internal root resorption surrounding post

Figure 2B: Post removed using Ruddle post extractor

Figure 3B: Clinical image of maxillary right lateral incisor abutment

Volume 7 Number 1

Figure 3C: Pretreatment periapical image of gutta percha tracing sinus tract of maxillary left central incisor

So there we have it. We have a problem, or we can simply say we have a situation requiring smart thinking. We also have a plan. Endodontic disease comes from pathogens escaping from inside the root canal system. We also know without a cause endodontic disease does not occur. We also know that if we eliminate the cause of endodontic disease, the sequelae of endodontic disease (LEOs) will “predictably” heal. So our endodontic job is clear and simple: Prevent LEOs where they do not exist, and cure LEOs where they do exist. No disease source, no disease. Mother Nature made the rules. She agrees to stay healthy or heal if we can prevent or heal LEOs by nonsurgically or surgically cleaning, shaping, and obturating the

2C: Sixteen-month posttreatment image successful endodontic retreatment result

Figure 3D: Clinical of sinus tract before tracing

Figures 3A-3L: “Iatrogenic and natural underfilled Portals of Exit” in same fixed bridge abutments. A. Pretreatment image of maxillary right lateral incisor

Figure 3E: Clinical of gutta-percha cone tracing sinus tract

Endodontic practice 45

ANATOMY MATTERS

Summary

Patient No. 6: “Which POE don’t you want?” (Figures 6A-6D) Which POE don’t we want could be answered only if we knew which POEs were essential for endodontic predictability. We don’t. And that’s the whole thing. Endodontic clinicians can never clean too much, can never shape just right, and can never obturate too thoroughly. There will always be a “sweet spot” of cleaning, shaping, and obturation based on the effectiveness of the technologies

of the day. In 2001, when patient No. 6 complained of swelling and palpation symptoms, a periapical image revealed a mandibular right canine FPD abutment with a surrounding LEO and with internal resorptive sites. In addition, a lower right crowned premolar with an underfilled root canal system was causing an adjacent LEO of its own. The gingival crevice probed within normal limits. Emergency care (access, cleaned endodontic anatomy, and closed) was successful, and patient was treatment planned to nonsurgically treat patient’s canine and nonsurgically retreat underfilled lower right premolar. Thirteen-year posttreatment validates osseous repair, and patient remains asymptomatic (Figures 6A-6D).

Canal Sealer™? We will never know for sure. From Mother Nature’s perspective, she cared very little at this moment. She is always whispering to us, “Clean me, shape me, and seal me.” In return, she promises healing.

ANATOMY MATTERS

Figure 3F: Post removed

Figure 3J: Backpacking maxillary left central incisor

Figure 4C: Downpack

Figure 3G: Thermafil carrier removed

Figure 3K: Two-year posttreatment of maxillary left central incisor bridge abutment

4D: Posttreatment periapical image

Figures 5A-5D: We never know for sure. 5A. Pretreatment periapical of mandibular right first molar 46 Endodontic practice

Figure 3L: Clinical of facial sinus tract healing of distal bridge abutment

Figure 4E: Ten-year successful biologic and structural posttreatment

Figure 5B: Sinus tract traced to mid-root

Figure 3H: Posttreatment of maxillary right lateral nonsurgical retreatment

Figures 4A-4F: â&#x20AC;&#x153;Biology vs. structure vs. timeâ&#x20AC;? 4A. Pretreatment image of symptomatic underfilled maxillary right central incisor

Figure 3I: Two-year posttreatment of maxillary right retreatment

Figure 4B: Cone fit

Figure 4F: Successful 10-year esthetic result

Figure 5C: Posttreatment

Volume 7 Number 1

ANATOMY MATTERS

5D: Five-year clinical of restored crown and no sign of original draining buccal sinus tract

root canal system. Anything short of the Endodontic Seal means success must be achieved differently: good host resistance, presence or absence of LEO in the first place, virulence of pathogens, and time. The question that is unresolved is, What is good enough? To me, the unequivocal answer is, Good enough is not good enough. Most dentists try to finish everything they start — I suggest we start only what we can finish well. This is not a call for perfection. This is a call to do our best; to “Do It Right.” In a nutshell, my 10-part endodontic series entitled Anatomy Matters is simply a reminder and an invitation. The reminder is that we are accountable for the result. Success is not dependent on the phase of the moon, the status of the marketplace, whether our favorite sports team won or lost, the lesion is too large, or some teeth just don’t heal. Success “X” factor is us. No labs, does not really matter if our patients brush their teeth, no one to blame. But this is not about blame. This is about responsibility for the result. And so, finally, the invitation: To be responsible for the endodontic result. Slow down; make a perfect access that allows for unrestricted access into the canals but preserves precious ferrule; produce a reproducible glidepath for safe manual and mechanical shaping; irrigate more; agitate the proper irrigation more; irrigate with the most effective endodontic irrigants and devices; precisely fit the gutta-percha Volume 7 Number 1

Figures 6A-6D: Which POE don’t you want? 6A. Pretreatment image of necrotic mandibular right cuspid bridge abutment and underfilled adjacent first premolar

Figure 6B: Posttreatment of obturated cuspid

Figure 6C: Posttreatment of premolar nonsurgical retreatment

Figure 6D: Nine-year successful posttreatment: Gingival tissues probe within normal limits

cone or carrier-based verifier; use the most three-dimensional technique depending on the length, width, and curvature of the canal and depending on your experience; pay as much attention to the coronal seal as the radicular seal; marry your patients back to their restorative dentists; and finally schedule posttreatment recalls in order to measure your outcome in 6 months, 1 year, 5 years, 10 years, and beyond. We don’t get what we want; we get what we measure. Not only does the great endodontic clinician do it well, our teeth have to last a long time. Mother Nature has offered us her agreement. We can comply or commit. The choice is ours, and we make that choice with every motion we make in the endodontic treatment. We have thousands of choices in every given patient treatment. What will your treatment mechanics choices be during all those motions, moments, and movements for your next patient? For Mother Nature, the “X” factor is the difference that makes the difference. Are you willing to be that difference? EP

References 1. West J. Anatomy matters. Endodontic Practice US. 2012;5(2):14-16. 2. West J. Anatomy matters — part 2. Endodontic Practice US. 2012;5(4):26-27. 3. West J. Anatomy matters part 3. Furcal endodontic seal heals furcal lesion of endodontic origin. Endodontic Practice US. 2012;5(6):22-24. 4. West J. Anatomy matters. Long-term case report. Endodontic Practice US. 2013;6(1):50-51. 5. West J. Anatomy matters. Root canal system anatomy only matters when it matters. Endodontic Practice US. 2013;6(2):56-58. 6. West J. Anatomy matters. Do lateral canals really matter? Part 6. Endodontic Practice US. 2013;6(3):52-53. 7. West J. Anatomy matters. “What’s it all about?” Part 7. Endodontic Practice US. 2013;6(4):52-54. 8. West J. Anatomy matters. “Could it all simply be a coincidence?” Part 8. Endodontic Practice US. 2013;6(5):52-55. 9. Harrington GW, Steiner DR. Periodontalendodontic considerations. In: Walton RE. Torabinejad M, eds. Principles and practice of endodontics. 3rd ed. Philadelphia, PA: W.B. Saunders Company; 2002;466-486.

Endodontic practice 47

ENDOSPECTIVE

The cookbook’s not working — what’s next? Dr. Rich Mounce discusses a superior method for cleaning canals

s an endodontist, whether challenging teeth or challenging patients (or both combined), the world inside my operatory is often complex due to the fact that to date, there is no magic wand to non-negotiably clean canals efficiently, predictably, and safely. Such challenges are met at the operatory door often by a “cookbook” clinical approach marketed by the dental industry and manifested as single file instrumentation and single cone obturation techniques (among many such concepts) sold with an emphasis on speed, simplicity, and cost savings. While these materials and techniques look great on paper and do most often work, the cookbook algorithm is not a substitute for sound principles, knowing where iatrogenic danger is present and what is in the patient’s best interest (especially with regard to restorability). The cookbook often meets the real world at places called a separated file, canal blockage, and apical extrusion, fractured roots, among many potential clinical misadventures. Using an algorithmic (cookbook) approach in the case pictured in Figure 1, (tooth No. 20) is the harbinger of a problem. My company, MounceEndo, markets a wide variety of endodontic products, the same products I use in my fulltime endodontic practice. As an owner and clinician, should I market a one-size-fitsall approach, or provide a broad base of options? Emphatically, my answer is “no” to the cookbook and “yes” to the options. When the tooth has not read the cookbook, iatrogenic issues are soon to follow. In the operatory, where it matters, clinicians should have options and be able to change

Dr. Mounce is in fulltime endodontic practice in Rapid City, South Dakota. He has lectured and written globally in the specialty. He owns MounceEndo, an endodontic supply company also based in Rapid City, South Dakota. Dr. Mounce has no commercial interest in Sonendo. He can be reached by phone at 605-791-7000 or by email at RichardMounce@MounceEndo.com, MounceEndo.com. Twitter: @MounceEndo

48 Endodontic practice

Figure 1

the recipe at will, as long as the destination is the same, optimal three-dimensional cleaning, shaping, and obturation of the canal system. It bears asking, is reciprocating single file or carrier-based obturation the solution for every canal encountered? If you ask a salesperson, the likely answer is “yes”. Inside the operatory door, my answer is “no”. If these and other technologies and materials are all superior, why are there so many options, and why do some manufacturers sell so many different systems within the same category, for example, multiple instrumentation systems? I suspect in large measure, because at the present time, none is truly superior. If any one system or method were truly superior, we would all be using it, and all the time! The above notwithstanding, my reading of the tea leaves is that in the foreseeable future, the myriad array of everevolving instrumentation and obturation methods will, to one degree or another, become obsolete with the emergence of a new and novel disruptive canal cleaning technology called Sonendo® (Sonendo. com). Sonendo, a multisonic cleaning method, is the future of the endodontics. The technology, now being tested at

multiple levels, with breathtaking results, is highly effective, easy to use, and comfortable for the patient. Sonendo will likely settle the debate about optimal methods and materials for any given anatomy — this may be the first true universally accepted “superior” method of cleaning canals. I really wish Sonendo had been available for the case pictured in Figure 1! It is the closest thing I believe we will see to a magic wand for generations to come. Stay tuned. For the present, until Sonendo or a facsimile arrives, when the cookbook is not working, what next? The astute clinician, while having favored materials and techniques, must foresee where iatrogenic events lurk and be able to turn on a dime using a new recipe to complete the procedure to the highest standard possible, given a challenging patient, challenging tooth, or a combination of both. Regardless of which clinical space one lives in, endodontist or generalist, the best procedure is one where the materials and techniques employed are chosen individually for the specific indication, not made to fit from limited options. Patient and doctor, and ultimately the profession, will all be the better for it. I welcome your feedback. EP Volume 7 Number 1

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The AEU-27A-ME Electric endodontic motor is customized with rpm and torque pre-sets for the MounceFiles in Controlled Memory and Standard Nickel Titanium. Alternatively, the rpm and torque can easily be adjusted for any rotary nickel titanium file on the market. Solid performance at a great price. $1595.

Stropko Irrigators

The Stropko irrigator can be used in every dental procedure to assure a gentle and effective stream of water and/or air for superior and efficient cleaning and drying of any surface or working area. The Stropko easily adapts to old or new air/water dental syringes. Priced at $75

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PRODUCT INSIGHT

What is the ideal endodontic interappointment medicament, and what are its most effective placement and removal techniques? Drs. Carlos A.S. Ramos, Richard D. Tuttle, and Mr. Daniel C. White explain the benefits of UltraCal® XS

ue to the central role of microbes in the pathogenesis of primary apical periodontitis, it is logical that eradication of the microorganisms from the infected tooth is regarded as the key to healing. The technical and biological goal of root canal treatments is to shape the root canal(s) in such a way that complete disinfection can be achieved and the root canal system can be prepared for successful obturation. If eradication of the infection cannot be successfully completed and if the residual microbes communicate with host tissues, healing will be compromised. Furthermore, the new ecological environment may contribute to the development of a more resistant facultative microflora. The most common sites for bacteria to remain after root canal therapy are in

the apical portion of the main canal and in the apical delta (the apical lateral canals). In teeth affected with apical periodontitis, the bacteria residing in the dentinal tubules can develop a biofilm on the external root

Dr. Carlos Spironelli Ramos graduated in dentistry in 1987 from State University of Londrina, Brazil. During that year he got a scholarship to study in Japan at the University of Tokyo. In 1990, he received the title of Endodontics Specialist from the University of São Paulo, Bauru School of Dentistry. From 1991 to 1993, he attended the Master’s program in endodontics at the same university, receiving a Master of Science degree and presenting a dissertation on accuracy of apex locators in vitro. From there, he began the PhD program in endodontics, completing it in 1997 and culminating in his presentation of an in vivo thesis on apex locators. In the same year, he published his first book, Endodontics, Biological and Clinical Foundations. From 1995 to 2012, as Professor of Endodontics at the State University of Londrina, he coordinated the endodontics sector, predoctoral endodontic dental course, and graduate program. Now Dr. Ramos is an Adjunct Professor in the Endodontics Department at Roseman University, College of Health Sciences, Salt Lake City, Utah. He has performed many lectures, hands-on workshops, and conferences in the U.S. and other countries each year, and has published articles in national and international journals. Dr. Richard Tuttle practices general dentistry in a limited practice in South Jordan, Utah, while also serving as the R&D Clinical and Laboratory Division Manager and the Clinical Applications Advisor for Ultradent Products, Inc. Dr. Tuttle graduated from the University of Iowa in 1975 with a Doctor of Dental Surgery degree. After graduating, he served for 2 years in the U.S. Navy where he practiced endodontics for 1½ years. He then entered private practice in Utah, performing general dentistry. In 1979, he entered the U.S. Air Force as a general dentist and spent 2 years performing endodontics, including surgical treatment. After completing an Advanced Clinical Dentistry Residency in the U.S. Air Force, he managed dental clinics and hospitals for the Air Force while maintaining a general dentistry practice. Daniel C. White earned a Bachelor’s degree from Brigham Young University and a Master’s degree from the Marriott School of Management. He has been working in the dental industry for over 17 years. He has lectured to dentists and dental schools in the United States, as well as several countries abroad, and has coauthored several articles for domestic and international publications. His career in the dental industry started with Ultradent Products, Inc., — Bachelor’s degree in 1996, where he held positions ranging from Director of Marketing to Director of Product Development. In 2003, he was recruited by a large cosmetic dental lab in his home state of California to be the Vice President of Marketing. During his tenure there, the lab’s revenue increased by over $12 million. He was responsible for branding and launching several new types of restorations as well as overseeing a multimillion-dollar consumer education campaign. In 2008, he was offered a position to oversee the marketing of a prominent dental company in the U.K. He lived near both the home office located in Yorkshire, England, as well as the division in Mallorca, Spain. In 2011, he returned to Ultradent, where he is currently enjoying working as the Global Brand Manager of the endodontic product line.

50 Endodontic practice

surface. In such teeth, there is a strongly increased possibility that invasion of dentin by microbes from the main root plays a major role in the development and resistance to treatment of endodontic infections. This will usually result in the development of a resistance to future treatments for endodontic infections. There are several necessary elements in the control of endodontic infection, each of which could be the cause of treatment failure or prolong the healing process. These elements include complete canal instrumentation, adequate irrigation during the procedure, and the proper placement of a medicament in the canal between appointments. The presence of biofilm in these situations makes the proper chemomechanical preparation paramount in any endodontic treatment. The biofilm and the surface layer of infected dentin must be eliminated during the instrumentation and chemical irrigation of the canal. Complex internal anatomy such as canal fins, wings, recesses, or isthmuses make absolute cleaning and disinfection nearly impossible. The popular engine-driven instrumentation techniques currently used can only reach the central body of the canal. These techniques will leave areas of the canal untouched because their design prohibits them from reaching and removing the microbes residing in the irregular recesses and apical ramifications of the canals. These are the same bacteria Volume 7 Number 1

Volume 7 Number 1

syringe through a 29ga NaviTip® delivery tip directly into the canal. The alternative to this technique is mixing a calcium hydroxide paste in the operatory and then using a spiral instrument to place the material into the canals. The syringe-delivered UltraCal XS technique is faster and more dependable for less-experienced operators or those practitioners not performing this treatment on a regular basis. The quality of the placement of calcium hydroxide in the canal system during the early stages after extirpation/debridement can be affected by the degree of remaining adherent tissue within the canal and possible persistent exudation. In such situations, the properties of the UltraCal XS paste when used as an interappointment medicament allow the inflammatory symptoms to subside and allow better fill at the second visit. As well as producing a more reliable result, especially in posterior teeth, the placing of Ca(OH)2 with a 29ga NaviTip eliminates the possibility of separating a spiral instrument during the procedure. When there is instrument separation in the canal, it is troublesome for the treating dentist and may possibly require the involvement of a specialist. UltraCal XS allows the operator to deliver the correct amount of Ca(OH)2 to the working length, preventing any material from being inadvertently extruded past the open apex into the periradicular tissues, especially if a chronic or large lesion is present. UltraCal XS formulation has been shown to have good antibacterial activity starting in as quickly as 12 hours. Studies have shown it is more effective over longer periods of time when compared with camphorated paramonochlorophenol (CPMC) and less toxic than formocresol. The prolonged antibacterial activity of UltraCal XS is the result of its ability to destroy bacterial cytoplasmic membranes by releasing hydroxyl ions, and the activation of tissue enzymes such as alkaline phosphates. Studies have shown that up to 35% of 16-year-old males have suffered either primary or secondary dentition trauma. This demonstrates how common this trauma occurs in adolescents and how important it is that there is a reliable product and quick and simple technique available on the market. When a treatment requires apexification, the Ca(OH)2 must be placed into the open-ended canal to provide a

The properties of the UltraCal XS paste when used as an interappointment medicament allow the inflammatory symptoms to subside and allow better fill at the second visit.

favorable environment for the formation of a hard-tissue barrier. A paste preparation containing nonsetting calcium hydroxide can be difficult to completely remove from the canal walls without the proper materials and technique. The paste is difficult to remove because of the irregular surfaces of the canal walls. It has been shown that UltraCal XS can be removed by using 20% citric acid and the NaviTip® FX® tip. This is a strong but flexible delivery tip with small fibers attached to the last few millimeters, making it look like a miniature bottle brush. The citric acid is expressed into the canal and used to “scrub” away the paste from the canal walls. After approximately 60 seconds, the citric acid has softened and broken down the UltraCal XS so it can then be easily rinsed away. Once the canal has been adequately rinsed, it is ready for obturation. EP

References Setzer FC, Kim S. Comparison of long-term survival of implants and endodontically treated teeth. J Dent Res. 2014;93(1):19-26. Vera J, Siqueira JF Jr, Ricucci D, Loghin S, Fernández N, Flores B, Cruz AG. One- versus two-visit endodontic treatment of teeth with apical periodontitis: a histobacteriologic study. J Endod. 2012;38(8):1040-1052. Haapasalo M, Shen Y, Ricucci D. Reasons for persistent and emerging post-treatment endodontic disease. Endod Topics. 2008;18(1):31-50. Zmener O, Pameijer CH, Banegas G. An in vitro study of the pH of three calcium hydroxide dressing materials. Dental Traumatol. 2007;23(1):21-25. Haapasalo M, Shen Y. Current therapeutic options for endodontic biofilms. Endod Topics. 2010;22(1):79-98. Gibson R, Howlett P, Cole BO. Efficacy of spirally filled versus injected non-setting calcium hydroxide dressings. Dental Traumatol. 2008;24(3):356-359. Pérez F, Franchi M, Péli JF. Effect of calcium hydroxide form and placement on root dentine pH. Int Endod J. 2001;34(6):417-423.

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PRODUCT INSIGHT

associated with apical periodontitis that are found in the dentinal tubules. Proper use of chemical irrigation will help disinfect these areas, but the antibacterial irrigants are not left in the canal long enough for them to reach effective concentrations that would kill bacteria harbored in these anatomic complexities. An interappointment medication is used so that the prolonged exposure will allow the chemical to have the proper antibacterial effect in those areas inaccessible to instruments and/or irrigants. The most effective interappointment dressing is a material that is not easily dissolved and replaced by tissue fluid and that can remain relatively intact over weeks or months. A calcium hydroxide paste combines several attractive features of a good canal dressing. It is strongly alkaline (pH 12.5) and dissociates into calcium and hydroxide ions in an aqueous solution without completely dissolving. The released hydroxide ions are absorbed into the surrounding tissues, elevating the pH, which provides the antimicrobial effect. Because of the fairly low solubility of the paste, it may be left in the canals for relatively long periods of time. Calcium hydroxide is also effective in arresting inflammatory root resorption and promotes the reparative process of periapical tissues resulting in the formation of hard tissues. One of the advantages of calcium hydroxide is that it has an effect on microorganisms even when not in direct contact. This is because of the high pH environment created and because it absorbs the CO2 required by bacteria for growth. Therefore, the most effective formulation of the Ca(OH)2 material will allow the hydroxyl ions to escape and diffuse into the dentinal tubules or pass through the apical foramen and reach surrounding tissues. The best technique for using calcium hydroxide is to place and condense the paste into the canals. Historically, this has been done with the same instrumentation files or engine-driven paste carriers, and can be difficult to execute—especially when working with very narrow or curved canals. One canal dressing currently on the market is UltraCal® XS from Ultradent Products, Inc. It is an aqueous, radiopaque formulation of nonsetting calcium hydroxide paste with a pH of 12.5. This premixed paste is delivered or “injected” from a

PRACTICE MANAGEMENT

Feedback – lateral thinking Jacqui Goss explains how to gather reliable patient feedback

e all want to know what our patients think, so let’s apply some lateral thinking to finding out what makes them tick. I read the Dental Complaints Service Annual Review 2011-2012 recently. The Dental Complaints Service is a team of trained advisors in the U.K. who help private dental patients and dental professionals settle complaints about private dental care. This is a free service, funded by the General Dental Council, the organization that regulates dental professionals in the U.K. The headline news from the report is that complaints increased by 17% compared with the previous year. What I focused on in respect of this article is that root canal treatment was equal fourth (with implants) in the top five treatment types for complaints. Of all complaints received, the Dental Complaints Service (DCS) resolved two thirds in less than a week. The DCS has recovered in excess of one million pounds (which is equivalent to $1.64 million U.S.) for patients since it began operating 6 years ago. Do these two facts suggest that not only is the DCS doing a good job, but that many complaints are readily resolved with dentists not holding back when it comes to giving financial compensation? For you as an endodontist, the inference from this report is that you should receive relatively few complaints (9% or less of your total patients) compared with other general and specialist dental practices. The complaints should be resolved quickly, and they may involve a refund or free treatment.

What patients dislike The other information of great interest in this review is the most frequent concerns raised by patients. They are: • Not being made aware of the prognosis of treatment or alternative treatment options

Jacqui Goss is a dental consultant in the U.K, and also the managing partner of Yes!results. For futher information, please visit www.yesresults.co.uk.

52 Endodontic practice

• Information or clinical terminology not explained fully • A refusal to continue care or ignoring attempts to resolve the matter when concerns were raised. To my mind, the first two reinforce the need for all dental practices to employ (either in-house or subcontracted) a patient coordinator. This is someone who (unlike a dentist) has the time to explain fully to a patient what a treatment plan involves – how long it will take, what lifestyle considerations/ restrictions may be involved, any on-going aftercare required for the patient, the expected results and, importantly, how they can pay for it. A patient coordinator needs some clinical knowledge – focusing on root canal treatments in the case of a specialist endodontic practice – but not full clinical training. Indeed, patient coordination works best when patients feel they are discussing the treatment plan with someone who is knowledgeable of dentistry that is not way above their own understanding. You may be surprised to learn that your evident expertise may actually make patients reluctant to ask questions for fear of feeling foolish. A good patient coordinator will automatically translate dentistry jargon into everyday language and explain the

meaning of clinical terminology. Clinically trained dentists, particularly specialist dentists, can find this harder to do when talking with patients, as their everyday “working” language is necessarily jargon rich.

Google alerts According to a link I found via Google, 60,000 new websites and 140 million tweets are created daily (this information was current last December; the numbers are probably much greater now). I’m illustrating (as if I need to) that there’s a lot of information out there. A tiny, tiny proportion of it could be useful to you. Now, I’m assuming that you already have mechanisms for being alerted to clinical news. I suggest you also look into Google Alerts (www.google.com/alerts). With this free service you receive emails when there are relevant Google results based on your queries – a sort of daily automatic “Google.” Requesting, for example, “dental research news” can be quite useful. This drew my attention to an article in Rochdale Online (which I would never have seen otherwise) about research that had shown dentists are more trusted than doctors. A quotation from psychologist, Emma Kenny, caught my eye. She said: “Trust underpins much of our motivation in life; when we feel that someone is on our Volume 7 Number 1

How do you build trust? This sounds to me as though neurolinguistic programming (NLP) might provide some answers. I’m not an NLP expert, but

I have colleagues who are, and I’ve gained a working knowledge of it as a result. In order to gain trust, NLP states that you must establish rapport. This is done in a number of ways, which there is only space to describe briefly here. There’s body language and facial expressions – I guess we’re all familiar with the “shifty eyes” and hence untrustworthy person. There’s how you speak and the words you use. NLP advises matching a person’s tone and pace (and so on) of speaking and using the exact same words to avoid misunderstanding. For example, a patient might say: “Did you say you’ll fill my roots with a sort of rubber substance? Won’t this make my teeth feel funny?” Your reply could be: “Yes, it is a rubber-like material, which we call gutta percha. On top of that I’ll put a normal filling so, no, your teeth won’t feel funny.”

Keeping the patient happy • Patient complaints increased by 17% last year

• Think about what patients need to feel secure with the service they are receiving • Try not to bombard patients with dental jargon • Employ a patient coordinator to help explain procedures • Attempt to build rapport with your patients. You should also try to match experiences. I guess this is why politicians so often talk about their upbringing, schooling, family life, working life and so on – to attempt to “connect” with the widest section of the population. You might say: “I had an operation to replace damaged knee cartilage a few years ago – a rugby injury. I was the same as you – wanting to know exactly what was involved, so go ahead and ask as many questions as you like.” The same processes of building trust with patients also applies to your patient coordinator, of course. For reasons explained earlier in this article, a patient coordinator may find creating this relationship easier than you. EP

The must-read journal for US Endodontists! 3 EASY WAYS TO SUBSCRIBE VISIT www.endopracticeus.com EMAIL agood@medmarkaz.com CALL 1.866.579.9496

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Volume 7 Number 1

Endodontic practice 53

PRACTICE MANAGEMENT

side and has our best interests at heart, it makes sense that we will act in accordance with their suggestions.” The British Dental Trade Association (BDTA) published results from a similar survey called Perceptions of Dentistry and Motivation Research in April 2012, and one of its findings was: “Customers typically rely on their dentist and trust their advice and the majority say they would ask their dentist if they wanted to find out more about non-essential dentistry.” You can access the full results via the BDTA website (www.bdta.org.uk/ perceptions-of-dentistry). Here we have the results of two surveys that no endodontist could afford to carry out – even within their local area – but that yield gems of information, including that trust is important to patients.

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Efficient endodontics with ScanX Swift™ The ScanX Swift™ (Air Techniques) is a one-slot PSP processor that is small enough to fit on a countertop in a dental treatment room. It’s benefits include: • Compact for chairside intraoral images that fits in any operatory. • Accepts sizes: 0, 1, and 2. • Significantly more image area. ScanX’s thin, cordless phosphor sensors can capture 17% - 38% more image area. • Capture the complete coronal-to-apical length. • Provide more mesial-distal information. • Never miss a root tip or distal cusp. • Fewer retakes. • ScanX flexible sensors deliver sharp, clear digital images. • 30 times thinner than rigid sensors, and cordless. • Less expensive than rigid sensors. • No annual maintenance costs. For more information, visit http://www.airtechniques.com/.

SuperEndo™ compact, convenient, smart and versatile, consistent heat, 3D-obturation DEXIS, an industry leader and the manufacturer of the highly awarded DEXIS® Digital X-ray system, is now in the process of completing its development for the Mac platform and will soon be expanding its Imaging Suite of products to natively support Apple® hardware and the OS X operating system 10.8.0 and above. DEXIS Mac™ is an innovative dental imaging solution that offers dentists a unified experience across Mac and iOS products. Once released, the native OS X software will provide clinicians with a highly efficient digital imaging workflow and seamless integration with Mac-based practice management programs Viive™ and MacPractice®. This DEXIS software product will provide an intuitive user interface and advanced functionality that Mac users expect — combined with tried-and-true DEXIS image management and enhancement tools, as well as a tight integration with the awardwinning DEXIS go® app for patient communication, and the justreleased DEXIS photo™ app for extra-oral image acquisition. For more information, visit http://www.dexis.com.

Affinity for consistently accurate impressions Research shows that 89% of partial denture impressions have detectable errors (voids, tearing, as well as flow issues) that will impact the fit of the final restoration.* These errors were especially prevalent where the sulcus was less than 0.20 mm in width. Tissue management varies from patient to patient and dentist to dentist. Light Body XL is designed to flow into virtually any sulcus. Light Body XL has the highest flow on the market with exceptionally high tear strength. Available in regular set only. *Samet N, Shohat M, Livny A, Weiss E. A clinical evaluation of fixed partial denture impressions. Journal Prosthet Dent. 2005 Aug; 94(2):112-117.

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54 Endodontic practice

SuperEndo-α2 Cordless obturation device for optimal warm vertical condensation • Maximizes user convenience — Unique design that incorporates cordless and ergonomic features. • Balance — Great weight distribution for ease of use. • Cordless — No limit on usage, reduces fatigue on hand and wrist. • Hexagonal keyholes — Six keyholes (in increments of 60 degrees) on the connecting joint of the plugger safely secure and prevent rotation of the plugger during use. • Extended battery time for operator — 4 hours of continuous use on a single charge, equivalent to about 1 week of endodontic treatment in a busy practice. SuperEndo-ß Cordless Obturation device for optimal Backfill (Filling) • Unique design and engineering — Incorporates the 360 degree swivel needles, as well as cordless and ergonomic features, for maximum user convenience. • Balance — Great weight distribution for ease of use. • Cordless — No limit on usage, reduces fatigue on hand and wrist. • Secondary safety feature against accidental burns — Thermal protector cap that prevents accidental burns from a hot needle or gutta percha. • Extended battery time for operator — 4 hours of continual use on a single charge, equivalent to about 1 week of endodontic treatment in a busy practice. For more information, visit B&L Biotech http://www.bnlbio.com/.

Volume 7 Number 1

AUTHOR GUIDELINES

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

Submitting articles Endodontic Practice US requires original, unpublished article submissions on endodontic topics, multidisciplinary dentistry, clinical cases, practice management, technology, clinical updates, literature reviews, and continuing education. Typically, clinical articles and case studies range between 1,500 and 3,000 words. Authors can include up to 15 illustrations. Manuscripts should be double-spaced, and all pages should be numbered. Endodontic Practice US reserves the right to edit articles for clarity and style as well as for the limitations of space available. Articles are classified as either clinical, continuing education, technology, or research reports. Clinical articles and continuing education articles typically include case presentations, technique reports, or literature reviews on a clinical topic. Research reports state the problem and the objective, describe the materials and methods (so they can be duplicated and their validity judged), report the results accurately and concisely, provide discussion of the findings, and offer conclusions that can be drawn from the research. Under a separate heading, research reports provide a statement of the research’s clinical implications and relevance to endodontic dentistry. Clinical and continuing education articles include an abstract of up to 250 words. Continuing education articles also include three to four educational aims and objectives, a short “expected outcomes” paragraph, and a 10-question, multiple-choice quiz with the correct answers indicated. Questions and answers should be in the order of appearance in the text, and verbatim. Product trade names cited in the text must be accompanied by a generic term and include the manufacturer, city, and country in parentheses. Additional items to include: • Include full name, academic degrees, and institutional affiliations and locations • If presented as part of a meeting, please state the name, date, and location of the meeting • Sources of support in the form of grants, equipment, products, or drugs must be disclosed • Full contact details for the corresponding author must be included • Short author bio • Author headshot Volume 7 Number 1

Pictures/images

Disclosure of financial interest

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

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

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

References References must appear in the text as numbered superscripts (not footnotes) and should be listed at the end of the article in their order of appearance in the text. The majority of references should be less than 10 years old. Provide inclusive page numbers, volume and issue numbers, date of publication, and all authors’ names. References should be submitted in American Medical Association style. For example: Journals: (Print) Greenwall L. Combining bleaching techniques. Aesthetic & Implant Dentistry. 2000;1(1):92-96. (Online) Author(s). Article title. Journal Name. Year;vol(issue#):inclusive pages. URL. Accessed [date]. Or in the case of a Book: Greenwall L. Bleaching techniques in Restorative Dentistry: An Illustrated Guide. London: Martin Dunitz; 2001. Website: Author or name of organization if no author is listed. Title or name of the organization if no title is provided. Name of website. URL. Accessed Month Day, Year. Example of Date: Accessed June 12, 2011. Author’s name: (Single) Doe JF

(Multiple) Doe JF, Roe JP

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

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

Proofing Page proofs will be supplied to authors for corrections and/or final sign off. Changes should be limited to those that are essential for correctness and clarity. Articles should be submitted to: Mali Schantz-Feld, managing editor mali@medmarkaz.com

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

Checklist for article submissions: 3 A copy of the manuscript and figures/ captions, including all pictures (low res) necessary for reviewers 3 Manuscript: double-spaced including separate references, figure legends, and tables 3 Abstract, educational objectives, expected outcomes paragraph 3 References: double-spaced, alphabetical, American Medical Association style 3 Tables: titled and cited in the text 3 Mandatory submission form, signed by all authors Please contact managing editor Mali SchantzFeld with any questions via email: Mali@medmarkaz.com

Endodontic practice 55

DIARY

lllllllllllllllllllllll OF EVENTS llllllllllllllllllllllllllllllllllllllllllllllllllll CE Courses Endodontic Solutions: Strategies for Performing Endodontic Treatment Predictably, Profitably, and Painlessly Dr. Gary Glassman February 7, 2014 www.sybronendo.com Current Scientific Evidence in Endodontic Therapy Dr. George Bruder February 21, 2014 Albuquerque, NM www.tulsadentalspecialties.com/default. aspx Current Scientific Evidence in Endodontic Therapy Dr. Kevin Edwards March 7, 2014 Spokane, WA www.tulsadentalspecialties.com/default. aspx Current Scientific Evidence in Endodontic Therapy Dr. Diwakar Kinra March 14, 2014 Cincinnati, OH www.tulsadentalspecialties.com/default. aspx Current Scientific Evidence in Endodontic Therapy Dr. George Bruder March 21, 2014 Charlotte, NC www.tulsadentalspecialties.com/default. aspx Current Scientific Evidence in Endodontic Therapy Dr. David Landwehr March 28, 2014 St. Louis, MO www.tulsadentalspecialties.com/default. aspx

Events Midwinter Meeting February 20-22, 2014 Chicago, IL www.sirona.com/en

56 Endodontic practice

2014 Spring Scientific Meeting: The Biomechanics of Root Canal Treatment Dr. Anil Kishen Dr. Paula Ng March 8, 2014 London, England www.britishendodonticsociety.org.uk/ 2014 ADEA Annual Session & Exhibition March 15-18, 2014 San Antonio, TX www.adea.org

Free webinars

One and Done? The Nuances of Single-File Endodontics Dr. Esther Tam www.tulsadentalspecialties.com/default. aspx Optimizing Root Canal Cleaning and Disinfection Dr. Markus Haapasalo Dr. James Gutmann www.tulsadentalspecialties.com/default. aspx

A New Look at Filling Techniques Dr. Sergio Kuttler www.tulsadentalspecialties.com/default. aspx

Root Morphology and Material Selection On Demand Webinar Dr. William Nudera www.tulsadentalspecialties.com/default. aspx

Changing the State of Obturation Dr. William Nudera www.tulsadentalspecialties.com/default. aspx

Start to Finish Dr. Clifford Ruddle www.tulsadentalspecialties.com/default. aspx

Endodontic Case Selection Dr. Diwakar Kinra www.tulsadentalspecialties.com/default. aspx

The Missing Link in Carrier-Based Obturation Dr. Stephen Niemczyk http://www.tulsadentalspecialties.com/ default.aspx

Endodontology: Diagnosis Dr. George Bruder www.tulsadentalspecialties.com/default. aspx Making Waves in Canal Shaping: Single File Dr. Robert Roda www.tulsadentalspecialties.com/default. aspx Mastering Compaction of Warm Vertical Techniques for Predictability Obturating 3D Root Canal Systems Dr. Thomas McClammy www.tulsadentalspecialties.com/default. aspx More Clean, More Fill: The Latest Techniques and Tools of Root Canal Irrigation and Obturation Dr. David Landwehr www.tulsadentalspecialties.com/default. aspx

Tip Taper and Blue: When New Instruments Meet Tried and True Techniques Dr. Frank Cervone www.tulsadentalspecialties.com/default. aspx Tsunami Irrigation Dr. Clifford Ruddle www.tulsadentalspecialties.com/default. aspx Ultrasonic Irrigation Dr. John Nusstein www.tulsadentalspecialties.com/default. aspx What Tool to Use: Why, Where, and How Dr. John West www.tulsadentalspecialties.com/default. aspx

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