Endodontic Practice US - March/April 2014 - Vol7.2 - AAE Show Issue by MedMark, LLC

clinical articles • management advice • practice profiles • technology reviews

A new concept in canal preparation Dr. Ghassan Yared

TF™ Adaptive: a novel approach to nickel-titanium instrumentation

ENDODONTICS

Clinical guidelines for the use of ProTaper Next™ instruments: part 2 Drs. Peet J. van der Vyver and Michael J. Scianamblo

Drs. Gianluca Gambarini and Gary Glassman

Practice profile

Product profile

Corporate profile

Coltene Surgitip-Endo

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Dr. Ernest Reeh

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March/April 2014 – Vol 7 No 2

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T h e V-Tape r™2H NITI rota ry endodontic fil e system util izes onl y 3 fil es to a llow y ou to complete m os t root can al cases. The V-Taper™ 2H performance enha nced system is the only sy stem that off e rs you t h e se industry l eading adv a ntages, a l l in one fil e:

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Endodontist Recommended “All dentin is not created equally, EndoGuide® Burs and V-Taper™2H Files foster conservation at the heart of the tooth, peri-cervical dentin. The preservation of healthy dentin leads to longer lasting restorations.” – Dr. Eric Herbranson, Endodontist

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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

PUBLISHER | Lisa Moler Email: lmoler@medmarkaz.com MANAGING EDITOR | Mali Schantz-Feld Email: mali@medmarkaz.com Tel: (727) 515-5118 ASSISTANT EDITOR | Elizabeth Romanek Email: betty@medmarkaz.com EDITORIAL ASSISTANT | Mandi Gross Email: mandi@medmarkaz.com DIRECTOR OF SALES | Michelle Manning Email: michelle@medmarkaz.com NATIONAL SALES/MARKETING MANAGER | Drew Thornley Email: drew@medmarkaz.com

Striving for perfection The theme of the upcoming AAE meeting in Washington, DC, is “Striving for Perfection.” What a great title for an annual meeting and life philosophy. One of the aspects we enjoy the most about having six partners at Commonwealth Endodontics is the impromptu discussions on treatment planning and patient management that have helped us as we strive for perfection. Just over a year ago, we added cone beam computed tomography (CBCT) to our office. Although we knew that it would be an important tool to have at our disposal, we were not sure of the benefits it would offer. After all, we have been providing top level care for over 15 years without a CBCT. “How would a CBCT really improve our patient care?” was the lingering question. Like other important advances that have specifically benefited the specialty of endodontics, the CBCT is considered an indispensable tool for treatment. Although the CBCT has value in general practice and other dental specialties, its impact will likely be the greatest on endodontics. Having the ability to appreciate the tooth in three dimensions revolutionizes patient care. No longer are we wholly dependent on a static two-dimensional image that provides an incomplete picture. Finally, we can see the tooth in its true form. One immeasurable advantage of the CBCT is how it provides a platform for patient discussions. Unlike two-dimensional static radiography, we are able to move throughout a tooth and surrounding tissues to help tell a story. The story can be about a cracked tooth where the patient can now see the resulting bone loss at the level that the crack propagates. The story can be about a periapical radiolucency that was obscured by the maxillary sinus. The story can be about how extensive the resorptive defect really is. Ultimately, the CBCT empowers the patient to make better informed treatment decisions. The conversation changes from “We can access your tooth and see if we can locate another canal” to “The canal right there needs to be located.” The CBCT has made treatment, retreatment, and apicoectomies more predictable. It has also made the choice of extraction and replacement more clear. We have been able to save our patients money, time, and have spared them postoperative discomfort by being able to make more accurate and appropriate diagnoses with CBCT imaging. The AAE recommends the use of CBCT imaging for a variety of purposes. These uses include evaluating canal and root morphology, diagnosis of periapical and non-endodontic pathology, intraoperative and postoperative assessment, root resorption, trauma, pre-surgical treatment planning, and dental implant treatment planning. We ultimately chose the Orthophos® XG 3D by Sirona. This unit provides options for both small view and mid-size views. The small view provides 100-micron slices of a sextant for endodontic evaluation. The voxel size for both the mid and small views are well below the AAE-recommended maximum limit for endodontic evaluation. Our mid-size views have been requested by general dentists and specialists alike who do not have CBCT imaging capabilities in their offices. They typically prefer the mid-size view because they would prefer to see the entire maxillary and mandibular arch. Referral for CBCT has been requested for TMJ evaluations, implant placements, and hard structure pathology evaluations. The Orthophos XG 3D unit integrates nicely with the Cerec system, allowing complete restoration and placement of implants and other teeth that includes everything from the surgical stents to the crown milling. Being able to provide CBCT imaging for our referring dentists has augmented how we have become of further assistance to our community. While you are at the annual meeting this year, I encourage you to take time out to visit the vendors and ask questions of them. Then ask your colleagues how it has changed their practice. You will be pleasantly surprised at how well CBCT imaging benefits your practice. In the words of many of our patients, “That’s amazing!” One note of caution; if you try CBCT imaging, you will not want to practice without it.

PRODUCTION MANAGER/CLIENT RELATIONS | Adrienne Good Email: agood@medmarkaz.com PRODUCTION ASST./SUBSCRIPTION COORD. | Jacqueline Baker Email: JBaker@medmarkaz.com MedMark, LLC 15720 N. Greenway-Hayden Loop #9 Scottsdale, AZ 85260 Fax: (480) 629-4002 Tel: (480) 621-8955 Toll-free: (866) 579-9496 Web: www.endopracticeus.com www.medmarkaz.com SUBSCRIPTION RATES 1 year (6 issues) 3 years (18 issues)

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© FMC, Ltd 2014. All rights reserved. FMC is part of the specialist publishing group Springer Science+Business Media. The publisher’s written consent must be obtained before any part of this publication may be reproduced in any form whatsoever, including photocopies and information retrieval systems. While every care has been taken in the preparation of this magazine, the publisher cannot be held responsible for the accuracy of the information printed herein, or in any consequence arising from it. The views expressed herein are those of the author(s) and not necessarily the opinion of either Endodontic Practice or the publisher.

Volume 7 Number 2

Dr. Tim Finkler Dr. Tim Finkler received his DDS and Certificate in Endodontics from the Virginia Commonwealth University. Prior to entering his endodontic program, he completed a 2-year General Practice Residency at McGuire Veterans Affairs Medical Center in Richmond, Virginia. He received a BS in Electrical Engineering from The Virginia Military Institute and practiced as a Registered Professional Engineer before his dental career. He retired from over 20 years of service in the Virginia Air National Guard. His military service included time with the 203rd REDHORSE and the 192nd Fighter Wing. He is now a partner in Commonwealth Endodontics and practices in Richmond and Newport News, Virginia. Endodontic practice 1

INTRODUCTION

March/April 2014 - Volume 7 Number 2

TABLE OF CONTENTS Clinical Clinical guidelines for the use of ProTaper Nextâ&#x201E;˘ instruments: part 2 Drs. Peet J. van der Vyver and Michael J. Scianamblo illustrate the use of ProTaper Next instruments in difficult and challenging endodontic cases........................ 12

Practice profile

Dr. Ernest Reeh Focus on patients, family, academics, and endodontics

Corporate profile

Ultradent Ultradent continues to keep a finger on the pulse of the endodontic specialty

MTA: the new material of choice for pulp capping Drs. Leendert (Len) Boksman and Manfred (Manny) Friedman delve into the benefits of MTA .................... 20 The influence of mineral trioxide aggregate (MTA) thickness on its microhardness properties â&#x20AC;&#x201D;

ON THE COVER 0.2 mm tooth slice polarized photo Maxillary central incisor Transversal slice.

an in vitro study Drs. Iris Slutzky-Goldberg, Lea Sabag, and David Keinan test the effect of the MTA thickness on its microhardness properties............ 26

Photo courtesy of Dr. Stanislav Heranin

2 Endodontic practice

Volume 7 Number 2

simple, adaptable

endodontic solutions

Perfect delivery. Optimal performance. Easy removal.

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.

Don’t change your technique. Make it easier with UltraCal® XS and Citric Acid 20%. Scan to watch a short video of UltraCal XS.

NaviTip tip

NaviTip FX tip with brush fibers

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

32 3D Apical Cork

Technology 3D Apical Cork — part 3 In the third article of this series, Dr. Wyatt Simons reviews the technological breakthroughs of the Cork technique and system of obturation with emphasis given to the revolutionary 3D plugger ...............32

Continuing education A new concept in canal preparation Dr. Ghassan Yared discusses canal preparation with only one reciprocating instrument without prior hand filing......................................36 TF™ Adaptive: a novel approach

Product profile Sonendo® aims to transform the future of endodontics ................50 Surgitip-endo aspirator tip for root canals .........................................54

Endospective Transcendent endodontics: the seven key attributes Dr. Rich Mounce reflects on the qualities and equipment that can improve future results....................52

Step-by-step The Laschal FXP set incorporates transferred oscillation technology .....................................................56

Legal matters Ethics, morals, and law in the professional office Dr. Bruce H. Seidberg discusses how ethical and moral behavior are governed by law ...........................57

Industry news ............60 Materials & equipment ......................60 Anatomy matters Influence on Fees, Reputation, Longevity, and Because: part 10 Dr. John West discusses four more reasons why anatomy should matter. .....................................................61

to nickel-titanium instrumentation Drs. Gianluca Gambarini and Gary Glassman examine how to achieve rotary motion when you want it — and reciprocation when you need it......42 4 Endodontic practice

Volume 7 Number 2

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

Implantologists

Endodontists

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

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

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

General Practitioners will achieve greater diagnostic accuracy for routine cases.

ORTHOPHOS XG 3D

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.

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

PRACTICE PROFILE

Dr. Ernest Reeh Focus on patients, family, academics, and endodontics What can you tell us about your background? I have a bachelor’s degree in chemistry with a minor in business. I was accepted off of the alternate list for dental school and then attained my DDS degree, graduating third in my class and awarded the James McCutcheon Gold Medal. (This award is presented to the student who, over the 4 years of the DDS program, had shown to possess, to an outstanding degree, those qualities of scholarship, leadership, and character, which may be expected to lead to a distinguished position in the dental profession.) I have taken specialty training in endodontics and have a master’s degree in Material Science, a PhD in Biophysics with a related-field minor in engineering. I am a Diplomate of the American Board of Endodontics (Board Certified) and a former faculty member at the University of Minnesota Endodontics Department. I have consulted for 3M and Carestream Dental (formerly Kodak Imaging), and have lectured both nationally and internationally on a variety of science and dental topics, as well as written peer-reviewed scientific articles and abstracts.

Is your practice endodontics?

limited

Yes.

Why did you decide to focus on endodontics? By my second year in dental school, I developed a keen interest in endodontics. I especially enjoyed the particular attention to the fine detail and the high level of fine motor control needed. I had done research in chemistry and wanted to do research in endodontics. As a result of frequent discussions with the director of the endodontics department, arrangements were made for me to be able to conduct research as a graduating second-year dental student. I was able to present my work at an International Association of Dental Researchers (IADR) conference, as well as have my name associated with three other projects with which I was involved. I continued my research interests, and the following year also presented at 6 Endodontic practice

(AAE) meeting. I have always had a passion for endodontics and enjoy the challenges my many colleagues send me.

How long practicing?

the IADR conference and had my name associated with seven other projects that I had also been involved in during the year and summer break. After dental school, I had wanted to go into endodontics as a specialty, but felt I should appreciate general dentistry before going to graduate school. I worked in a private general dental practice for 2 years and then attended endodontic graduate school. I did research during my endodontic residency and published two papers as a result of my graduate program research, as well as winning a national research award for my student research presentation award at the American Association of Endodontists

have

you

been

I graduated from dental school in 1984 and practiced as a general dentist for 2 years. I then spent 2 years in an endodontic residency, graduating in 1988, and have been practicing as an endodontist since graduation. I went on to do a PhD after my endodontic specialty training but made it a requirement of my PhD program that I was able to do private practice 1 day a week. I worked for 7 years (during and after my PhD program) for Boynton Health Services as their endodontist. I then worked in several group practices before setting up our own endodontic practice with my wife, who is also an endodontist. Currently, I practice 2 to 3 days per week, and my wife practices 2 days per week, so we both can have some time to enjoy our four children ages 11, 9, 9 (yes, twins), and 5 year olds. They grow up so fast, and we both wanted to have time with them.

Who has inspired you? I have had several people who inspired me. Initially, my dad, who told me when I was deciding to either follow chemistry (when I had standing job offers after graduation in chemistry) or go into dentistry (which would have been an unknown). My dad, who was a man of few words, told me, “You have always wanted to be a dentist,” (which I had since I was about 8 years old), and he said to me, “You never want to look back

Volume 7 Number 2

PRACTICE PROFILE

Dr. Reeh’s team

at your life and say, ‘I wish I would have …’” I have lived his “no regrets” philosophy ever since. My other mentors include the head of the endodontics department in dental school, who made doing research possible; Dr. Don Collins, the Dean who created a program when none existed to make it possible for me to do research; Dr. Gordon Thompson and my mentor doing dental research, who was just joining the endodontic faculty at the time; and the abundantly enthusiastic Dr. Ken Zakariasen. In endodontic graduate school, I had two people who had a major influence in my life and career — Dr. Harold Messer, a brilliant scientist and the head of the endodontics division; and Dr. William “Bill” Douglas, a renowned biomaterials expert who opened his lab and mentored me during my masters and PhD programs. I learned many things, not only about dentistry and research, but also about teaching and mentoring.

What is the most satisfying aspect of your practice? I feel most satisfied when my doctors have the confidence in me to refer tough cases that challenge my skills and abilities. As I like to say, “I enjoy challenges; I just hope that not every case during the day will be a Volume 7 Number 2

tough one!” I feel satisfied when I can treat cases that were thought to be untreatable endodontically. I appreciate when I can be a part of their team and be a part of the treatment planning for cases.

Professionally, what are you most proud of? My master’s thesis work. I am sometimes at an endodontic meeting, and a resident will see my name tag and ask if I am the guy who published the work on stiffness of endodontically treated teeth. I reply that I am. Then they tell me that I am “classic literature in endo,” and I reply that I like to think of myself as contemporary literature in endo! I have been told that my work is one of the 10 most referenced papers in dentistry. That makes me very proud of the work I did.

What do you think is unique about your practice? We offer a very personalized experience. We work on one patient at a time, and each gets our undivided attention for his or her appointed time. We have created an environment that is very calming from the appearance of the office, to the music, to the aromas, to the friendly interaction from each staff member. Patients are exquisitely numb, so care is done comfortably. Many patients who tell us they are difficult to get

numb are surprised how easy care is for them.

What has been your biggest challenge? Insurance. Need I say more?

What would you have become if you had not become a dentist? Probably a neurovascular surgeon. I enjoy surgery, and I am very fine motor skilloriented, so it would be another good fit for me.

What is the future of endodontics and dentistry? There is so much information that it is not possible for one person to do everything well. General dentists who take a lot of programs in endodontics certainly advance their skills and can do more and more complex cases but at the expense of other areas of dentistry. Most dentists want some balance in their profession, so they do not want to do more advanced cases. Even those who have trained further still need the help of their endodontist as there is a lot to learn in a 2- to 3-year advanced specialty degree. There continues to be improvements, and it is part of the endodontist’s job to explain the pros and cons to our general dental colleagues. Clearly, as knowledge continues to Endodontic practice 7

PRACTICE PROFILE

Dr. Reeh’s family

expand, the need for specialists becomes increasingly important. Endodontics is not about to be replaced by implants, and we are now seeing that retaining natural teeth is still first best compared to a good second best of an implant as the pendulum starts to swing away from replacing many teeth to preserving natural teeth.

What are your top tips for maintaining a successful practice? There is no easy answer. First and foremost is providing a high level of care, but that is not enough. One has to create an experience for the patient that proves the value in the services provided. On top of it all is maintaining a highly motivated, welltrained staff that enjoy what they do. We create an environment in which the staff enjoys coming to work. Our staff currently averages over 10 years with our office.

What advice would you give to budding endodontists? It is to not about all the devices. Cone beam, torque-sensing motors, and so on are all good, but it is about the patient. One person once told me, “Patients don’t care how much you know until they know how much you care.” Keep the patient experience in the forefront, doing what is right, and the rest will follow naturally.

8 Endodontic practice

What are your hobbies, and what do you do in your spare time? My biggest hobby is my family. I love to spend time with my wife and kids, from little stuff like building a snowman to going to bigger things like going skiing. Four kids always take a lot of effort, but it’s worth it. I hope to share in my kids’ hobbies to the extent they want to include me. My kids enjoy chess, and I am the chess master for the chess club at their school. They wanted to try downhill skiing, so we took up skiing this year. I like cross-country skiing also, but none of them shows much interest, so I haven’t done any for a while. I have a few hobbies of my own that I enjoy. I enjoy automotives through reading car magazines (I subscribe to three), going to the auto show (usually with a friend as the kids typically don’t want to go), going to advanced driving skills courses; and I have an old car that I tinker with. I enjoy camping. I made a campsite down a path in our backyard. The kids and I go camping a couple of times each summer, as well as Cub Scout camps. (Mom typically doesn’t like to camp but, on occasion, is a good sport and joins us.) I have a wood shop in my basement and have a number of projects that I like to do. I am currently working on a chessboard and chess pieces with my boys. I also enjoy cooking. I do not like being a short-order cook preparing multiple different meals for the kids and

grown-ups, but unfortunately, that is most of what I do presently. It is just where we are at in our lives. When I get a chance, I like to cook and bake and am known for the cheesecakes that I make and for presentation of dishes. EP

Top Favorites There are two main aspects to my life: my home and family, and my office and staff. Hence, the list goes in two directions: Family favorites 1. Date night with my lovely wife 2. Kid activities 3. Family game night (Something we do one night per week usually on the weekend.) 4. Our home (I like to just be home and enjoy what we have done.) 5. Enjoying my hobbies Office favorites 6./5. Quiet time (because it is so rare) 4. P5 Newtron® (Satelec Acteon) ultrasonics 3. Schick Elite Digital radiography 2. Carestream 9000D cone beam computed tomography (threedimensional imaging) 1. Our staff (They are all great in their own ways and are an integral part of my life.)

Volume 7 Number 2

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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?

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CORPORATE PROFILE

Ultradent History of Ultradent Ultradent Products, Inc., began when one forward-thinking dentist, Dr. Dan Fischer, set out to create dental products more effective than those that were currently available. Dissatisfied with many dental options, Dr. Fischer hoped to develop better products that were not only advanced for their time but would also set future industry standards.

What began as a family-only business quickly grew as word of Ultradent’s groundbreaking, high-quality products spread. In 35 short years, the company expanded from a small home operation to the 220,000-square-foot facility in South Jordan, Utah, that Ultradent calls home today. Ultradent’s headquarters houses 1,100 employees and continues to expand, breaking ground last fall

products, application device materials, and techniques. Ultradent’s product family now includes world-class adhesives, composites, tooth whitening systems, and endodontic products that are used by clinicians around the world, including dental professionals in large group practices, dental and veterinary labs, private practices, government agencies, and universities. Over the last decade, Ultradent expanded its reach to orthodontics, serving as the parent company for Opal Orthodontics. Also headquartered in South Jordan, Utah, Opal Orthodontics houses its own on-site orthodontic clinic.

By maintaining close relationships with top endodontic researchers at several domestic and international universities, as well as by keeping several highly skilled dentists on staff, Ultradent continues to keep a finger on the pulse of this important and rapidly growing area of dentistry.

A minimally invasive philosophy

Dr. Dan Fischer

It all began in 1974, when, upon graduating from Loma Linda University and starting his own dental practice in the Salt Lake Valley, Dr. Fischer noticed a dire need for more rapid, profound hemostasis. At the time, no products existed on the market that predictably controlled bleeding and sulcular fluid, which made getting accurate impressions and the overall practice of high-quality operative dentistry a challenge. Experimenting with various chemistries after-hours and often drawing his own blood to test their hemostatic effects, Dr. Fischer discovered a solution that, when combined with his innovative scrubbing technique, achieved rapid, profound hemostasis every time. This product, known as Astringedent®, is now considered Ultradent’s flagship product. In order to share it with the industry, Dr. Fischer founded Ultradent in 1978. 10 Endodontic practice

on a 10,000-square-foot building to create space for increased molding and manufacturing. One of the most vertically integrated dental companies in the world, Ultradent manufactures over 90% of its products (which includes over 500 materials, devices, and instruments) at its Utah campus. Instead of saving on production costs through outsourcing, which many U.S. manufacturers do, Dr. Fischer firmly believes in the opposite. He says, “The more one outsources, the more one ships production, or R&D, or other aspects to other parts of the world, the more one loses touch with what has made them who they are.” Ultradent exports approximately 70% of its products internationally to countries in nearly every continent in the world. Ultradent currently holds dozens of patents and trademarks on unique

Dr. Fischer has said, “Respecting and preserving our patients’ dentate throughout their life: this should be among our principal responsibilities. I believe to my bootstraps in respecting human tissues to the ultimate degree, in preserving mineral mother dentin, and in respecting supporting tissues as well. It comes down to first and foremost, remembering the fabulous human behind that oral cavity.” He goes on, “The more I cut the tooth, the more I weaken the tooth, and the more of the tooth I cut, and the more times I cut, the sooner I will kill the tooth. Trauma to the tooth is additive, even over decades!” Ultradent strives to offer the latest and greatest in technology, and Dr. Fischer’s passion for a minimally invasive approach to dentistry has and will continue to guide the development of every new product created in the future. It was this very approach that led to the creation of Ultradent’s extensive line of endodontic products available to clinicians today.

Ultradent endodontics Endo-Eze® AET classic stainless steel files, Ultradent’s extensive line of endodontic products and solutions, were born out the necessity for a successful endodontic protocol that met the minimally invasive philosophy that Dr. Fischer so passionately advocates. The result: the EndoEze Anatomic Endodontic Technology (AET) technique. Because of the 30° reciprocating motion of the handpiece, the system produces less-invasive root canal therapies, as the combination of motion Volume 7 Number 2

NaviTip® In the year 2000, Ultradent introduced NaviTip — the very first endodontic tip capable of delivering irrigants to just about any part of the root canal system. Today, with the world’s smallest and most technologically sophisticated cannula for irrigation and delivery, NaviTip remains unsurpassed in its performance. NaviTip features a unique rigidity at the handle of the tip, making it strong enough to be introduced as deep as needed in the canal. And the annealed and rounded tip end gives it the ability to navigate down the tiny intricate curvatures of any canal of any tooth. Available in four lengths (17 mm, 21 mm, 25 mm, and 27 mm), three gauges (29 ga, 30 ga, and 31 ga), and even with a flocked end to help clean debris or product out of a canal, NaviTip is available in an option to suit any need a clinician may have. The NaviTip even has a version with sideport openings that deliver irrigants toward the canal walls rather than toward the apex, which minimizes the risk of

Volume 7 Number 2

CORPORATE PROFILE

and files proved able to better follow the natural canal anatomy. This stands in contrast to the popular rotary NiTi systems, which are not designed to replicate the naturally formed canal, but to prepare the canal in a round, conical shape. By following the natural canal shape, the files minimize excess removal of healthy tooth structure. Ultradent offered a number of endodontic products before introducing AET and has created a number of marketleading devices and chemistries since its introduction. A few of these are outlined here:

expressing strong chemistries past the apex. Endo-Eze® Arios™ and Endo-Eze AET TiLOS™ Building on the success of the AET files, Ultradent developed the Endo-Eze TiLOS system with several well-respected American and international specialists. This very simple technique uses both stainless steel and NiTi files in combination with traditional hand files. If the clinician prefers, the TiLOS system can be used without traditional hand files as well. The award-winning TiLOS system is available in convenient, autoclavable, preconfigured patient kits as well as refills. The simplest is the RediPack, which contains the files needed to treat about 90% of endodontic cases. The TiLOS technique still uses a reciprocating handpiece, which provides a “milling” rather than “drilling” motion. Experience has shown that a milling motion reduces the amount of file separation that occurs. And of course, the TiLOS

instruments and technique follow the minimally invasive Ultradent philosophy that the company has been built on. More and more clinicians are discovering Ultradent’s Engine Pack, which contains three engine-driven files. This preconfigured kit is perfect for the preflaring of canals — something every clinician does, but often requires gathering the necessary files from different kits to do so. The Engine Pack contains all the files needed for this preflaring procedure, it’s

autoclavable, very economical, and it can be integrated into any technique currently being taught today.

The pulse of the endodontists For many years, Ultradent has developed and provided endodontic equipment such as files, delivery tips, irrigants, handpieces, sealer, and gutta percha with the goal of simplifying and elevating the quality of endodontic outcomes. By maintaining close relationships with top endodontic researchers at several domestic and international universities, as well as by keeping several highly skilled dentists on staff, Ultradent continues to keep a finger on the pulse of this important and rapidly growing area of dentistry. Ultradent proudly offers the latest and most cuttingedge metals, file types, and technologies, while continually working to refine and work toward less-invasive endodontic solutions and protocol. To learn more about the endodontic products mentioned or the wide array of additional endodontic solutions provided by Ultradent, please visit ultradent.com, or call 800-552-5512. EP

This information was provided by Ultradent.

Endodontic practice 11

CLINICAL

Clinical guidelines for the use of ProTaper Next™ instruments: part 2 Drs. Peet J. van der Vyver and Michael J. Scianamblo illustrate the use of ProTaper Next instruments in difficult and challenging endodontic cases

n part 1 of this series, published in the January/February issue of Endodontic Practice US, the authors outlined the clinical guidelines for the use of the ProTaper Next™ (Dentsply/Maileffer) instruments. (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. The first instrument in the system is the ProTaper Next X1, 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 PathFile™ rotary files (DENTSPLY Tulsa Dental Specialties). The ProTaper Next X1 is always followed by the second instrument: the ProTaper Next X2 (0.25 mm tip and 6% taper). The 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. The ProTaper Next X1 and X2 have an increasing and decreasing percentage tapered design over the active portion of the instruments. The last three finishing instruments are the ProTaper Next X3 (0.30 mm tip with 7% taper), ProTaper Next X4 (0.40 mm tip with 6% taper), and the ProTaper Next X5 (0.50 mm tip with 6% taper). These instruments have a decreasing percentage taper from the tip to the shank. The 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.

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.

12 Endodontic practice

Figure 1A: Preoperative radiograph of a maxillary right second premolar

The advantages of the ProTaper Next system include the following: • The instruments are manufactured from M-Wire that contributes toward more flexible instruments, increased safety, and protection against instrument fracture (Gutmann and Gao, 2012), allowing the clinician to treat more complex root canal systems with a high level of success. • The instruments have a bilateral symmetrical rectangular cross section with an offset from the central axis of rotation (except in the last 3 mm of the instrument, D0-D3), creating an asymmetric rotary motion. The exception is the ProTaper X1, which has a square cross section in the last 3 mm to give the instruments a bit more core strength in the narrow apical part. The asymmetric rotary motion allows the instrument to experience a rotational phenomenon known as precession or swagger (Scianamblo, 2011). According to Van der Vyver and Scianamblo (2013), this design characteristic includes six benefits: 1. It further reduces (in addition to the progressive tapered design) the engagement between the instrument and the dentin walls because only two cutting

Figure 1B: Length determination radiograph. Note the “S”-shaped canal configuration

Figure 1C: Postoperative radiograph after canal obturation with GuttaCore obturators

Volume 7 Number 2

CLINICAL

points make contact with the canal wall at any time. This will contribute to a reduction in taper lock, screw-in effect, and stress on the file. 2. It ensures debris removal in a coronal direction 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. 3. The swaggering (asymmetric) rotary motion of the instrument initiates activation of the irrigation solution during canal preparation, improving debris removal. 4. It reduces the risk of instrument fracture because there is less stress on the file and more efficient debris removal. 5. Every instrument is capable of cutting a larger envelope of motion (larger canal preparation size) 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 the adequate shape and taper to allow for optimal irrigation and obturation. 6. There is a smooth transition between the different sizes of instruments because the design ensures that the instrument sequence itself expands exponentially. The aim of this article is to illustrate the use of ProTaper Next instruments in complex and challenging endodontic cases. The preparation technique for minimally invasive root canal preparation with ProTaper Next instruments will also be discussed.

“S”-shaped root canals A major challenge in endodontics is the treatment of “S”-shaped or bayonetshaped root canals. This type of root canal configuration can be present in root canal systems of maxillary laterals, canines, and premolars, as well as mandibular molars (Rueben, et al., 2008). The authors would recommend using PathFile No. 3 (ISO tip 0.19 mm) (after PathFile Nos. 1 and 2) in these challenging root canal systems as the final glide path preparation file. This will increase the glide path size before introducing the ProTaper Next X1, resulting in less engagement as the file travels down the canal curvatures. Volume 7 Number 2

Figure 2A: Preoperative radiograph of a maxillary right first molar

Figure 2B: Length determination radiograph. Note the “S”-shaped canal configuration in the distobuccal root canal

Figure 2C: Postoperative radiograph after glide path preparation with PathFiles and canal preparation with ProTaper Next X1 and X2. Obturation was done with GuttaCore obturators. Note maintenance of “S”-shaped curvature in the obturated distobuccal root canal system Endodontic practice 13

CLINICAL

Figure 3A: Non-vital mandibular left first molar and inadequately root canal treated mandibular right second molar

Figure 3B: Initial length determination radiograph. Note that the files were short in all the root canals in the mandibular second molar

Figure 3D: Final result after the canals were obturated with ProTaper obturators

Case report 1 The patient, a 41-year-old female, presented with irreversible pulpitis on her maxillary right second premolar (Figure 1A). The length determination radiograph revealed an “S”-shaped canal configuration (Figure 1B). The canal was negotiated and glide path enlarged using PathFile Nos. 1, 2, and 3. Canal preparation was done with ProTaper Next X1 and X2. In this case, emphasis was placed on using a backstroke, outward brushing motion with the ProTaper Next instruments to remove restrictive dentin in the canal, allowing the instruments to progress apically. The canal was obturated (Figure 1C) with a size 20 GuttaCore™ obturator to working length followed by another X2 GuttaCore obturator (DENTSPLY Tulsa Dental Specialties) to ensure adequate obturation of the oval coronal part of the root canal system. 14 Endodontic practice

Figure 3E: Periapical radiograph (30° mesial angulated) demonstrating respect of the original canal anatomy after canal preparation with ProTaper Next instruments

Case report 2 A 45-year-old male patient presented with severe pain on his maxillary right first molar. A preoperative periapical radiograph revealed placement of a deep amalgam restoration (Figure 2A). The length determination radiograph revealed an “S”-shaped canal configuration in the distobuccal root canal (Figure 2B). The root canals were negotiated to working length, and the glide paths enlarged using PathFile Nos. 1 and 2. PathFile No. 3 was used in the distobuccal root canal. Canal preparation was done with ProTaper Next X1 and X2 in all three root canals. After gauging with a size 25 nickeltitanium hand instrument, it was decided to enlarge the palatal root canal to a ProTaper Next X3. All three root canals were obturated with matching ProTaper Next gutta-percha cones using the Calamus® Dual Obturation Unit (DENTSPLY Tulsa

Figure 3C: Periapical radiograph demonstrating the fit of the plastic inserts of ProTaper obturators to the corrected working length (mandibular second molar) after canal negotiation with C+ and K-files and preparation with ProTaper Next

Figure 3F: Six-month follow-up periapical radiograph illustrating periapical healing

Dental Specialties) (Figure 2C). Note the maintenance of the “S”-shaped curvature in obturated distobuccal root canal system.

Challenging curvatures in the apical third of root canals Apical root canal curvatures must always be respected and never straightened. According to Catellucci (2005), straightening these curves would mean displacing the apical foramen from its original position, which can lead to treatment failure. Other problems that can be encountered when treating curved canals include ledge formation, perforation, zip formation, and file separation (Ingle, 2005). It is very important to identify canal curvatures during initial canal negotiation in order to avoid the above-mentioned preparation errors. The greater the angle of curvature and the smaller the radius of curvature, the more complex the Volume 7 Number 2

management and treatment will be (Pruett, Clement, Carnes, 1997). Again, the authors would recommend using all three PathFiles in these challenging root canal systems to enlarge the glide path prior to canal preparation. It is also important to note that the reduced apical tapers of the ProTaper Next instruments (compared to ProTaper Universal) are ideal for maintaining apical curvatures or “S”shaped root canals. Case report 3 The patient, a 27-year-old male, presented with a non-vital mandibular left first molar and an inadequately root canal treated mandibular right second molar (Figure 3A). Access cavities were prepared, and the previous gutta percha was removed from the canals of the second molar. A length determination radiograph revealed sharp apical curvatures in the last few millimeters of the mesial and distal roots of the mandibular first molar. It was also noted that the working length was short in the canals of the second molar (Figure 3B). A combination of C+ and K-files were used to negotiate the canals in the mandibular second molar to full working length. A reproducible glide path was established in all the root canals, and the glide paths enlarged to ISO 0.19 mm using PathFiles. The coronal two-thirds of the canals were prepared with ProTaper Next X1 and X2 using a backstroke, outward brushing motion to remove restrictive dentin in the canals, allowing the instruments to progress towards the apical third. The apical third of the root canals were prepared with a controlled push-pull motion, allowing the instruments to progress up to working length. The prepared root canals were gauged with a size 25 nickel-titanium hand file. The file was snug at working length except in the distal canal of the lower first molar. This canal was enlarged with a ProTaper Next X3 instrument. Figure 3C shows radiographic confirmation of the working length and the fit of the plastic carriers of size 25 ProTaper obturators (without gutta percha). All the canals were obturated (Figure 3D) with size 25 ProTaper obturators, except the distal root canal in the lower first molar that received a size 30 ProTaper obturator. Volume 7 Number 2

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Figure 4A: Preoperative radiograph of non-vital maxillary left first and second molars

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Figure 4B: Length determination radiograph for the maxillary first molar

Endodontic practice 15

CLINICAL

THE FUTURE HAS RETURNED.

CLINICAL

Figure 5A: ProTaper Next X1 is introduced into the canal and used in a pushpull motion. Restrictive dentin is removed on the outstroke, pulling motion. The push-pull motion was repeated a few times until the instrument progressed approximately 4 mm (arrow). The instrument was removed from the root canal; the flutes cleaned; and the canal irrigated, recapitulated, and reirrigated

Figure 3E demonstrates the final result after obturation, and Figure 3F illustrates healing of the periapical pathology around the roots on a 6-month postoperative radiograph.

Minimally invasive canal preparation According to Gutmann (2013), minimally invasive endodontic (MIE) procedures can range from diagnosis to making a decision to treat (or not to treat) the case. They also include the following: 1. Minimal removal of dentin during access cavity preparation (Clark, Khademi, 2010), enlarging and shaping of the root canal system to retain as much as sound dentin as possible 2. Retention of tooth structure during disassembly and retreatment procedures We have to accept that if access openings are too restricted, it can impact on the final result of treatment. Gutmann (2013) further suggests that efforts should be made to minimize the excess removal of cervical tooth structure in the canal orifice through the use of Peeso reamers, 16 Endodontic practice

Figure 5B: The file was reintroduced into the root canal, and the same protocol repeated. The instrument now progressed up to the apical third of the root canal (arrow)

Figure 5C: The last cutting cycle carried the file up to working length (arrow)

Gates Glidden burs, and orifice-opening instruments. These instruments tend to straighten the canal and weaken the root canal walls, predisposing them to cracks and, in some cases, can even lead to root canal wallstripping defects. For some clinicians, it might be an option not to brush excessively with ProTaper Next instruments but rather to use the â&#x20AC;&#x153;push-pullâ&#x20AC;? preparation technique. Case report 4 The patient, a 39-year-old male, presented with non-vital maxillary first and second molars (Figure 4A). He also reported that his previous dentist, for pain relief, did emergency root canal treatments on both teeth. The temporary filling on the upper first molar was removed, and four root canal orifices located and explored (mesiobuccal, mesiobuccal 2, distobuccal, and palatal). Figure 4B shows a periapical radiograph confirming the working lengths that were electronically measured with the Propex Pixiâ&#x201E;˘ apex locator (Dentsply/Maillefer).

Reproducible glide paths were established by using a size 10 K-file by hand, followed by mechanically enlarging the glide paths in all four root canals using PathFile Nos. 1, 2, and 3. All four root canals were prepared with ProTaper Next using the following technique, resulting in minimally invasive canal preparations. In order to explain the technique, we will outline the preparation steps for one of the mesiobuccal root canals. ProTaper Next X1 was introduced into the canal and used in a push-pull motion. Restrictive dentin was removed on the outstroke, pulling motion. The push-pull motion was repeated a few times until the instrument progressed approximately 4 mm (Figure 5A). The instrument was removed from the root canal; the flutes cleaned; and the canal irrigated, recapitulated, and re-irrigated. The file was re-introduced into the root canal, and the same protocol repeated (Figure 5B). After three cutting cycles of 4 mm each, the full working length was reached (Figure 5C). ProTaper Next X2 was introduced and used following the same protocol. Volume 7 Number 2

Now in single-use pouches to use only what you need.

Clinical Applications Pulp capping

Furcal repair

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Root resorption Repair of root perforation Apexification Root-end filling

CLINICAL

Figure 6A: ProTaper Next X3 gutta-percha cone and three size 20 GuttaCore verifiers fitted to working lengths prior to obturation

After two cutting cycles of 4 mm each, full working length was reached. A size 25/02 nickel-titanium hand file was used to gauge the apical foramen. The file fitted snug at working length, and shaping was complete. The mesiobuccal, mesiobuccal 2, and distobuccal canals were prepared up to ProTaper Next X2, and the palatal canal was prepared up to ProTaper Next X3. Because the instruments were used in a push-pull motion instead of a deliberate brushing motion, the canal shapes were generally smaller in size and more conservative. The concept of larger apical sizes has been advocated to improve bacterial reduction. However, maintaining smaller sizes (> 20 < 40) would seem desirable for the preservation of radicular dentin in the majority of cases and to rather focus on improved methods for cleaning and disinfecting root canal systems (Gutmann, 2013). The palatal canal was obturated with a ProTaper Next X3 gutta-percha cone using the Calamus Dual Obturation Unit (Dentsply/Maillefer). It was decided 18 Endodontic practice

Figure 6B: Postoperative result after obturation

to obturate the two mesiobuccal and distobuccal canals with GuttaCore crosslinked gutta-percha carriers. It must be noted that because of the more conservative canal preparations obtained with the push-pull preparation protocol, it was not possible to passively fit a size X2 GuttaCore verifier (size 025) up to working length in the prepared root canals. Only size 20 GuttaCore verifiers fitted passively, without resistance to working length (Figure 6A). The selected root canals were then obturated using three size 20 GuttaCore obturators. Figure 6B shows the final result after obturation. Carrierbased obturation also forms part of the MIE concept due to the minimal amount of application forces involved during the obturation process onto the remaining root structure. EP

References Castellucci A, ed. Endodontics Volume II. Florence, Italy: IL Tridente; 2005. Clark D, Khademi J. Modern molar endodontic access and directed dentin conservation. Dent Clin North Am. 2010;54(2):249-273. Gutmann JL. Minimally invasive dentistry (Endodontics). J Conserv Dent. 2013;16(4):282283. 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):113-128. Ingle JI. Root canal preparation. In: PDQ Endodontics. BC Decker, ed. Hamilton, Ontario: PMPH-USA; 2005: 129. Pruett JP, Clement DJ, Carnes DL Jr. Cyclic fatigue testing of nickel-titanium endodontic instruments. J Endod. 1997;23(2):77-85. Reuben J, Velmurugan N, Vasanthi S, Vijayalakshm P. Endodontic management of a maxillary second premolar with an S-shaped root canal. J Conserv Dent. 2008;11(4):168-170. Scianamblo MJ, inventor. US patents 6942484, 7094056,7955078, 20060228669. 2011. Van der Vyver PJ, Scianamblo. Clinical guidelines for the use of ProTaper Next instruments: part one. Endod Practice. 2013;16(4):33-40.

Volume 7 Number 2

The cursor on the tooth icon indicates the progression of the file in the canal

Extended apical zone from 0.9 to 0.0

Sharpen Your Clinician’s Root Canal Visibility Introducing the new Detect™ Apex Locator from Maillefer. Detect™ Apex Locator is innovative, aesthetically pleasing, and delivers successful root canal therapy. Other features include: • Large color display to facilitate ﬁle tracking

A solid tone will emit when the apex is reached

• Progressive sound control for dual control • Fully automatic device • Powered by rechargeable battery • Latest multi-frequency technology enables location of the apex in most types of canal conditions Check out our website for a short technique and product educational video perfect for customer demonstrations:

maillefer.com

The OVER icon indicates when the file passes the apex

DENTSPLY MAILLEFER / T: 1-800-924-7393 / F: 1-800-924-7389 / MAILLEFER.DENTSPLY.COM

©DENTSPLY International, Inc., DENTSPLY Maillefer

ADDAL3 Rev.0 11/13

CLINICAL

MTA: the new material of choice for pulp capping Drs. Leendert (Len) Boksman and Manfred (Manny) Friedman delve into the benefits of MTA

he use of MTA (Angelus, Londrina, Brazil/Clinician’s Choice Dental Products, New Milford, Connecticut) (Figure 1) has revolutionized endodontics, since its introduction to dentistry in 1993.1 (It has been on the dental market since about 1998.) In the years since, it has proven to be an exceptional material with a wide range of clinical uses, all scientifically and clinically proven.2-4 Initially recommended as a material for filling root end surgical preparations and for perforation repair, this material is also advocated for immediate apical sealing in teeth with open apices,5 pulpotomies, apexification, or apexogenesis in vital teeth with open apices,6-9 and other endodontic and reparative procedures. The extraordinary success in perforation repair since its introduction has motivated its use in these many other areas. This article will look at the success, practicality, and scientific basis for use in pulp capping procedures, particularly in permanent teeth, as MTA has been described very recently as “the material of choice”10 for this treatment.

Properties of MTA MTA stands for mineral trioxide aggregate, denoting the three dominant oxides in the material’s composition — namely, calcium, aluminum, and selenium. Its particle sizes are strictly controlled during manufacturing, as they all need to be less than 10 microns, so that the material may be completely hydrated. MTA has a similar mechanism

Figure 2: Preoperative radiograph of carious pulp exposure on tooth No. 30

Figure 1: MTA Angelus (Clinician’s Choice Dental Products)

of action to calcium hydroxide11 in that the main component of the material, calcium oxide, when in contact with a humid environment, is converted into calcium hydroxide.12 This results in a high pH of 12.5, making its surroundings inhospitable for bacterial growth, and producing an antibacterial effect for a long period of time. But unlike calcium hydroxide products, such as DYCAL® (Dentsply, York, Pennsylvania), MTA Angelus (Angelus Dental Solution, Londrina, Brazil/Clinician’s Choice Dental Products, New Milford, Connecticut) has very low solubility, so it maintains a hard, excellent marginal seal. Finally, unlike most dental materials, MTA actually needs moisture to set, so it thrives in a moist environment. Of

Figure 3: Radiograph of periapical radiolucency

Figure 4: One year follow-up with healthy pulp and resolution of the periapical lesion

Dr. Leendert (Len) Boksman, DDS, BSc, FADI, FICD, is a paid part-time consultant to Clinician’s Choice and is a former Associate Professor with tenure in the Department of Operative Dentistry, Faculty of Dentistry University of Western Ontario. He has recently retired from private practice, but consults on a part-time basis, lectures nationally and internationally, and publishes extensively in the field of Restorative Dentistry. He volunteers as an Adjunct Clinical Professor at UTech School of Oral Health Sciences Dental Faculty Kingston, Jamaica. He can be reached at lenpat28@gmail.com. Manfred (Manny) Friedman, BDS, BChD, maintains a private practice limited to endodontics in London, Ontario, and is an adjunct clinical professor in the Division of Restorative Dentistry at the Schulich School of Medicine and Dentistry at the University of Western Ontario. He can be reached at ndofriedman@rogers. com

20 Endodontic practice

Figure 5: Preoperative radiograph of pulp exposure

Figure 6: MTA placed after caries removal and pulp exposure

Figure 7: Dentin bridge formation after 40 days

Volume 7 Number 2

CLINICAL

Figure 8: Preoperative radiograph of clinical case

Figure 9: Clinical presentation of the lesion after rubber dam isolation

Figure 10: Initial rough cavity outline

Figure 11: Use of short shank bur interferes with vision

Figure 12: Relative lengths of short vs. long burs

Figure 13: Increased visibility of lesion with long shank bur

Bo A ot AE h# 22

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Up to 600% more resistant to fatigue failure with 2-3 times the torsional strength of regular NiTi files.* Unlike traditional NiTi files that try to straighten within the canal, TYPHOON files adapt perfectly to the canal path. These balanced lateral cutting forces along the length of the canal dramatically reduce ledging and transportation – effortlessly navigating even the most tortuous of canals. ™

* Shen Y, Qian W, Abtin H, Gao Y, Haapasalo M. Effect of Environment of Fatigue Failure of Controlled Memory Wire Nickel-Titanium Rotary Instruments. J Endod 2012;38:376-380

Navigate the canal and find working length quickly with X-PLORER Canal Navigation Files. Available in 15/.01, 20/.01, 20/.02, and 25/.02.

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Volume 7 Number 2

Endodontic practice 21

CLINICAL

Figure 14: Photo of pulp exposure

Figure 15: NaOCl placed over pulp exposure

Figure 16: Cotton used to dry area

Figure 17: Bleeding of the pulp exposure controlled

Figure 18: MTA is placed by ultrasonic vibration of plastic instrument

Figure 19: First increment of MTA placed

Figure 20: Second increment of MTA fully covers pulp exposure

Figure 21: LC Glass Ionomer is placed with a Skini syringe

Figure 22: Initial placement of the light cured glass ionomer

the commercially available MTA products, MTA Angelus is well suited for pulp capping procedures due to its setting time of 10 minutes, compared with the 4-hour setting time of the other commercially available MTA. It is also packaged in airtight bottles, allowing the practitioner to use only what is exactly needed without introducing undue moisture into the remainder.

with conventional materials, MTA is a more predictable and reliable material for direct pulp capping teeth, with reversible pulpitis, as borne out by numerous clinical and histological studies.15-19 Mente, et al., recently concluded, “MTA appears to be more effective than calcium hydroxide for maintaining long-term pulp vitality after direct pulp capping.”20 Numerous other studies show much promise in the longterm health of pulps that have been capped using MTA, and years of clinical use have demonstrated the superlative ability of this material in dentin bridge formation (Figures 5-7).21,22

by the radiograph in Figure 8. Since there was no evidence of periapical rarefaction and no spontaneous pain, it was decided to place a direct pulp cap, if after excavating the caries, the bleeding could be controlled without the use of hemostatic agents. After delivering a mandibular block, and isolation with the rubber dam (Paro Dam – Clinician’s Choice Dental Products, New Milford, Connecticut), the clinical photograph of the distal caries is shown in Figure 9. The initial outline form was created using a pear-shaped 332 carbide bur followed by removal of the soft caries with a round carbide bur (Figure 10). When excavating deep caries and using a regular length bur (Figure 11), the head of the handpiece interferes with adequate vision of the caries removal process. As evidenced by Figure 12, the use of a long shank bur (Figure 13)

Use of MTA for direct pulp capping This combination of desirable qualities makes MTA “the material of choice” for cases of pulp exposure in both primary teeth and permanent teeth13,14 (Figures 2-4). Pulpal exposure is inevitable when excavating many large carious lesions. While many dentists are hesitant to perform direct pulp capping procedures due to previously unpredictable results 22 Endodontic practice

MTA clinical case presentation A young female patient presented to the dental office with a large carious exposure on the distal of tooth No. 30, as evidenced

Volume 7 Number 2

simple, adaptable

endodontic solutions

Irrigation amplification

All grown up Ultradent now offers Consepsis (2% chlorhexidine), ChlorCid (3% sodium hypochlorite), and EDTA 18% in 480ml bottles* to give you the best value on the irrigants you use with every endodontic procedure.

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And with Ultradent’s economically priced irrigants, you do not have to sacrifice ease of use. Designed with a unique flip-top cap, Ultradent’s economy-size irrigants are easy to dispense into a container or even backfill a syringe—so easy, in fact, you can do it with one hand.

800.552.5512 ultradent.com Use NaviTip to easily deliver Ultradent irrigants just short of the apex. Available with regular and sideport delivery. *Smaller-volume syringes still available. © 2014 Ultradent Products, Inc. All Rights Reserved.

Irrigants

Unique flip-top cap makes backfilling syringes easy.

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CLINICAL

Figure 24: Triodent V3 ring used to create separation for tight contact

Figure 23: Valo LED curing light used to set the glass ionomer

Figure 25: UltraEtch is placed on enamel first

Figure 26: Then the entire cavity is flooded by phosphoric acid

Figure 27: MPa bonding agent is placed as a single coat and light cured

Figure 28: Initial fill with Cosmedent Nano

may complicate access for distal molars, but the distancing of the head of the handpiece from the occlusal cavo-surface margins allows better visualization of the caries removal process. The final removal of the caries is accomplished with the use of a new sterile diamond round bur, which causes less tissue damage to the pulp than the round carbide bur (which also will be contaminated by the caries excavation). The initial carious pulp exposure is shown in Figure 14. A cotton pledget soaked in 5½% sodium hypochlorite (NaOCl) is placed over the pulp tissue and removed when the bleeding has stopped (Figure 15). The area is delicately dried with the use of tissue in cotton pliers (Figure 16). At this point in the procedure, the area is not washed, nor air dried. With the area decontaminated with the bleach and the

bleeding stopped (Figure 17), the MTA (Angelus Dental Solution, Londrina, Brazil/ Clinician’s Choice Dental Products, New Milford, Connecticut) is prepared by mixing the powder and liquid according to the manufacturer’s instructions. The MTA is picked up by a plastic instrument, carried to the exposure site, and is deposited by vibrating the plastic instrument with an ultrasonic tip (Figure 18). Figure 19 shows the first increment placed. Similarly, a second increment is carried to the exposure site and is deposited by the vibration of the ultrasonic (Figure 20). The vibration simplifies the placement of the MTA with the material smoothly flowing from the plastic instrument and adapting well to the tooth structure facilitating a good seal. To protect the MTA during its setting, a lightcured glass ionomer (Fuji 2 LC GC America,

Alsip, Illinois) is injected precisely over the MTA site with a Skini Syringe and EndoEze® canula (Ultradent Products, Salt Lake City, Utah) (Figures 21, 22) and fully light cured with a Valo® broad spectrum curing light (Figure 23). After careful cutback of the glass ionomer cement and a cleaning of all the margins, a Triodent contoured matrix band was placed, followed by the insertion of a Wave-Wedge. The Wave-Wedge does not cause separation but only serves to adapt the matrix gingivally. A Triodent V3 green molar ring (Triodent) was placed to create tooth separation, and the band was burnished with a ball burnisher to confirm contact with tooth No. 31 (Figure 24). Ultra-Etch® was placed for 15 seconds over the glass ionomer, remaining dentin, and enamel margins (Figures 25, 26), gently washed, and lightly dried. A single

24 Endodontic practice

Volume 7 Number 2

CLINICAL Figure 30: After occlusal adjustment, a Groovy polishing point is used

Figure 31: Final clinical result Figure 29: Initial trimming with 7802 multi-fluted finishing bur

coat of the fifth-generation bonding agent MPa (Clinician’s Choice Dental Products, New Milford, Connecticut) was applied with a micro-brush (Figure 27), air thinned, and the ethanol solvent evaporated. After light curing with the Valo, the A2 Cosmedent Nano composite (Cosmedent) was incrementally placed, first laterally to decrease the C factor vectors, light cured, and then the center valley filled in, adapted, and light cured (Figure 28). After initial recapitulation of the occlusal anatomy with

a 7802 bur (Figure 29), the rubber dam was removed, and a diamond impregnated Groovy Occlusal polishing point (Clinician’s Choice Dental Products, New Milford, Connecticut) (Figure 30) was used to create the final polish of the Nano-filled composite. The final restoration is shown in Figure 31 with the final postoperative radiograph (Figure 32) showing the close adaptation of the MTA, glass ionomer and the Cosmedent Nano.

Figure 32: Postoperative radiograph of MTA pulp cap

Summary statement The clinical and research evidence clearly support the use of MTA as the “new” pulp capping material of choice. EP

References 1. Lee SJ, Monsef M, Torabinejad M. Sealing ability of a mineral trioxide aggregate for repair of lateral root perforations. J Endod. 1993;19(11):541-544.

8. Ng FK, Messer LB. Mineral trioxide aggregate as a pulpotomy medicament: an evidence-based assessment. Eur Arch Paediatr Dent. 2008;9(2):58-73.

16. Faraco IM Jr, Holland R. Response of pulp of dogs to capping with mineral trioxide aggregate or a calcium hydroxide cement. Dent Traumatol. 2001;17(4):163-166.

2. Parirokh M, Torabinejad M. Mineral trioxide aggregate: a comprehensive literature review--Part I: chemical, physical, and antibacterial properties. J Endod. 2010;36(1):16-27.

9. Chacko V, Kurikose S. Human pulpal response to mineral trioxide aggregate (MTA): A histological study. J Clin Pediatr Dent. 2006;30(3):203-210.

17. Bogen G, Kim JS, Bakland LK. Direct pulp capping with mineral trioxide aggregate. J Am Dent Assoc. 2008;139:305-315.

10. Parirokh M, Torabinejad M. Mineral trioxide aggregate: a comprehensive literature review--Part III: Clinical applications, drawbacks, and mechanism of action. J Endod. 2010;36(3):400-413.

18. Bodem O, Blumenshine S, Zeh D, Koch MJ. Direct pulp capping with mineral trioxide aggregate in a primary molar: a case report. Int J Paediatr Dent. 2004;14(5):376-379.

11. Castellucci A. The use of mineral trioxide aggregate in clinical and surgical endodontics. Dent Today. 2003;22(3)74-81.

19. Mussolino de Queiroz A, Assed S, LeonardoI MR, Nelson-Filho P, Bezerra da Silva LA. MTA and calcium hydroxide for pulp capping. J Appl Oral Sci. 2005;13(2).

12. Duarte MA, Demarchi AC, Yamashita JC, Kuga MC, Fraga Sde C. pH and calcium ion release of 2 rootend filling materials. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2003;95(3):345-347.

20. Mente J1, Geletneky B, Ohle M, Koch MJ, Friedrich Ding PG, Wolff D, Dreyhaupt J, Martin N, Staehle HJ, Pfefferle T. Mineral trioxide aggregate or calcium hydroxide direct pulp capping: an analysis of the clinical treatment outcome. J Endod. 2010;36(5).

3. Torabinejad M, Parirokh M. Mineral trioxide aggregate: a comprehensive literature review-part II: leak-age and biocompatibility investigations. J Endod. 2010;36(2):190-202. 4. Parirokh M, Torabinejad M. Mineral trioxide aggregate: a comprehensive literature review-Part III: Clinical applications, drawbacks, and mechanism of action. J Endod. 2010;36(3):400-413. 5. Kratchman SI. Perforation repair and one-step apexification procedures. Dent Clin North Am. 2004;48(1):291-307. 6. Shayegan A, Petein M, Abbeele AV. Beta-tricalcium phosphate, white mineral trioxide aggregate, white Portland cement, ferric sulfate, and formocresol used as pulpotomy agents in primary pig teeth. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008;105(4):536-542. 7. Holland R, de Souza V, Murata SS, Nery MJ, Bernabé PF, Otoboni Filho JA, Dezan Júnior E. Healing process of dog dental pulp after pulpotomy and pulp covering with mineral trioxide aggregate or Portland cement. Braz Dent J. 2001;12(2):109-113.

Volume 7 Number 2

13. Farsi N, Alamoudi N, Balto K, Al Mushayt A. Clinical assessment of mineral trioxide aggregate (MTA) as direct pulp capping in young permanent teeth. J Clin Pediatr Dent. 2006;31(2):72-76. 14. Tuna D, Olmez A. Clinical long-term evaluation of MTA as a direct pulp capping material in primary teeth. Int Endod J. 2008;41(4):273-278. 15. Pitt Ford TR, Torabinejad M, Abedi HR, Bakland LK, Kariyawasam SP. Using mineral trioxide aggregate as a pulp-capping material. J Am Dent Assoc. 1996;127:1491-1494.

21. Min KS, Park HJ, Lee SK, Park SH, Hong CU, Kim HW, Lee HH, Kim EC. Effect of mineral trioxide aggregate on dentin bridge formation and expression of dentin sialoprotein and heme oxygenase-1 in human dental pulp. J Endod. 2008;34(6):666-670. 22. Asgary S, Parirokh M, Eghbal MJ, Ghoddusi J, Eskandarizadeh A. SEM evaluation of neodentinal bridging after direct pulp protection with mineral trioxide aggregate. Aust Endod J. 2006;32(1):26-30.

Endodontic practice 25

CLINICAL

The influence of mineral trioxide aggregate (MTA) thickness on its microhardness properties â&#x20AC;&#x201D; an in vitro study Drs. Iris Slutzky-Goldberg, Lea Sabag, and David Keinan test the effect of the MTA thickness on its microhardness properties Abstract Aim: The purpose of this study was to test the effect of the MTA thickness on the microhardness properties. Materials and method: A total of 30 roots from extracted single canal human teeth were divided into 3 groups of 4-mm, 6-mm, and 10-mm long root sections. After canal preparation, white MTA (ProRootÂŽ, DENTSPLY Tulsa Dental Specialties) was delivered into the root canal space using an MTA carrier. The microhardness was measured after 4 weeks using a Vickers Diamond Microhardness Test for each sample. Statistical analysis included oneway analysis of variance and the t-test at a 5% level of significance. Results: The 10-mm thick ProRoot MTA was significantly harder than the 6-mm or 4-mm material (p < 0.0001); there was no statistical difference in microhardness between the 4-mm thick and the 6-mm thick material (p > 0.05). Conclusions: MTA was found suitable for filling the entire root canal space in compromised cases on the basis of its microhardness.

Introduction Mineral trioxide aggregate (MTA) was first described in the dental literature by Lee, et al.1 MTA is composed of three powdered ingredients, which are 75%

Dr. Iris Slutzky-Goldberg is from the Department of Endodontics, The Hebrew University-Hadassah School of Dental Medicine, Jerusalem, Israel. Dr. Lea Sabag is a graduate student, The Hebrew University-Hadassah School of Dental Medicine, Jerusalem, Israel. When this study was carried out, Dr. David Keinan was a postgraduate student, Department of Endodontics, The Hebrew University-Hadassah School of Dental Medicine, Jerusalem, Israel. He now works in the Department of Endodontics, Medical Corps, Tel Hashomer Hospital, Ramat-Gan, Israel.

26 Endodontic practice

Portland cement, 20% bismuth oxide, 5% gypsum, and trace amounts of SiO2, CaO, MgO, K2SO4, and Na2SO4.1 There are four major components in Portland cement: tricalcium silicate, dicalcium silicate, tricalcium aluminate, and tetracalcium aluminoferrite. The self-setting properties of calcium silicate cements are attributed to the progressive hydration reaction of the orthosilicate ions.3 Calcium silicate hydrate gel polymerizes and hardens over time, forming a solid network, which is associated with an increased mechanical strength.4 MTA proved to be superior to materials, such as amalgam, IRM, and Super-EBA, in both biocompatibility and sealing ability.5-10 Many applications were suggested for the clinical use of this material, among them as a root endfilling material,11 root perforation repair,12,13 and a direct pulp capping following pulpotomy.14-15 MTA is also commonly used for one-step apexification.16 In an in vivo study, which compared MTA and calcium hydroxide ability to stimulate root-end closure in necrotic permanent teeth with immature apices, none of the MTA-treated teeth showed any clinical or radiographic pathosis.17 It was also shown that root canal-treated teeth obturated with MTA exhibit higher fracture resistance than untreated teeth.18 The compressive strength and surface microhardness of calcium silicate cements tend to increase with time.19 The effect of condensation pressure on the surface hardness of ProRoot demonstrate a negative correlation, in which higher condensation pressures produce lower surface hardness values.20 This may be related to forcing the liquid out of the mix prior to setting resulting in alteration to the powder liquid ratio. However, higher condensation pressures resulted in fewer voids and micro-channels when analyzed by SEM.20

The microhardness of MTA can be influenced by the pH values of the mixing medium, and even the mixing techniques used.21 More porosity and unhydrated structure were observed in White MTA (WMTA) exposed to low pH values.22,23 The placement of MTA is techniquesensitive, and according to several studies, the application of ultrasonic energy may improve its sealing properties.24,25 It was also demonstrated that acid etch applied 4 hours after mixing MTA with water significantly reduced its resultant compressive strength compared with the controls, but these differences were not significant after 24 and 96 hours.19 However, newer formulas of trioxide aggregate may set even after 15 minutes that may make it more resistant to acid etching. The manufacturer recommends to place 3- to 5-mm thick MTA. This is in accordance with the results of previous studies, which suggested a minimum thickness of 3-4 mm when the material was used as a root-end filling material26 to prevent apical leakage.27 In another in vitro study, which tested white and gray MTA for microhardness, a 5-mm thick barrier was significantly harder than a 2-mm barrier,28 regardless of the type of MTA used. This may be attributed to a sufficient bulk of material that can also get hydration through all its thickness. The purpose of this study was to measure the microhardness of MTA in vitro in relation to its thickness and to compare the microhardness when the material was used only as root-end filling (4- or 6-mm thick) or for obturation of the entire root canal (10 mm).

Materials and methods An in vitro examination of MTA microhardness in extracted teeth was carried out using the technique previously described by Valois and Costa.27 Volume 7 Number 2

CLINICAL Thirty extracted, single-canal human teeth, stored in tap water at 4° C, were used for this study. The crowns were separated from the roots at the cemento-enamel junction and were divided according to length into three groups of 10 teeth each: standardized to 10 mm, 6 mm, and 4 mm. The canals were instrumented with Gates Glidden burs No. 1-No. 4 (Dentsply Maillefer Switzerland) in a crown-down manner until the No. 1 size bur could pass through the apical foramen. The specimens were then prepared with K-files until an ISO size 90 file could be visualized 1 mm past the apex. Irrigation with 10 ml 3% sodium hypochlorite was used throughout the instrumentation, followed by a final flush of 5 ml. To provide a simulated periapical environment, the root segments were placed in saline, as previously described by Lee, et al.1 Following previously described procedures white MTA (Dentsply Maillefer Switzerland) was delivered into to the canal space by using ultrasonically vibrated pluggers,29 and the teeth were sealed with Coltosol® F (Coltène Whaledent), a premixed non-eugenol provisional filling material. The MTA was allowed to set at 37° C and 100% humidity for 24 hours. All samples were stored in tap water for 4 weeks at 37° C and 100% humidity. The samples were then removed, sectioned longitudinally with a diamond bur, and embedded in resin. The samples were then polished with a variable speed grinder polisher (IsoMet®-6 Buehler Düsseldorf, Germany). Microhardness measurements were carried out using a Vickers Diamond Microhardness Tester MHT-1 (Matsuzawa, Tokyo, Japan) on each sample. The indenter exerted 500g pressure for 15 seconds on the set material, producing one impression with two orthogonal diagonals. The samples were evaluated under an optical microscope (Olympus Optical Microscope, Hamburg, Germany) at 10X magnification; digital images were captured and imported into a Photo Shop Pro version 5.01 (Jasc Software, Inc., Minneapolis, Minnesota). Indentation size was measured in microns. Microhardness was calculated according to the following equation:

F - Pressure in kg applied to the material d - average of the two diagonals in millimeters 28 Endodontic practice

Table 1: Microhardness of MTA samples Group 1 10 mm

Group 2 6 mm

Group 3 4 mm

Number of items

Mean value (MPa)

1131

823

760

Highest value (MPa)

1568.69

1099.46

975.55

Lowest value (MPa)

423.28

602.92

509.73

Standard deviation

254

182

146

Confidence interval 95%

[1059-1203]

[709,6-936,1]

[646,3-872,8]

Median

1177

795

756

160

154

120

Average absolute deviation from median

The results were statistically analyzed by one-way analysis of variance and the t-test. Significance was set at 5%.

Results More measurements were carried out in the 10-mm samples (N = 37) than in the 4-mm (N = 15) or 6-mm (N = 15) samples, as the 10-mm length roots allowed more indentation sites (Table 1). As can be seen in the 10-mm thickness group (N = 37), the indentation size was between 76-146 microns (average, 92 ±16 microns). In the 6-mm thickness group (N = 15), indentation size was 90-123 microns (average 107 ±12 microns). In the 4-mm thickness group (N = 15), the indentation size was 96.5-133.5 microns (average 110 ±11 microns). The microhardness in the 10-mm group was an average 1131 ±254 MPa; for the 6-mm group,823 ± 182 MPa; and for the 4-mm group, 760 ± 146 MPa. Statistical analysis showed that the 10mm thick MTA was significantly harder than the 6-mm or 4-mm thick MTA (p < 0.0001); no statistical difference in microhardness was found between the two other groups (p > 0.05).

Discussion Initially, mineral trioxide aggregate was introduced for the repair of root perforations.1 As hard tissue induction is one of its exceptional properties, it has been recommended for use as an apical barrier in the treatment of immature teeth with necrotic pulps and open apices.30 The setting and hardening of calcium silicate cements are hydration reactions and require water.31 We used ProRoot

white MTA, since gray MTA may cause discoloration when placed in the coronal area or near the CEJ in anterior teeth.32 There are several composition differences between gray MTA and white MTA. White MTA contents of Al2O3, MgO, and Fe2O3 are much less than in gray MTA.33 The particle size distribution of white MTA is approximately 8 times smaller than that of gray MTA, and this could provide more surface area for hydration reactions and greater early strength.33 The minimal thickness recommended in the literature for ProRoot MTA when used as root-end filling material is 3 mm26 and; for apexification, 4 mm.34 Five-mm thick ProRoot MTA was recommended as an apical barrier, based on findings that showed that 5-mm MTA was significantly harder than 2-mm thick MTA.28 The results of our study did not show any statistical difference between the 6-mm and 4-mm thick samples, suggesting that with regard to microhardness, a minimum MTA thickness of 4 mm may be sufficient for apical closure. The higher microhardness demonstrated in the 10-mm group as compared with the 4-mm group or the 6-mm group was a surprising finding of the study. MTA requires moisture for setting.9 An in vitro study by Budig and Eleazer35 had shown that even dry MTA packed into the root canal space can set by outside moisture penetrating through the root when soaked in saline for 72 hours. Therefore, it should have been expected that there will not be any statistical difference in microhardness between the 4- and 6-mm long samples. One possible explanation for the better results of the 10-mm long samples can Volume 7 Number 2

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CLINICAL be related to a higher pH remaining in the longer sample following irrigation with the basic sodium hypochlorite. Nekoofar, et al.,21 had already demonstrated the effect of the pH on the physical properties of MTA. The results of this study imply that MTA can be used for obturation of the entire root canal, as previously suggested by Whiterspoon, et al.29 This holds true for the coronal fragment of a horizontally fractured tooth,36 for short-length canals as well as in compromised cases, such as treatment of a necrotic immature tooth37 or young permanent teeth after traumatic injury.38 The superior healing properties of MTA, which are attributed to its osteoconductive and cementogenic properties, appear to render the use of MTA for filling of the entire root canal system with improved healing rate,39 and in compromised cases, such

References 1. Lee SJ, Monsef M, Torabinejad M. Sealing ability of a mineral trioxide aggregate for repair of lateral root perforations. J Endod. 1993;19(11):541–544. 2. Sarkar NK, Caicedo R, Ritwik P, Moiseyeva R, Kawashima I. Physicochemical basis of the biologic properties of mineral trioxide aggregate. J Endod. 2005;31(2):97−100. 3. Gandolfi MG, Van Landuyt K, Taddei P, Modena E, Van Meerbeek B, Prati C. Environmental scanning electron microscopy connected with energy dispersive x-ray analysis and Raman techniques to study ProRoot mineral trioxide aggregate and calcium silicate cements in wet conditions and in real time. J Endod. 2010;36(5):851–857. 4. Zhao W, Wang J, Zhai W, Wang Z, Chang J. The selfsetting properties and in vitro bioactivity of tricalcium silicate. Biomaterials. 2005;26(31):6113–6121. 5. Torabinejad M, Watson TF, Pitt Ford TR. Sealing ability of a mineral trioxide aggregate when used as a root end filling material. J Endod. 1993;19(12):591–595. 6. Torabinejad M, Hong CU, McDonald F, Pitt Ford TR. Physical and chemical properties of a new root-end filling material. J Endod. 1995;21(7):349-353. 7. Fischer EJ, Arens DE, Miller CH. Bacterial leakage of mineral trioxide aggregate as compared with zinc-free amalgam, intermediate restorative material, and Super-EBA as a root-end filling material. J Endod. 1998;24:176–179. 8. Adamo HL, Buruiana R, Schertzer L, Boylan RJ. A comparison of MTA, Super-EBA, composite and amalgam as root-end filling materials using a bacterial microleakage model. Int Endod J. 1999;32(3):197–203. 9. Torabinejad M, Hong CU, Pitt Ford TR, Kettering JD. Cytotoxicity of four root end filling materials. J Endod. 1995;21(10):489–92. 10. Camargo SE, Camargo CH, Hiller KA, Rode SM, Schweikl H, Schmalz G. Cytotoxicity and genotoxicity of pulp capping materials in two cell lines. Int Endod J. 2009;42(3):227–237. 11. Torabinejad M, Smith PW, Kettering JD, Pitt Ford TR. Comparative investigation of marginal adaptation of mineral trioxide aggregate and other commonly used root-end filling materials. J Endod. 1995;21(6):295–299.

as internal root resorption.40 Furthermore, it was also found that MTA resisted bacterial leakage to a higher degree than did gutta percha and sealer when used as an obturation material.38 The use of MTA for filling the entire root canal system may also serve to reinforce the root.41 Furthermore, sealing the entire root canal with MTA will enable completion of the root filling in one visit, a reduction in treatment time, thereby facilitating the timely restoration of the tooth.29 The microhardness test is nondestructive, and any further consequences of any changes of strength in the superficial layers will affect the possibility of the material to fail over time.42 One should also bear in mind that microhardness is only one of the physical properties that should be examined when considering the ability of MTA to serve as a total root filling material

15. Holland R, de Souza V, Murata SS, Nery MJ, Bernabé PF, Otoboni Filho JA, Dezan Júnior E. Healing process of dog dental pulp after pulpotomy and pulp covering with mineral trioxide aggregate or Portland cement. Braz Dent J. 2001;12(2):109–113. 16 . Kratchman SI. Perforation repair and one-step apexification procedures. Dent Clin North Am. 2004;48(1):291-307. 17. El-Meligy OA, Avery DR. Comparison of apexification with mineral trioxide aggregate and calcium hydroxide. Pediatr Dent. 2006;28(3):248-253.

in compromised cases. The prudent clinician has also to recognize the fact that removal of the set material, especially in curved canals may be impossible.43 Further study, including long-term success, is required to determine the suitability of MTA as a root canal obturation material.

Conclusions Based on the results obtained from this in vitro study, the 10-mm thick ProRoot MTA exhibits greater microhardness than the 4-mm thick or 6-mm thick material. No statistical difference in microhardness was observed between the 4-mm and the 6-mm thick groups. On the basis of its microhardness, it appears that ProRoot MTA is suitable for root canal obturation in selected compromised cases. EP

29. Witherspoon DE, Small JC, Regan JD, Nunn M. Retrospective analysis of open apex teeth obturated with mineral trioxide aggregate. J Endod. 2008;34(10):1171–1176. 30. Bakland LK. Management of traumatically injured pulps in immature teeth using MTA. J Calif Dent Assoc. 2000;28(11):855– 858. 31. Maltese C, Pistolesi C, Bravo A, Cella F, Cerulli T, Salvioni D. Effects of setting regulators on the efficiency of an inorganic acid based alkali-free accelerator reacting with a Portland cement. Cements and Concrete Research. 2007;37:528–3536.

18. Bortoluzzi EA, Souza EM, Reis JM, Esberard RM, TanomaruFilho M. Fracture strength of bovine incisors after intra-radicular treatment with MTA in an experimental immature tooth model. Int Endod J. 2007;40(9):684–691.

32. Asgary S, Parirokh M, Eghbal MJ, Brink F. Chemical differences between white and gray mineral trioxide aggregate. J Endod. 2005;31(2):101–103.

19. Kayahan MB, Nekoofar MH, Kazandağ M, Canpolat C, Malkondu O, Kaptan F, Dummer PM. Effect of acid-etching procedure on selected physical properties of mineral trioxide aggregate. Int Endod J. 2009;42(11):1004–1014.

33. Asgary S, Parirokh M, Eghbal M, Stowe S, Brink F. A qualitative X-ray analysis of white and grey mineral trioxide aggregate using compositional imaging. J Mater Sci Mater Med. 2006;17(2):187−191.

20. Nekoofar MH, Adusei G, Sheykhrezae MS, Hayes SJ, Bryant ST, Dummer PM. The effect of condensation pressure on selected physical properties of mineral trioxide aggregate. Int Endod J. 2007;40(6):453-461.

34. Giuliani V, Baccetti T, Pace R, Pagavino G. The use of MTA in teeth with necrotic pulps and open apices. Dent Traumatol. 2002;18(4):217-221. 35. Budig CG, Eleazer PD. In Vitro Comparison of the Setting of dry ProRoot MTA by moisture absorbed through the Root. J Endod. 2008;34(6):712-714.

21. Nekoofar MH, Aseeley Z, Dummer PM. The effect of various mixing techniques on the surface microhardness of mineral trioxide aggregate. Int Endod J. 2010;43(4):312–320. 22. Saghiri MA, Lotfi M, Saghiri AM, Vosoughhosseini S, Aeinehchi M, Ranjkesh B. Scanning electron micrograph and surface hardness of mineral trioxide aggregate in the presence of alkaline pH. J Endod. 2009;35(5):706-710. 23. Shie MY, Huang TH, Kao CT, Huang CH, Ding SJ. The effect of a physiologic solution pH on properties of white mineral trioxide aggregate. J Endod. 2009;35(1):98-101. 24. Hachmeister DR, Schindler WG, Walker WA 3rd, Thomas DD. The sealing ability and retention characteristics of mineral trioxide aggregate in a model of apexification. J Endod. 2002;28(5):386– 390. 25. Lawley GR, Schindler WG, Walker WA III, Kolodrubetz D. Evaluation of ultrasonically placed MTA and fracture resistance with intracanal composite resin in a model of apexification. J Endod. 2004;30(3):167-172.

36. Erdem AP, Ozdas DO, Dincol E, Sepet E, Aren G. Case Series: root healing with MTA after horizontal fracture. Eur Arch Paediatr Dent. 2009;10(2):110–113. 37. Mohammadi Z, Yazdizadeh M. Obturation of immature non-vital tooth using MTA. Case report. N Y State Dent J. 2011;77(1):33-35. 38. Al-Kahtani A, Shostad S, Schifferle R, Bhambhani S. In-vitro evaluation of microleakage of an orthograde apical plug of mineral trioxide aggregate in permanent teeth with simulated immature apices. J Endod. 2005;31(2):117–119. 39. Bogen G, Kuttler S. Mineral trioxide aggregate obturation: a review and case series. J Endod. 2009;35(6):777–790. 40. Jacobovitz M, de Lima RK. Treatment of inflammatory internal root resorption with mineral trioxide aggregate: a case report. Int Endod J. 2008;41(10):905-912.

26. Lamb EL, Loushine RJ, Weller RN, Kimbrough WF, Pashley DH. Effect of root resection on the apical sealing ability of mineral trioxide aggregate. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2003; 95(6):732-735.

41. Cauwels RG, Pieters IY, Martens LC, Verbeeck RM. Fracture resistance and reinforcement of immature roots with gutta percha, mineral trioxide aggregate and calcium phosphate bone cement: a standardized in vitro model. Dent Traumatol. 2010;26(2):137-142.

13. Main C, Mirzayan N, Shabahang S, Torabinejad M. Repair of root perforations using mineral trioxide aggregate: a long-term study. J Endod. 2004;30(2):80–83.

27. Valois C, Costa ED Jr. Influence of the thickness of mineral trioxide aggregate on sealing ability of root-end fillings in vitro. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2004;97(1):108-111.

42. Kang JS, Rhim EM, Huh SY, Ahn SJ, Kim DS, Kim SY, Park SH. The effects of humidity and serum on the surface microhardness and morphology of five retrograde filling materials. Scanning. 2012;34(4):207-214.

14. Pitt Ford TR, Torabinejad M, McKendry DJ, Hong CU, Kariyawasam SP. Use of mineral trioxide aggregate for repair of furcal perforations. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1995;79:756–763.

28. Matt GD, Thorpe JR, Strother JM, McClanahan SB. Comparative study of white and gray mineral trioxide aggregate (MTA) simulating a one- or two-step apical barrier technique. J Endod. 2004;30(12):876-879.

43. Boutsioukis C, Noula G, Lambrianidis T. Ex vivo study of the efficiency of two techniques for the removal of mineral trioxide aggregate used as a root canal filling material. J Endod. 2008,34(10):1239-1242.

12. Ford TR, Torabinejad M, Abedi HR, Bakland LK, Kariyawasam SP. Using mineral trioxide aggregate as a pulp capping material. J Am Dent Assoc. 1996;127(10):1491–1494.

30 Endodontic practice

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TECHNOLOGY

3D Apical Cork – part 3 In the third article of this series, Dr. Wyatt Simons reviews the technological breakthroughs of the Cork technique and system of obturation with emphasis given to the revolutionary 3D plugger Introduction Michelangelo eloquently outlined the axiom of a sculptor when he said, “Every block of stone has a statue inside it, and it is the task of the sculptor to discover it.” So too is the mission of an endodontic practitioner to sculpt, disinfect, and seal the unique pulpal anatomy present within each tooth. Endodontic beauty is discovered in this final phase of endodontic treatment. Three-dimensional (3D) obturation is when the uniqueness of pulpal anatomy is displayed and when the mindful efforts to three dimensionally expose and disinfect individual root canal systems are revealed. Adequately sealing the complexities of root canal systems has been an understood objective for sustained endodontic success for many years. The word obturation comes from the Latin word obturat, which means “stopped up.” Pathways of the Pulp outlines that, “The aim of canal obturation is to fill the entire volume of the root canal space, including patent accessory canals and multiple foramina, completely and densely with biologically inert and compatible filling material.”1 This is the third article of a series that reviews the revolutionary Cork technique of 3D obturation. The Cork technique stems from a pursuit to reproducibly obturate the vast array of anatomic possibilities present in nature. The first two articles introduced the technologic breakthroughs that the Cork technique employs, reviewed how these advances contribute to reproducible 3D obturation, and displayed clinical cases in an effort to highlight the benefits given to many clinical situations.2-3 It is worth mentioning that even though the technological breakthroughs of the Cork technique can contribute to higher levels of desired outcomes, it is the desire to reach higher levels of outcomes that matters most. Michelangelo’s statue of David shown in Figure 1 is a great example of how passion and commitment to excellence influences individual achievements. One of the most impressive aspects of this work of art completed in 1504 was Michangelo’s ability to accurately capture the anatomic beauty and complexity that lies within each of us. Appreciation for the 32 Endodontic practice

Figure 2: The anatomic beauty and complexity of this maxillary molar was displayed upon 3D obturation with the Cork technique

Figure 1: The statue of David. Michelangelo used tools available in 1504 to find the beauty and complexity of man’s anatomy within a stone

beauty and uniqueness of pulpal anatomy can also be found when complexities are three dimensionally obturated. The Cork technique was used to reveal the beauty found within the maxillary molar in Figure 2. In this final article of the series, the technological breakthroughs of the Cork technique are reviewed, and the revolutionary 3D plugger is introduced.

Review of Cork technology The unique design of the Cork delivery device, illustrated in Figure 3, gives rise to many of the technological breakthroughs of the Cork technique. The design consists of an apical gutta-percha “master-cone” wrapped in a thin silver sheath. This silver extends the full length of the delivery device and is removed as part of the technique. Having a thin sheath of silver wrap apical gutta percha and extending the entire length of the delivery device bring several new functionalities to clinical obturation. First, the design of the Cork delivery device allows for the use of an apex locator

Figure 3: The unique design of the Cork delivery device enables several new functionalities in clinical obturation

to electronically verify the position of the gutta percha at the time of obturation.4 Bringing apex locator technology to obturation decreases the typical need to radiographically verify the “master-cone fit,” thereby saving time and decreasing unnecessary radiation exposure. Figure 4 displays the Cork obturation apex locator. The second distinctive advantage of this design is that a precise, calibrated heat delivery can be achieved throughout the entire intracanal gutta percha. This is shown in more detail in the first article of this series.2 In short, the Cork delivery device is able to overcome gutta percha’s limited thermomechanical ability to transfer temperature more than a few millimeters. This precise heat delivery produces a uniform thermo-softening of the entire apical gutta percha. This calibrated intracanal heat delivery facilitates flow of gutta percha upon compaction. Producing such conditions assisted compaction into the four apical ramifications discovered in the maxillary second premolar shown in Volume 7 Number 2

TECHNOLOGY

Figure 4: The Cork technique brings apex locator technology to obturation

Figure 5A: An off-angle digital radiograph of a Cork delivery device and plugger in position for molding

Figure 5B: The postoperative straight view shows how calibrated temperature delivery contributed to the sealing of the four apical branches that where present in this maxillary second premolar

Figures 5A-5B. In addition, this reproducible warming of gutta percha for 3D molding is calibrated to control the temperature under phase-transition temperatures. Keeping gutta percha under these temperatures avoids potential shrinkage complications.5 The third advantage of wrapping the gutta percha is this allows for adding additional gutta percha and/or molding within the canal simultaneously as conditions are produced and verified to be ideal for reproducible molding. Another advantage of the design is that the Cork delivery device can be prebent, which often facilitates placement under difficult clinical situations, such as when facing intracanal impediments, bifurcations, or sharp turns. Finally, the revolutionary Cork 3D plugger produces more functional compaction forces. This new selfadjusting plugger has the ability to better fit the canal, which in turn helps to keep the softened gutta percha ahead of the plugger. 3D molding into secondary or accessory anatomy is promoted when the 3D plugger is utilized simultaneously as precise intracanal heat is delivered to apical gutta percha. For example, upon preoperative CBCT examination, a fairly large apical tributary was found to branch off of the main canal of the maxillary second premolar shown in Figure 6A. Compaction forces were applied in conjunction with the activated Cork delivery device to accomplish flow into this apical branch (Figure 6B). Additional activation, and removal of the delivery device left a dense fill of homogeneous gutta percha (Figure 6C).

The delivery device that matches the final shaping file is chosen and pre-bent as needed. A small amount of sealer is applied, and apex locator functionality confirms that the gutta percha and delivery device are positioned appropriately in relation to the periradicular tissues. Additional softened gutta percha is delivered into the canal, onto the delivery device in an initial phase of 3D molding. The delivery device is then removed as simultaneous molding occurs with the revolutionary 3D plugger (discussed more below). Successful 3D obturation is completed with an appropriate backfill and the placement of a bonded coronal restoration.

cushion of the softened gutta perchaâ&#x20AC;? to compensate for displaced compaction forces as conventional pluggers plunge through softened gutta percha. The effort to increase molding efficacy within a narrowing, often oval canal gave rise to the design of Cork 3D plugger, illustrated in Figure 7. This revolutionary plugger addresses the need to better conform to individual canal morphology. The design allows for a more functional fit within individual root canal systems. It also has the capacity to adjust to the changing shape of the canal as it progresses and molds apically. This ability to better fit the canal helps to kept the soften gutta percha ahead of the plugger. This facilitates molding into the complexities of individual root canal systems upon compaction. The Cork technique was employed to produce forces of compaction in the maxillary premolar shown in Figures 7A-7B. Compaction forces transferred throughout this oval canal and ultimately contributed to the filling of the two apical branches that came off of the main root canal system. Another benefit of the Cork 3D plugger over conventional endodontic pluggers is that most clinical cases only require one plugger. In addition to having better compaction forces, the need to pre-fit several pluggers is eliminated. The Cork technique and 3D plugger will be demonstrated at the 2014 AAE Annual Session, in Washington D.C., as part of a hands-on workshop on May 1 from 2 p.m. to 5 p.m.

Cork technique The Cork technique starts with the placement of a Cork delivery device into a well-shaped, disinfected, and dried canal. Volume 7 Number 2

Introducing the Cork 3D Plugger 3D obturation is influenced by the efficacy of pluggers to condense thermosoftened gutta percha. Establishing ideal conditions for molding has limited value if corresponding compaction forces are inadequate in transferring needed forces for 3D molding. Controlling thermal conditions for molding and transferring forces of compaction is where the art and science of sealing root canal systems come together. Dr. Herbert Schilder first qualified the physics of the forces of compaction encountered in vertical compaction of warm gutta percha.6 He outlined the difference between a tri-axial type of compaction to a uni-axial type of compaction. A tri-axial system is analogous to a piston in which load is produced in a confined space. This is quite different from the uni-axial force produced, for instance, when a load is applied to a loose-fit plugger within a tapered root canal system. Although some forces of compaction do transfer apically and laterally, much of the moldable gutta percha is simply displaced in the path of least resistance around the plugger. Many clinicians attempt to â&#x20AC;&#x153;capture the maximum

Closing comments Michelangeloâ&#x20AC;&#x2122;s description of a stone having an infinite array of possibilities within is a great analogy to root canal treatment. In his analogy, it is the sculptor who guides the resulting anatomy within each stone. In contrast, as endodontic practitioners, there Endodontic practice 33

TECHNOLOGY

Figure 6A: Preoperative CBCT examination revealed the apical branch that came off of the main system

Figure 6B: The Cork delivery device established calibrated heat delivery to the apical gutta percha while the Cork 3D plugger was utilized to transfer compaction forces to fill the known secondary anatomy

Figure 6C: Postoperative digital radiograph after the Cork technique was completed, including the removal of the delivery device that facilitated accurate molding

Figure 8A: Cork Delivery Device in position to help facilitate 3D molding in this maxillary second premolar

Figure 7: Illustration of the Cork 3D plugger. This functional plugger has the ability to conform to canal shapes between 0.6 and 1.2 millimeters in diameter and self-adjust to tapered canals as it molds apically

Figure 8B: The Cork 3D plugger has the capacity to better fit and transfer compaction forces within an oval canal. Compaction forces helped accomplish the 3D obturation of these apical branches References

is value in allowing the natural anatomy of each root canal system to dictate how we sculpt, disinfect, and ultimately, seal. Successful clinical endodontic treatment starts with the way we mindfully sculpt the anatomy presented to us. Appropriate shape facilitates comprehensive disinfection and reproducible obturation. Once the stage has been set, successful endodontic treatment is influenced greatly by our ability to provide the three-dimensional seal of the root canal system. Although this objective is difficult, it is obtainable. This series of articles reviewed the Cork system of obturation, and how this technique serves to bring new treatment modalities to clinical obturation. 34 Endodontic practice

From adding apex locator functionality and controlling apical temperature delivery to a single 3D endodontic plugger, the Cork system of obturation serves to modernize clinical obturation. Todayâ&#x20AC;&#x2122;s endodontic armamentarium has greatly increased the efficacy of clinical endodontics. High levels of clinical results are obtainable with greater ease due to these technological breakthroughs. However, in the end, it is our individual passion that will guide our practice. Technology and tools will empower us, but it will be our desire that will dictate the level of treatment we render and ultimately define us. EP

1. Cohen S, Burns R. Pathways of the Pulp. 6th ed. St. Louis, MO: Mosby; 1994: 269. 2. Simons WD. 3D apical cork - Part 1. Endodontic Practice US. 2013;6(1):42-45. 3. Simons WD. 3D apical cork - Part 2. Endodontic Practice US. 2013;6(3):36-40. 4. West JC. A Novel Approach to Apical Gutta Percha Control and Sealing of the Root Canal Systems [MSD presentation]. Seattle, WA: University of Washington; 2012. 5. Schilder H, Goodman A, Aldrich W. The thermomechanical properties of gutta-percha. Part V. Volume changes in bulk gutta-percha as a function of temperature and its relationship to molecular phase transformation. Oral Surg Oral Med Oral Pathol. 1985;59(3):285-296. 6. Schilder H, Goodman A, Aldrich W. The themomechanical properties of gutta-percha. I. The compressibility of gutta-percha. Oral Surg Oral Med Oral Pathol. 1974;37:946-953.

Volume 7 Number 2

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CONTINUING EDUCATION

A new concept in canal preparation Dr. Ghassan Yared discusses canal preparation with only one reciprocating instrument without prior hand filing

ffective cleaning and shaping of the root canal system is essential for achieving the biological and mechanical objectives of root canal treatment (Sjögren, et al., 1997). These objectives are to remove all the pulp tissue, bacteria, and their byproducts while providing adequate canal shape to fill the canal. Traditionally, the shaping of root canals was achieved by the use of stainless steel hand files. However, techniques using stainless steel hand files have several drawbacks: 1. They require the use of numerous hand files and drills to adequately prepare the canals (Schilder, 1974). 2. Hand instrumentation with stainless steel files is time consuming (Ferraz et al., 2001). 3. Stainless steel hand instrumentation techniques have an increased incidence of canal transportation (Kuhn, et al., 1997; Reddy, Hicks, 1998; Ferraz, et al., 2001; Pettiette, et al., 2001). 4. From a clinical standpoint, the use of hand instruments in narrow canals can be very frustrating, especially in teeth with difficult access. Nickel-titanium hand or rotary instruments are also used to achieve the mechanical objectives of canal preparation. Nickel-titanium instruments offer many advantages over conventional stainlesssteel files. They are flexible (Walia, et al., 1988), have increased cutting efficiency (Kazemi, et al., 1996) and have improved time efficiency (Ferraz, et al., 2001). Furthermore, nickel-titanium instruments maintain the original canal shape during preparation and have a reduced tendency to transport the apical foramen (Kuhn, et al., 1997; Reddy, Hicks, 1998; Ferraz, et al., 2001; Pettiette, et al., 2001).

Ghassan Yared, DDS, MSc, is an endodontist practicing in Ontario, Canada. He completed his endodontic specialty training at University Paris VII (Paris, France) in 1987 and obtained his MSc from the Lebanese University (Beirut, Lebanon) in 1994. Dr. Yared has supervised the research projects of graduate endodontic students at the University of Toronto and has published extensively in peer-reviewed international endodontic journals. He has also given numerous lectures and continuous education courses worldwide.

36 Endodontic practice

Educational aims and objectives This clinical article aims to present a new approach to canal preparation that allows the use of a single reciprocating nickel-titanium instrument without the need for prior hand filing. Expected outcomes Correctly answering the questions on page 41, worth 2 hours of CE, will demonstrate that the reader can: • Identify the possibilities of this technique. • Realize the limitations of this technique.

Figure 1: Reciproc instruments

Figure 2: Reciproc paper points

However, as these techniques also require the use of numerous instruments to enlarge the canal to an adequate size and taper, they are relatively time-consuming. The use of hand instruments (for example, to create a glide path prior to using a rotary instrument) is also required, which can be very frustrating in narrow canals in teeth with a limited access. The purpose of this article is to introduce a new concept for canal preparation: a paradigm shift. The canal preparation is accomplished using only one specifically designed nickeltitanium engine-driven instrument used in reciprocation and without prior hand filing, which means hand files are not used to enlarge the canal prior to using the reciprocating file. This concept goes completely against the traditional teaching standards, which requires the gradual enlargement of the canal with different files/instruments until the desired shape is obtained. Only one instrument, the reciprocating instrument,

Figure 3: Reciproc gutta percha

is needed to enlarge the canal — even a narrow and curved canal — to an adequate size and taper. There are, however, some exceptions that will be discussed later in this article. In addition, the concept requires the creation of a glide path with smaller instruments prior to using a shaping instrument to minimize the incidence of fracture. A glide path is no longer a prerequisite with this concept of canal preparation. This article also introduces the notion of the “path of least resistance.” The shaping instrument will follow the existing and natural path of least resistance, which is the canal. This not only saves time, but also is particularly convenient in teeth with limited access. Additionally, errors associated with the use of hand filing prior to using mechanically driven instruments can be avoided. The first paper on the use of only one engine-driven instrument in reciprocation to prepare a root canal was published in the Volume 7 Number 2

Figure 5: Selection of the appropriate Reciproc instrument, based on adequate preoperative radiograph

Figures 6A and 6B: Canal is considered narrow: R25

International Endodontic Journal (Yared, 2008). The article described the use of an F2 ProTaper® instrument. However, the use of that instrument in reciprocation presented two drawbacks: 1. Instrument fracture by cyclic fatigue in relation to the relative rigidity of the instrument due to its size, taper, and cross section (Pruett, 1997) 2. The necessity of creating a glide path with additional hand files prior to using the F2 instrument in reciprocation. The clinical impression was that the F2 instrument does not cut efficiently enough into a narrow and uninstrumented canal. Frequently, it did not advance in the canal without a glide path. Other rotary instruments were also tested in a single file preparation technique. Issues similar to those encountered with the use of the F2 were observed (unpublished results). An ATR Vision motor (Advanced Technology Research, Italy) was used with the F2. However, this motor is no longer manufactured. Volume 7 Number 2

For these reasons, a new system for single file reciprocation without the prior use of hand files was developed (VDW GmbH, Germany). The system includes three instruments, the Reciproc® instruments (R25, R40, and R50) (Figure 1), matching paper points (Figure 2), gutta-percha cones (Figure 3), and a motor (VDW Silver® Reciproc). Only one Reciproc instrument is used for the canal preparation, depending on the initial size of the canal. The instruments are made from M-Wire™ nickel titanium that offers greater flexibility and resistance to cyclic fatigue than traditional nickel titanium. They have an “S”-shaped cross section (Figure 4). The three instruments have a regressive taper: • The R25 has a diameter of 0.25 mm at the tip and an 8% (0.08 mm/mm) taper over the first 3 mm from the tip. The diameter at D16 is 1.05 mm. • The R40 has a diameter of 0.40 mm at the tip and a 6% (0.06 mm/mm) taper over the first 3 mm from the tip. The diameter at

D16 is 1.10 mm. • The R50 has a diameter of 0.50 mm at the tip and a 5% (0.05 mm/mm) taper over the first 3 mm from the tip. The diameter at D16 is 1.17 mm. The motor is battery operated. The battery is rechargeable, and the motor can be used while the battery is charging. The instruments are used at 10 cycles of reciprocation per second, the equivalent of approximately 300 rpm. The motor is programmed with the angles of reciprocation and speed for the three instruments. The values of the clockwise (CW) and counter clockwise (CCW) rotations are different. When the instrument rotates in the cutting direction, it will advance in the canal and engage dentin to cut it. When it rotates in the opposite direction (smaller rotation), the instrument will be immediately disengaged. The end result, related to the degree of CW and CCW rotations, is an advancement of the instrument in the canal. Consequently, only very light apical pressure should be applied on the instrument, as its advancement would be almost automatic. These angles are specific to the Reciproc instruments. They were determined using the torsional properties of the instruments and are influenced by specific features related to the motor such as torque.

Technique The technique is extremely simple. In the majority of canals, only one Reciproc instrument is used in reciprocation to complete the canal preparation, and there is no need for hand filing. The access cavity requirements, the Endodontic practice 37

CONTINUING EDUCATION

Figure 4: Reciproc cross-section

CONTINUING EDUCATION

Figures 7A and 7B: Canal clearly visible from access cavity to apex: considered medium or wide (R50 was used for the canal preparation; an increased apical enlargement was obtained with a size 70 hand file)

straight-line access to the canals, and the irrigation protocol are the same as standard preparation techniques. It is not necessary to widen the root canal orifice with a Gates Glidden drill or an orifice opener. Selection of the appropriate Reciproc instrument (Figure 5) Selection of the Reciproc instrument is based on an adequate preoperative radiograph. If the canal is partially or completely invisible on the radiograph, the canal is considered narrow, and the R25 is selected (Figures 6A and 6B). In the other cases, where the radiograph shows the canal clearly from the access cavity to the apex, the canal is considered medium or wide (Figures 7A and 7B). A size 30 hand instrument is inserted passively (with a gentle watchwinding movement but without filing action) to the working length. If it reaches the working length, the canal is considered large; the R50 is selected for the canal preparation. If the size 30 hand file does not passively reach working length, a size 20 hand file is inserted passively to the working length. If it reaches working length, the canal is considered medium; the R40 is then selected for the canal preparation. If the size 20 hand instrument does not reach the working length passively, the R25 is selected. Preparation step by step (without creating a glide path) In reciprocation, clockwise and counterclockwise angles determine the amplitude of reciprocation, the right and left rotations. These angles are lower than the angles at which the Reciproc instrument would usually fracture (if bound). When a 38 Endodontic practice

reciprocating file binds in the canal, it will not rotate past its specific angle of fracture. Therefore, the creation of a glide path to minimize binding is not required for the Reciproc instruments. The cutting efficiency of the Reciproc instruments and the centering ability associated with reciprocation (Hata, et al., 2002; Song, et al., 2004) allow the instruments to enlarge uninstrumented and narrow canals in a safe manner. Before starting preparation, the length of the root canal is estimated with the help of an adequately exposed and angulated preoperative radiograph. The silicone stopper is set on the Reciproc instrument at two-thirds of that length. The Reciproc instrument is introduced in the canal with a slow in-and-out pecking motion without pulling the instrument completely out of the canal. The amplitude of the in-and-out movements should not exceed 3-4 mm. Only very light pressure should be applied. The instrument will advance easily in the canal in an apical direction. After three in-and-out movements, or when more pressure is needed to make the instrument advance further in the canal, or when resistance is encountered, the instrument is pulled out of the canal to clean the flutes. A size 10 file is used to check patency to two-thirds of the estimated working length. The canal is copiously irrigated. The Reciproc instrument is used until it has reached two-thirds of the estimated working length as indicated by the stopper on the instrument. The instrument is then removed from the canal, the canal is irrigated, and a size 10 file is used to determine the length. The Reciproc instrument is then reused in the same manner until the working length has been reached. As soon as the working length has been reached, the Reciproc instrument

Figures 8A-8C: Glide path was created in the DB canal

Figure 9: Abrupt apical curvature

is withdrawn from the canal. The Reciproc instrument can also be used in a brushing motion against the lateral walls of wide canals. Creating a glide path during the use of the Reciproc instruments: indication and management (Figure 8) With continuous rotary nickel-titanium systems, it is necessary to create a glide path in order to minimize the risk of fracture (Peters, et al., 2003; Yared, et al., 2004; Patino, et al., 2005). During the use of a rotary instrument, the tip of the instrument may bind in the canal. The motor will keep rotating the instrument while the tip of the instrument is bound. The instrument will rotate past its plastic limit and will eventually fracture at a specific angle of rotation. For this reason, it is necessary to create an initial glide path, or a minimal canal enlargement, before using continuous rotary instruments. The glide path will minimize the incidence of instrument Volume 7 Number 2

CONTINUING EDUCATION

Figures 10A and 10B: Gradual curvature. Size 10 file used for the working length determination will reach working length without being pre-curved

binding and, therefore, minimize the risk of fracture. Just as with any continuous rotary nickel-titanium system, it is also possible to use the Reciproc reciprocating file after creating an initial glide path with hand instruments to a size 10 or 15. A glide path may also have to be created in some canals when the Reciproc instrument stops advancing in the canal or if advancement becomes difficult. In this case, pressure should not be exerted on the Reciproc instrument. The instrument should be removed from the canal, and the canal irrigated. If the Reciproc instrument still advances with difficulty, or if it does not advance, it should be removed from the canal and the canal irrigated once again. At this point, size 10 and 15 hand files should be used to create a glide path to the working length. The Reciproc instrument would then be used until the working length has been reached. If, however, the progress of the Reciproc instrument is still difficult or not possible, the canal preparation would need to be completed with hand files. Using hand files to finish the apical canal preparation In some canals, the size 10 file used for the working length determination (after the Reciproc instrument has reached twothirds of the estimated working length) has to be pre-curved; otherwise, it cannot reach working length. This indicates the presence of an abrupt apical curvature (Figure 9). The use of the Reciproc instruments is contraindicated in this instance. The canal preparation has to be finished with hand files. However, in most of the cases, the size 10 file used for the working length Volume 7 Number 2

determination will reach that length without being pre-curved (indicating the presence of a gradual curvature) (Figures 10A and 10B). The Reciproc instrument will be used to working length to complete the preparation. Increased apical enlargement (Figure 7) In some canals, an increased apical enlargement (based on gauging the canal, for example) may be required. A larger Reciproc instrument or a hand instrument may be used for this purpose following the R25 and the R40, and a hand instrument is used following the R50.

Figures 11A-11C: Severely curved canals prepared with the R25 without the creation of a glide path

Additional advantages of the Reciproc concept and instruments Centering ability Preliminary evidence has demonstrated the centering ability of the reciprocating instruments used according to this concept (unpublished results). Figures 11 and 12 show severely curved canals prepared with the R25 without the creation of a glide path. The radiographs show that the canal curvature was maintained despite the severity of the curvature. Safety A rotary instrument can also fracture if it binds in the canal, especially at its tip. When using a rotary system, the tip of the instrument may bind in the canal; the motor will keep rotating the instrument while its tip is bound, and the instrument will eventually fracture at a specific angle of rotation. In reciprocation, clockwise and counter-clockwise angles determine the amplitude of reciprocation, the right and left rotations. These angles, stored in the motor, are significantly lower than the angles at which the instrument would usually fracture. If the instrument binds in

Figures 12A-12C: Severely curved canals prepared with the R25 without the creation of a glide path

Endodontic practice 39

CONTINUING EDUCATION

Figures 13A and 13B: Retreatment of gutta-percha obturations

References Alapati SB, Brantley WA, Svec TA, Powers JM, Mitchell JC. Scanning electron microscope observations of new and used nickel titanium rotary files. J Endod. 2003;29(10):667-669.

Figures 14A and 14B: Retreatment of gutta-percha obturations

the canal, it will not fracture because it will never reach the angle required to fracture. In this respect, single file reciprocation is safer than rotary techniques because fracture by binding (fracture by taper lock or torsional fracture) is eliminated. One Reciproc instrument replaces several hand and/or rotary instruments for a canal preparation procedure. The Reciproc instrument is thus subjected to cyclic fatigue and should be discarded after the completion of a case. The plastic band on the handle of the instrument deforms if the instrument is autoclaved; this safety feature eliminates fatigue fracture due to repeated use in more than one case. Shorter working time Working time was 4 times faster with the single file reciprocation in comparison with a nickel-titanium rotary preparation technique (unpublished results). Faster learning It has been found that 92% of Reciproc users were able to prepare three canals consecutively without errors compared to 30% of the continuous rotary nickeltitanium system users (unpublished results). Fewer procedural errors A lower incidence of complications, such as canal transportation, ledging, and blockage, was observed with the single reciprocation technique than with a major 40 Endodontic practice

rotary technique (unpublished results) Retreatment of gutta-percha obturations (Figures 13 and 14) Gutta-percha filling material can be easily removed from the canal with the R25. First of all, the bulk of the gutta percha in the coronal third of the canal should be removed with an appropriate instrument (e.g., electric heat carrier, ultrasonic tip). A solvent (e.g., eucalyptus oil) is used as required, and the R25 is used as described above until working length has been reached. If resistance is encountered, pressure should not be applied. The instrument should be removed from the canal, the solvent replaced, and the R25 used again. After reaching working length with the R25, the R40 or R50 can be used for an increased apical enlargement, as necessary. Reciproc instruments can also be used in a brushing motion against the lateral walls of the canal to remove any residual filling material. Retreatment of carrier-based obturators Carrier-based obturators can be removed in the same manner as gutta-percha filling material. The carrier may be removed in one piece during the use of the Reciproc instrument; otherwise, it will be removed in small pieces with the gutta percha. EP

Ferraz CC, Gomes NV, Gomes BP, Zaia AA, Teixeira FB, Souza-Filho FJ. Apical extrusion of debris and irrigants using two hand and three engine-driven instrumentation techniques. Int Endod J. 2001;34(5):354-358. Kazemi RB, Stenman E, Spångberg LS. Machining efficiency and wear resistance of nickel-titanium endodontic files. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1996;81(5):596-602. Kuhn WG, Carnes DL Jr, Clement DJ, Walker WA III. Effect of tip design of nickel-titanium and stainless steel files on root canal preparation. J Endod. 1997;23(12):735-738. 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):114116. 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. Pettiette MT, Delano EO, Trope M. Evaluation of success rate of endodontic treatment performed by students with stainless-steel K-files and nickel-titanium hand files. J Endod. 2001;27(2): 124-127. Pruett JP, Clement DJ, Carnes DL Jr. Cyclic fatigue testing of nickel-titanium endodontic instruments. J Endod. 1997;23(2):77-85. Reddy SA, Hicks ML. Apical extrusion of debris using two hand and two rotary instrumentation techniques. J Endod. 1998;24(3):180-183. Schilder H. Cleaning and shaping the root canal. Dent Clin North Am. 1974;18(2):269-296. Schneider K, Korkmaz Y, Addicks K, Lang H, Raab WH. Prion protein (PrP) in human teeth: an unprecedented pointer to PrP’s function. J Endod. 2007;33(2):110-113. Sjögren U, Figdor D, Persson S, Sundqvist G. Influence of infection at the time of root filling on the outcome of endodontic treatment of teeth with apical periodontitis. Int Endod J. 1997;30(5):297-306. Song YL, Bian Z, Fan B, Fan MW, Gutmann JL, Peng B. A comparison of instrument-centering ability within the root canal for three contemporary instrumentation techniques. Int Endod J. 2004;37(4):265-271 Sonntag D, Peters OA. Effect of prion decontamination protocols on nickel-titanium rotary surfaces. J Endod. 2007;33(4):442-446. Spongiform Encephalopathy Advisory Committee. Annual Report ; 2006:6. 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. Yared G. In vitro study of the torsional properties of new and used ProFile nickel titanium rotary files. J Endod. 2004;30(6):410-412. Yared G. Canal preparation using only one NiTi rotary instrument: preliminary observations. Int Endod J. 2008;41(4):339-344.

Volume 7 Number 2

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TFâ&#x201E;˘ Adaptive: a novel approach to nickeltitanium instrumentation

A new concept in canal preparation

GAMBARINI-GLASSMAN

1. The clockwise (CW) and counter-clockwise (CCW) rotations used by Yared were fourtenths and two-tenths of a circle respectively, and the rotational speed utilized was _____. a. 200 rpm b. 300 rpm c. 400 rpm d. 500 rpm 2. The concept of using a single nickeltitanium instrument to prepare the entire root canal was made possible due to the fact that a reciprocating motion is thought to reduce _____. a. instrumentation stress b. rigidity c. the angle of reciprocation d. debris 3. Therefore, when discussing the advantages and disadvantages of reciprocation, the exact motion should also be mentioned, since the actual angle of reciprocation can have a substantial influence on the _____ of nickel-titanium instruments. a. clinical behavior b. experimental behavior c. size d. both a and b 4. It is well-known that a small, inadvertent degree of ______ into the periapical tissues is a frequent complication during the cleaning and shaping procedures, both with manual stainless steel and nickel-titanium rotary instrumentation techniques. a. MTA b. extrusion of debris c. extrusion of irrigants d. both b and c 5. Since reciprocation movement is formed by a wider cutting angle and a(n) ____ releasing angle, while rotating in the releasing angle, the flutes will not remove debris but push them apically. a. equally as wide b. smaller

Volume 7 Number 2

c. much wider d. deeper 6. Moreover, the cutting ability of a reciprocating file is ______when compared to continuous rotation. a. increased b. stays the same c. decreased d. totally eliminated 7. When the TF Adaptive instrument is not (or is only very lightly) stressed in the canal, the movement can be described as ________. a. an algorithm b. instrument intensity c. a continuous rotation d. metal fatigue 8. The TF Adaptive technique is basically a ______technique, designed to treat the majority of cases encountered in clinical practice. a. single-file b. two-file c. three-file d. four-file 9. The number of instruments within each sequence can also vary and adapt to canal anatomy, with the last instrument of the sequence used only when a _____apical enlargement is needed due to larger original canal dimensions and/or enhanced final irrigation techniques. a. greater b. smaller c. narrower d. more curved 10. The use of a final apical enlargement with a _____ is not only meant to allow the use of the EndoVacÂŽ (SybronEndo) irrigation technique, but to improve canal shaping by touching more canal walls. a. size 25 b. size 35 c. size 40 d. size 45

YARED

1. Effective cleaning and shaping of the root canal system is essential for achieving the biological and mechanical objectives of root canal treatment. These objectives are to remove all the ______ while providing adequate canal shape to fill the canal. a. pulp tissue b. bacteria c. pulp tissue and bacteria byproducts d. all of the above 2. In the majority of canals, _____ Reciproc instrument(s) is(are) used in reciprocation to complete the canal preparation, and there is no need for hand filing. a. only one b. two c. three d. four 3. _____ (is)are the same as standard preparation techniques. a. The access cavity requirements b. The straight-line access to the canals c. The irrigation protocol d. All of the above 4. Selection of the Reciproc instrument is based on an adequate ______. a. visual examination b. intraoral photograph c. preoperative radiograph d. patient history 5. If the canal is partially or completely invisible on the radiograph, the canal is considered narrow, and the ____ is selected. a. R20 b. R25 c. R30 d. R40

6. When a reciprocating file binds in the canal, it will _____ past its specific angle of fracture. a. rotate b. not rotate c. glide d. cut 7. The amplitude of the in-and-out movements should not exceed ____. a. 1 mm b. 2 mm c. 3-4 mm d. 5 mm 8. _____ will minimize the incidence of instrument binding and, therefore, minimize the risk of fracture. a. The glide path b. The working length c. The brushing motion d. Using the stopper 9. In some canals, the ______ used for the working length determination (after the Reciproc instrument has reached two-thirds of the estimated working length) has to be pre-curved; otherwise, it cannot reach working length. a. size 10 file b. size 20 file c. size 25 file d. size 30 file 10. A rotary instrument can also fracture if it binds in the canal, especially _____. a. during counter-clockwise motion b. during clockwise motion c. when autoclaved d. at its tip

Endodontic practice 41

CE CREDITS

ENDODONTIC PRACTICE CE

CONTINUING EDUCATION

TF™ Adaptive: a novel approach to nickel-titanium instrumentation Drs. Gianluca Gambarini and Gary Glassman examine how to achieve rotary motion when you want it — and reciprocation when you need it

or more than a decade, nickel-titanium instruments have been traditionally used with a continuous rotary motion, but more recently, a new approach to the use of nickel-titanium instruments in a reciprocating movement has been introduced by Yared (2004). The clockwise (CW) and counter-clockwise (CCW) rotations used by Yared were four-tenths and two-tenths of a circle respectively, and the rotational speed utilized was 400 rpm. The concept of using a single nickeltitanium instrument to prepare the entire root canal was made possible due to the fact that a reciprocating motion is thought to reduce instrumentation stress. Recent literature data show that reciprocating motion can extend cyclic fatigue resistance of nickel-titanium instruments when compared to continuous rotation, mainly because it reduces instrument stress. As the instrument rotates in one direction (usually the larger angle), it cuts and becomes engaged into the canal, then disengages in the opposite direction (usually with the smaller angle); and the stresses are, therefore, reduced. Following these concepts, new instruments have been recently commercialized:

Gianluca Gambarini, MD, DDS, is a full-time professor of endodontics at the University of Rome. In addition to being an international lecturer, he is the author of more than 450 scientific articles, three books, and chapters in other books. He has focused his interests on endodontic materials and clinical endodontics. He is actively cooperating as a consultant with many manufacturers all over the world to develop new technologies, operative procedures, and materials for root canal treatment. He maintains a private practice limited to endodontics in Rome, Italy. Gary Glassman, DDS, FRCD(C), graduated from the University of Toronto, Faculty of Dentistry in 1984. 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. The author of numerous publications, Dr. Glassman lectures globally on endodontics. He maintains a private practice, Endodontic Specialists, in Toronto, Canada.

42 Endodontic practice

Educational aims and objectives This clinical article aims to describe the benefits that application of the TF Adaptive technique brings to reciprocating movement in endodontic procedures. Expected outcomes Correctly answering the questions on page 41, worth two hours of CE, will demonstrate that the reader can: • Realize the limitations of reciprocation. • Recognize the benefits of adaptive motion.

Figure 1: Canal transportation in curved canals using reciprocation. The most flexible file (TF) allows better maintenance of original trajectory

Reciproc® (VDW, Germany) and WaveOne® (DENTSPLY Tulsa Dental Specialties), which uses specially developed motors that produce reciprocating movement (using approximately 150°-30° angles). This reduction of instrumentation stress (both torsional and bending stress) is the main advantage of reciprocating movement, even if it has been shown that a lot of different reciprocating movements can be used. Each one affects the performance and the safety of the nickel-titanium instruments. Therefore, when discussing the advantages and disadvantages of reciprocation, the exact motion should also be mentioned, since the actual angle of reciprocation can have a substantial influence on both the clinical and experimental behavior of nickeltitanium instruments. Another possible advantage of reciprocation is a better maintenance of the original canal trajectory, mainly related

Figure 2: Complex curvature: the initial use of a very flexible, small tapered instrument (SM1) allows negotiation of the most complex curvature without iatrogenic errors such as zipping, ledging, or transportation

to lower instrumentation stress and, consequently, its elastic return. However, it must be underlined that reciprocation does not affect the inherent rigidity of the instruments. If a quite rigid nickel-titanium instrument of greater taper is slightly forced into a curved canal, it will create more canal transportation than a more flexible one, due to its inherent tendency to straighten. Moreover, tip design can strongly influence canal transportation, with a cutting tip being more dangerous than a non-cutting pilot tip. While reciprocation with nickel-titanium Volume 7 Number 2

Figure 4: Color-coded file identification. An intuitive, colorcoded system designed for efficiency and ease of use. Just like a traffic light, start with green and stop with red

Figure 5: LA Axxess half kit 2.0 – everything you need to prepare and refine access preparation

instruments has become very popular in recent years, with a significant number of published articles, some of these studies have shown that there are also inherent disadvantages in reciprocating movement. It is well-known that a small, inadvertent degree of extrusion of debris and irrigants into the periapical tissues is a frequent complication during the cleaning and shaping procedures, both with manual stainless steel and nickel-titanium rotary instrumentation techniques (Oginni, Udoye, 2004; Siqueira, et al., 2002). However, recent studies have shown that commercially available reciprocating instrumentation techniques seem to significantly increase the amount of debris extruded beyond the apex (Bürklein, Schäfer, 2012; Jaramillo, Rraydolfo, 2013) and, consequently, the risk of postoperative pain. A clinical study comparing Reciproc and nickel-titanium rotary instruments has also confirmed these findings (Gambarini, et al, 2012). Since reciprocation movement is formed by a wider cutting angle and a smaller releasing angle, while rotating in the releasing angle, the flutes will not remove debris but push them apically. Reciproc and WaveOne motions are very similar (even if not precisely disclosed by manufacturers), and this fact could also explain the higher incidence and intensity of postoperative pain that has been found in recent research studies (Gambarini, et al., 2012; Gambarini, et al., 2013). Moreover, both WaveOne and Reciproc techniques use a quite rigid, large single file of increased taper (usually 08 taper, size 25), which is directed to reach the apex. In many cases, in order to reach the apical working length, reciprocating

instruments are used with apically directed pressure, which produces an effective piston to propel debris through a patent apical foramen — and possibly directing debris laterally — making canal debridement more difficult. Since instruments are commonly used without first performing preliminary coronal enlargement, this may result in greater engagement of the file flutes and, consequently, may produce more torque and/or applied pressure on the file. Moreover, the cutting ability of a reciprocating file is decreased when compared to continuous rotation. Debris removal is also reduced, thus increasing the frictional stress and torque demand on the file, due to entrapment of debris within the flutes. To reduce this tendency, some authors have advocated the use of nickeltitanium rotary glide path instruments before using WaveOne or Reciproc instruments, meaning the overall technique is no longer a single file technique but a more complex and more costly one that utilizes two different types of nickel-titanium instruments, glide path instruments, and then shapers (Berutti, et al., 2012).

and flute designs are meant to perform at their best in a clockwise motion. More precisely, it is an interrupted motion with the following CW-CCW angles: 600°-0°. This interrupted motion is not only as effective as continuous rotation in lateral cutting — thus allowing optimal brushing or circumferential oval canals — but it also minimizes iatrogenic errors by reducing the tendency of “screwing in” that is commonly seen with nickel-titanium instruments of great taper. On the contrary, due to increased instrumentation stress and metal fatigue, the motion of the TF Adaptive instrument changes into a reciprocation mode while negotiating the canal, with specifically designed CW and CCW angles that vary from 600°-0° up to 370°-50°. These angles are not constant, but vary depending on the anatomical complexities and the intracanal stress placed on the instrument. This “adaptive” motion is therefore meant to reduce the risk of intracanal failure without affecting performance, due to the fact that the best movement for each different clinical situation is automatically selected by the Adaptive motor. It is quite interesting to note that the clinician will hardly perceive the differences in the changing motion due to a very sophisticated algorithm, which permits a smooth transition between the changing angles. As far as disadvantages of reciprocation are concerned, TF Adaptive motion is reciprocal, with much greater cutting angles (CW angles) than WaveOne/Reciproc movements. Consequently, the TF Adaptive instrument works more at a CW angle, which allows for better cutting efficiency and debris removal (and less tendency to

Volume 7 Number 2

TF™ Adaptive The TF Adaptive technique has been proposed in order to maximize the advantages of reciprocation while minimizing its disadvantages. It achieves this by using a patented motion, the innovative TF Adaptive motion technology, which automatically adapts to instrumentation stress. When the TF Adaptive instrument is not (or is only very lightly) stressed in the canal, the movement can be described as a continuous rotation. This allows better cutting efficiency and removal of debris, since cross-sectional

Endodontic practice 43

CONTINUING EDUCATION

Figure 3: Deep shaping. The clinical use of a second instrument (06/35) after the 08/25 significantly increases the preparation in the apical third, improving the quality of canal shaping and allowing room for enhanced irrigation technique such as negative pressure

CONTINUING EDUCATION

Figure 6: MiniEndo II ultrasonic unit

Figure 7: M4 Safety handpiece

push debris apically and laterally), because the flutes are designed to remove the debris in a CW rotation. In such cases, TF Adaptive takes advantage of a motion that is more similar to continuous rotation for optimal debris removal. There are obviously some changes in the angles depending on canal anatomy (the more complex, the smaller the CW angle), but they do not seem to significantly influence the overall result. On the contrary, these changes influence resistance to metal fatigue, since TF instruments used with the adaptive motion were found to have superior resistance to cyclic fatigue when compared to the same TF instruments used in continuous rotation (Gambarini, 2012). This explains why TF Adaptive has shown better performance in a clinical study than other commercially available reciprocating instruments. The use of a sequence and more flexible nickel-titanium instruments can also be important factors in determining a lower incidence and intensity of postoperative pain, by reducing the amount of apical transportation and the extrusion of debris as the instruments are directed apically. TF instruments have been found to be the most flexible nickel-titanium instruments available, being significantly more flexible than ProTaper® and M2, instruments with a design and mass very similar to WaveOne and Reciproc. As mentioned before, flexibility is a fundamental property for minimizing iatrogenic errors while negotiating canals, both in reciprocation and in continuous rotation. Figure 1 shows that even if the same reciprocating motion was used as in the other reciprocating file systems, the more flexible files (seen with TF files) allow better maintenance of original trajectory

with less canal transportation. Therefore, the use of reciprocating movement does not significantly help a nickel-titanium instrument of greater taper to negotiate curved canals with no iatrogenic errors. It mainly helps to reduce instrumentation stress and the risk of intracanal failure. The TF Adaptive technique is basically a three-file technique, designed to treat the majority of cases encountered in clinical practice. Two sets of three-file systems are available — one for small calcifying canals and one system for more “standard” and larger canals. In both scenarios, this allows adequate taper and increased apical preparation. The number of instruments within each sequence can also vary and adapt to canal anatomy, with the last instrument of the sequence used only when a greater apical enlargement is needed due to larger original canal dimensions and/or enhanced final irrigation techniques. The sequences are also different in their shaping concepts. The medium/ large canal sequence is a “true” crowndown technique, while the small canal sequence employs a smaller, more flexible instrument (04 taper 20 tip size) to preenlarge the canal and create a glide path, which decreases instrument stress for the next larger size file to sequence. This also allows better maintenance for the original canal trajectory, as seen in Figure 2. The use of a final apical enlargement with a size 35 is not only meant to allow the use of the EndoVac® (SybronEndo) irrigation technique, but to improve canal shaping by touching more canal walls. Figure 3 clearly shows how improved and deeper the apical one-third shape is when a 06 taper 35 tip instrument follows a 08 taper 25 tip instrument. This is why in the majority of cases, two instruments are

44 Endodontic practice

much better than a single file technique, provided that the second instrument is a flexible one. The superior flexibility allowed by the use of TF technology permits TF Adaptive to follow these criteria and safely enlarge canals with a minimal risk of iatrogenic errors, such as tooth weakening and canal/apical transportation. The use of a more rigid alloy would have not made this possible, especially in curved canals.

TF Adaptive technique TF Adaptive is an intuitive, color-coded system designed for efficiency and ease of use. The color-coded system is based on a traffic light (Figure 4). Start with green, continue or stop with yellow, and stop with red. Green means go. Yellow means continue or stop. Red means stop.

Coronal access and glide path 1. Place rubber dam 2. Obtain straight line coronal access with slightly diverging axial walls. The LA Axxess™ Diamond Bur (SybronEndo) (Figure 5) is recommended for access preparation and may be refined with a CT4 diamond-coated tip used with the MiniEndo™ II ultrasonic unit (SybronEndo) (Figure 6). 3. Achieve apical patency and establish an apical glide path using a size 8 hand file. Follow with a size 15 hand file. The glide path may be facilitated with the M4 Safety® Handpiece (SybronEndo) (Figure 7) and SlickGel™ (SybronEndo) can be used as your lubricant. The pulp chamber should be filled to the brim with sodium hypochlorite (NaOCl).

Canal size and file sequence determination (Figures 8 and 9) Small canals (SM) Using tactile feel, if you struggle to get a Volume 7 Number 2

CONTINUING EDUCATION

size 15 K-file to working length, then the canal size is deemed to be “small.” Use the small pack (one-color band) and its instrument sequence. Medium/large canals (ML) Using tactile feel, if a size 15 K-file feels loose at working length, then the canal size is deemed to be “medium/large.” Use the medium/large pack (two-color bands) and its instrument sequence. Establish working length Using an apex locator (such as the SybronEndo Apex ID™), a radiograph may be taken to assist in length determination. TF Adaptive canal shaping technique 1. Use the TF Adaptive setting on your Elements™ Motor (SybronEndo). 2. Ensure the pulp chamber is flooded with NaOCl or EDTA, and make sure the file is rotating as you enter the canal. 3. Slowly advance the green instrument (SM1 or ML1) with a single controlled motion until the file engages dentin; then completely withdraw the file from the canal. Do not force apically. Do not peck. 4. Wipe off flutes. Deliver irrigant to the pulp chamber, and confirm canal patency with a size 15 K-file. 5. Repeat steps 3 and 4 using the file you started with until working length is achieved. 6. Repeat steps 3 and 4 with the yellow instrument (SM2 or ML2) until the file reaches working length. If the desired apical size is achieved, the sequence is complete. For larger apical sizes, repeat steps 3 and 4 with the red instrument (SM3 or ML3) until the file reaches working length.

Irrigate and dry When irrigating with EndoVac in small canals, you must take SM3 to working length. In medium/large canals, you must take at least ML2 to working length. TF Adaptive matching gutta percha or obturators may be used to obturate the root canal system.

Volume 7 Number 2

Figure 8: TF Adaptive technique card, showing size and sequence determination

References 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.

Figure 9: File size reference chart

Conclusions Adaptive motion technology is based on a patented, smart algorithm designed to work with the TF Adaptive file system. This technology allows the TF Adaptive file to adjust to intracanal torsional forces, depending on the amount of pressure placed on the file. This means the file is in either a rotary or a reciprocation motion, depending on the situation. The result is exceptional debris removal with the triedand-trusted classic rotary Twisted File design and less chance of file pull-in and debris extrusion with Adaptive motion technology. The TF Adaptive file design is based in clinically proven Twisted File technology, which means the file is twisted to shape for improved file durability, features R-Phase technology to improve file flexibility, and provides exceptional debris removal. With TF Adaptive and Adaptive motion technology, you get the best of both worlds. Now that’s rotary when you want it, reciprocation when you need it. EP

Bürklein S, Schäfer E. Apically extruded debris with reciprocating single-file and full-sequence rotary instrumentation systems. J Endod. 2012;38(6):850852. De-Deus G, Moreira EJ, Lopes HP, Elias CN. Extended cyclic fatigue life of F2 ProTaper instruments used in reciprocating movement. Int Endod J. 2010;43(12):1063-1068. Gambarini G, Sudani DAL, Di Carlo S, Pompa G, Pacifici A, Pacifici L, Testarelli L. Incidence and intensivity of postoperative pain and periapical inflammation after endodontic treatment with two different instrumentation techniques. Europ J Inflam. 2012;10:99-103. Gambarini G, Gergi R, Naaman A, Osta N, Al Sudani D. Cyclic fatigue analysis of twisted file rotary NiTi instruments used in reciprocating motion. Int Endod J. 2012;45(9):802-806. Gambarini G. Influence of a novel reciprocation movement on the cyclic fatigue of twisted files (TF) instruments. www.healthcare-learning.com. 2012. Gambarini G, Testarelli L, De Luca M, Milana V, Plotino G, Grande NM, Rubini AG, Al Sudani D, Sannino G. The influence of three different instrumentation techniques on the incidence of postoperative pain after endodontic treatment. Ann Stomatol (Roma). 2013;4(1):152-155. Jaramillo D, Rraydolfo A. Comparison of the extrusion of dentin debris using a new instrumentation [publication pending]. 2013. Oginni A, Udoye CI. Endodontic flare-ups: comparison of incidence between single and multiple visit procedures in patients attending a Nigerian teaching hospital. BMC Oral Health. 2004;4(1):4. Pruett JP, Clement DJ, Carnes DL Jr. Cyclic fatigue testing of nickel-titanium endodontic instruments. J Endod. 1997;23(2):77-85. Siqueira JF Jr, Rôças IN, Favieri A, Machado AG, Gahyva SM, Oliveira JC, Abad EC. Incidence of postoperative pain after intracanal procedures based on an antimicrobial strategy. J Endod. 2002;28(6):457-460. Yared G. In vitro study of the torsional properties of new and used ProFile nickel titanium rotary files. J Endod. 2004;30(6):410-412. You SY, Bae KS, Baek SH, Kum KY, Shon WJ, Lee W. Lifespan of one nickel titanium rotary file with reciprocating motion in curved root canals. J Endod. 2010;36(12):1991-1994.

Endodontic practice 45

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Volume 7 Number 2

PRODUCT PROFILE

Sonendo® aims to transform the future of endodontics GentleWave™ system brings Multisonic Ultracleaning™ technology to AAE 2014 Solving the real problems with RCT According to the AAE, over 15 million cases of root canal therapy (“RCT”) are performed each year in the United States. However, the current methodologies rely on technologies invented over 200 years ago. The tools used today are in part not only inefficient — it is typical for at least 35% (and as high as 50%) of the canal surface to be passed over during instrumentation1,2 — but also are associated with several procedural and safety issues such as leaving uninstrumented recesses, root weakening, ledge formation, perforations, over-instrumentation, instrument separation, extrusion of debris into the periapical tissue, and periapical extrusion of sodium hypochlorite.

ultrasound – where only one frequency of sound is applied – the GentleWave delivers multiple, various, and specific wavelengths ranging from large (e.g., tissue scale) to small scale (e.g., cellular scale). These waves are distributed over a broad range of frequencies, and remove unhealthy pulp tissue and bacteria safely, regardless of the complexity of the canal system.

Figure 2: Challenging canal anatomy fully cleaned by GentleWave™

Figure 1: GentleWave™

New paradigm: Multisonic Ultracleaning Sonendo has developed a system — the GentleWave™ — that delivers broad spectrum sonic energy through a disposable dental handpiece to the root canal structures. This closed loop, fluidbased Multisonic Ultracleaning System™ 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 employs advanced fluid dynamics and hydroacoustics to generate a wide spectrum of waves and deliver them via a liquid medium throughout the root canal system, creating highly effective cavitation. Unlike 50 Endodontic practice

Every aspect of the GentleWave is acutely focused on addressing the major challenges that continue to exist within root canal therapy, including: cleaning of the entire canal system fully, as well as the isthmus, lateral canals, etc., all the way to the apex; complete removal of the smear layer created during shaping; complete removal of tenacious biofilm; and deep penetration and removal of bacteria within the dentin tubules. In short, the Multisonic mechanism of action greatly optimizes the treatment fluids being used (NaOCl, EDTA). This allows for rapid tissue dissolution and bacteria removal within the entire canal system, in only a few minutes. At first look, the GentleWave console provides a glimpse into an exciting future for endodontic therapy. Presenting a slender and elegant profile, the console perfectly complements and enhances the modern dental practice as a statement to the patient that the practitioner is serious

about integrating cutting-edge technology into the office. After rubber dam placement and tooth preparation, including access, all that remains is patency and some minimal shaping before the handpiece is placed over the treatment area, and within minutes, simultaneous cleaning of the entire canal system is achieved. Efficiency and predictability are now seamlessly integrated into the procedure as the userfriendly touch screen interface guides the operator through the treatment steps. In designing the treatment delivery handpiece, clinical feedback played a strong role in guiding development. After performing a simple procedure to determine the depth of the pulp chamber floor, a color-coded corresponding spacer is attached to the tip, therefore providing the correct indexing every time for every procedure. This allows the cleaning to take place without any part of the handpiece actually entering a canal, which is consistent with Sonendo’s commitment to minimally invasive endodontics. From start to finish, the GentleWave System is designed to provide the highest level of performance as well as patient comfort in every endodontic procedure. At the time of this writing, the GentleWave was not cleared for use and is not currently available for distribution. However, AAE attendees will be able to view the system and take part in demonstrations as Sonendo debuts the GentleWave at their booth No. 823. For more information, please visit www.sonendo.com EP This information was provided by Sonendo, Inc.

References 1. Peters OA, Peters CI, Schönenberger K, Barbakow F. ProTaper rotary root canal preparation: effects of canal anatomy on final shape analysed by micro CT. Int Endod J. 2003 Feb;36(2):86-92. 2. Shuping GB, Ørstavik D, Sigurdsson A, Trope M. Reduction of intracanal bacteria using nickel-titanium rotary instrumentation and various medications. J Endod. 2000;26:751-5

Volume 7 Number 2

GentleWave ™ ultracleans the entire root canal system. Quickly. Thoroughly. Comfortably. GentleWave’s patented multisonic technology takes you where no file has gone...ever. For the first time, simultaneously ultraclean all canals within minutes—including isthmus, lateral canals, and tubules. Effective in the simplest procedure to the most complex, GentleWave lets you schedule your day with confidence. Imagine giving your patients a cleaner and more comfortable root canal therapy. SEM of a dentin tubule cleaned with GentleWave™

VISIT SONENDO AT A AE BOOTH 823

sonendo.com

ENDOSPECTIVE

Transcendent endodontics: the seven key attributes Dr. Rich Mounce reflects on the qualities and equipment that can improve future results

reat endodontic clinicians produce consistent results. How do they do this? What characteristics do they have in common? Listed in no particular order are seven attributes (among many potential choices) that I believe most personify top endodontic clinicians:

1. The best clinicians learn from their mistakes so each setback improves future results. Seeing a potential problem early, as a result of past experience, and taking evasive action is far preferable to repairing iatrogenic problems later. Continuing education is a priority. 2. Top clinicians are compassionate. They keep their emotions in check. These individuals don’t internalize the stress and negativity that can come from routinely treating people in pain. Rather than burn out from the technical and personal challenges of endodontic practice, the astute clinician sees the opportunity to both help people and improve technically. Inherent in this skill is the ability to communicate well at a personal level with both patients and referring doctors. In essence, to arrive excited, refreshed, and more experienced every day at the office. 3. Pain control is essential in modern endodontics. Being proficient with intraosseous systems like the Anesto (W&H) or the X-tip® (Dentsply), as well as periodontal ligament (PDL) injection/ anesthesia delivery systems such as the The Wand® STA™ (Aseptico), can be a lifesaver.

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

52 Endodontic practice

4. Receptiveness to new technology challenges one’s comfort level and raises the standard of care. An endodontist without nitrous oxide (among other anxiolytic techniques) or without cone beam computed tomography (CBCT) is handicapped, in my opinion, by not offering patients all they deserve. When you need these tools, you need them, not platitudes about how expensive and unnecessary they are. An example of new and emerging technology is Sonendo® (Sonendo.com), a future game changer in the endodontic space. Be prepared to see existing treatment concepts, protocols, and armamentaria cast aside like honeymoon pajamas. A growing body of double-blind university-based literature is in line for submission and publication that will show

be many areas where improvisation and innovation “on the fly” are essential, the endodontic procedure is a series of many small steps that cumulatively add up to what we call a root canal. Get all the small steps right, and the final result is assured. 7. Flexible treatment strategies and preparation for the unexpected should be the norm, not the exception. Stuff happens. The clinician should anticipate any number of potential scenarios at any given moment, some more probable, some extremely unlikely. Based on the circumstances, the clinician must be prepared to shift gears quickly and be aware that the correct forward path may not be absolutely clear. For example, if the perforating needle of an X-tip (mentioned above) were to break, does the clinician immediately lay a flap to

The best clinicians learn from their mistakes so each setback improves future results. Seeing a potential problem early, as a result of past experience, and taking evasive action is far preferable to repairing iatrogenic problems later.

canals and dentinal tubules cleared of tissue, bacteria, and biofilm. Stay tuned. 5. Masterful clinicians appreciate canal anatomy through tactile sensation with stainless steel hand files before using rotary instruments. Creating patency, especially in blocked and transported canals, is an art that requires skill, passion, and time. There are no shortcuts to the apex. 6. Patience, skepticism, and attention to detail are all virtues. Savvy clinicians do not make assumptions or skip steps in the interest of saving time. While there may

remove the fragment? Does her/she refer to an oral surgeon? Should the removal be done by the endodontist later? Is it essential to remove the fragment? Can it be left? Said differently, there is no place for tunnel vision at the highest level, only focus on both the problem as well as the range of given solutions at that moment. Seven key attributes of top endodontic clinicians have been discussed. Emphasis has been placed on a high level of communication, focus, and dedication to continuous learning and investigation of new technology and techniques. I welcome your feedback. EP Volume 7 Number 2

THE NEW STANDARD

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Standard NiTi $25* Controlled Memory NiTi $35*

D Finders

Mani D Finders are stiff hand files used for the negotiation of calcified canals— available in sizes 8-15 in 21 and 25 mm lengths—highly efficient and economical when a “stiff” file is needed. $5.95/box of 6 files.

*Pack of 6 instruments, limited time offer, minimum purchase quantities apply, please call for this pricing and details.

Aseptico

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

EFFICIENT, SAFE, ECONOMICAL

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PRODUCT PROFILE

Surgitip-endo aspirator tip for root canals The international dental specialist Coltene has added the Surgitip-endo endodontic aspirator tip to its ROEKO Surgitip product line

urgitip-endo has been specially developed for drying root canals, and its flexible front section allows comfortable insertion in hard-to-reach root canals (mesiobuccal 1 and mesiobuccal 2 in the maxillary molar and mesiobuccal and distolingual in the mandibular molar) without having to bend the tip of the aspirator. This was achieved by developing a special multi-part fully rotating ball joint. The Surgitip-endo can be used to dry root canals quicker and more efficiently than is possible with paper points alone. From a visual point of view, it is immediately obvious that the Surgitip-endo belongs to the Surgitip family which includes the Surgitip (surgical aspirator tip) and the Surgitip-micro (microsurgical aspirator tip). All aspirators are characterized by the green tip that provides excellent contrast in the operating field. The sales pack contains 20 individually packaged Surgitip-endo aspirator tips manufactured under clean room conditions. The aspirator tip is ready for immediate use and can be hygienically removed from the pack and connected without any contact. The included autoclavable Double Adapter allows alternative connection to the standard water aspirator hose and the saliva aspirator hose. The aspirator tube can be held like a pencil without any difficulties and ensures a firm grip and comfortable work position. The outer diameter of the canal tip corresponds to ISO 60, the inner diameter is 0.35 mm, and therefore, it is optimally adapted to the prepared ISO sizes of root canals. In addition, the three-dimensional rotational flexibility of the tip is a notable feature. Due to the special ball design, the tip is highly flexible and thus ensures unrestricted high suction performance together with an optimal view of the field of treatment. As the Surgitip-endo has a very small inner diameter, tissue and larger particles should be aspirated using a Surgitip/ Surgitip-micro. To prevent the Surgitipendo tips from clogging, the tips can

54 Endodontic practice

be rinsed occasionally with water or, if clogged, flushed from the front using an irrigation cannula. In conclusion, here is a summary of the main advantages of the Surgitip-endo aspirator tips: • Its innovative ball design ensures optimal aspiration and good canal access • Surgitip-endo is ideally suited for work under the operating microscope

• Thorough drying of the canals optimizes adhesion of the filling material to the root canal walls • The time required for final drying of the canal with paper points is reduced significantly • The aspirator tips are packaged individually and hygienically and are ready for immediate use. EP This information was provided by Coltene. Volume 7 Number 2

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STEP-BY-STEP

The Laschal FXP set incorporates transferred oscillation technology Background There are other ultrasonic devices on the market that depend upon direct contact with a separated file to loosen and remove. However, it is absolutely impossible to restrict the contact of the tip to the file remnant itself. The vibrations will cause the ultrasonic tip to “wander” circumferentially around the file while always resulting in direct contact with the canal wall. It has been reported that as little as 12-15 seconds of direct ultrasonic contact with the canal wall will cause tissue and bone degeneration secondary to the heat and ultrasonic waves. The transferred oscillation technology of the Laschal FXP probes completely eliminates heat buildup and greatly buffers the ultrasonic waves upon the canal walls.

Method of using the file extraction probes Insert the probe along the wall of the canal with a slight pressure that allows the probe to flex up against the canal wall, and allow the flexible, flat prong to follow the wall to the junction of tip of the broken file and wall of the canal. There, the probe is wedged into the junction. The tip of the vibratory or ultrasonic device is then placed and stabilized in the hole of the probe just distal to the flattened portion and activated. The probe is extremely thin, light, and flexible and allows the vibrations of the ultrasonic or vibratory device to be readily transferred through the probe to its tip and into the junction of the wall of the canal and file remnant.

The transferred oscillation technology of the Laschal FXP Probes completely eliminates heat buildup and greatly buffers the ultrasonic waves upon the canal walls.

Two separate and distinct actions ensue: a) On the side of the wall of the canal, the combination of the abrasive and transferred vibrations cause an abrasion or “wearing away” of the dentinal wall of the canal, creating a trough between the file and the wall of the canal. b) On the side of the broken file, the diamond-dusted prong relieves the sharp flutes while creating a micro-mechanical retention between the [dulled] flutes of the broken file and the probe, thereby increasing the trough between the canal wall and the remnant. The vibrations then cause a further loosening of the file from the wall of the canal itself.

56 Endodontic practice

The use protocol: 1. The probe is pushed into the junction of the canal wall and file fragment. 2. Once stabilized, the probe is tightly held in place. 3. While the probe is tightly held in place with one hand, the ultrasonic device is then pushed tightly into the hole with the other hand, as pictured, and activated. 4. With the probe tip tightly held in the junction of the canal wall and the file remnant in one hand and the ultrasonic tip held firmly in the other hand, slight up/down coordinated movements of both hands cause the probe tip to start to loosen and elevate the file remnant. When there is a slight movement of the file remnant on the one side, use a different angled probe to access the opposite side, and repeat the process. 5. Continued repetition of the process [first one side then the other], loosens and elevates the file remnant until it can be easily grasped with the Laschal Stieglitz Forceps and removed. EP

Volume 7 Number 2

Dr. Bruce H. Seidberg discusses how ethical and moral behavior are governed by law

relationship exists between medicine, dentistry and the law1 (Figure 1). Dentistry is to medicine as medicine is to dentistry: They have a cause and effect on each other; both are subject to ethical and moral behavior; and both are governed by law. Ethics can be defined as a set of rules provided to an individual by an external source, i.e., a professional organization or the social system. In contrast, morals are derived from one’s upbringing and beliefs, an individual’s own principles regarding right and wrong. Concepts of ethics are learned through education as a framework for acceptable behavior, whereas morals involve behavior usually influenced by family, religion, and the social atmosphere. You don’t have to be wrong to be sued.2 Doctors are engaged in litigation for many reasons, including, but not limited to, poor or unexpected outcome, patient anger, lack of clear communication, colleagues trying to explain a previous treatment from another colleague without knowing the circumstances, and the lack of morality or breach of ethics (Figure 2). While providing a scientific and technological service, patients may decide that the treatment hasn’t met their expectations. What may have begun as a difference in opinion could turn into a costly and timeconsuming lawsuit. There is usually a

Bruce H. Seidberg, DDS, MScD, JD, is a practicing Endodontist in Liverpool (Syracuse), New York, Past President of the American College of Legal Medicine and the Onondaga County Dental Society in New York state. He was awarded the AAE Presidential Award for his dedication to Endodontics and the ACLM Gold Medal for his work on behalf of law and dentistry. A former Associate Professor of Endodontics at SUNY at Buffalo and Director of a General Dentistry Residency Program at the St. Joseph’s Hospital Health Center in Syracuse. He is currently Chief of Dentistry at Crouse Hospital in Syracuse, Chairman of the American Board of Medical Malpractice, Secretary of the ACLM Foundation, and a member of the NY State Board of Dentisty. Dr. Seidberg has contributed many articles to the dental literature and a chapter in the dental text Dentistry for the Special Patient, the legal text Legal Medicine, and the 6th edition of Ingle’s Endodontics. He lectures about risk management issues in the dental office and can be reached at bseidbergddsjd@me.com.

Volume 7 Number 2

Figure 1: The three major professions of medicine, dentistry, and law all intersect with each other

Figure 2: Doctors can face alleged claims for various reasons leading to litigation

Figure 3: Develop good patient relations

Figure 4: Basic risk management skills

negative perception of the doctor. Types of treatment know no boundaries. Patients expect to receive the same conscientious care no matter where they are treated or by whom. You need a license to practice dentistry, but you do not need one to practice ethically or morally. Lawsuits can be avoided not only by keeping good documentation, but also by communicating with compassion, providing adequate informed consent, and following appropriate risk management procedures. Risk management offers a way to improve the profession and our practices before, instead of after, lawyers and juries impose legal precedents. Lawsuits can be diffused by having good interactions with patients (Figure 3). Good risk prevention skills must be adhered to (Figure 4). The accepted definition of standard of care is that reasonable care and diligence provided for a patient and exercised by members of the profession in similar cases, in like conditions, are given due regard for the state of the art at that time. Standards apply nationally, although there are some localities that accept local standards. It is a myth to believe that specialty

organizations set the standard. Actually, in court, the expert witness who is dressed the best and speaks with more convincing authority to educate the jury and judge sets the standard for that particular case. Precedence, reference to specialty organizations guidelines as a basis for evidence or evidence-based studies for that case in question and other salient references can influence the development of the concept of standards of care. The ethical basis for the standard of care includes beneficence, to recommend the best therapy while minimizing potential harm, avoid placing a patient at an unreasonable risk of harm, and which can be disputed in court by an opposing witness. Notably, there is an interaction between ethics, law, and risk management (Figure 5). Dentists share an office culture3 that demonstrates a professionalism (Figure 6) that translates to receiving the trust of patients and society. In return, dentists commit to adhere to high ethical standards of conduct as set down by the ADA4 and other organization’s principles of ethics (Figure 7). Ethical behavior encompasses Endodontic practice 57

LEGAL MATTERS

Ethics, morals, and law in the professional office

LEGAL MATTERS

Figure 5: Ethics and law overlap and interact with risk management

Figure 6: Every professional office has a culture to define who they are and what they do

Figure 7: Codes of ethics are provided by every scientific organization and developed personally

rules and standards that govern members of a profession and a systematic study of moral behavior whose actions must be supported by reason. Ethical concepts include patient autonomy (the patient has the right to understand and consent), nonmaleficence (Hippocratic Oath to “do no harm”), beneficence (doing what’s best for the patient), justice (fairness in allocation of services), and veracity (requires honesty in all dealings) and defined as noted in Figure 8. Ethics requires that in most cases, patients are allowed to determine their own destiny and that they be given honest, helpful answers to their questions. That is known as the relationship between veracity and autonomy. Patients must be informed of their oral status without disparaging comment about prior services, referred to as veracity and justice. Because one more than likely has not witnessed alleged circumstances of an event between a patient and doctor, one should never be critical about or berate another colleague, or imply negativism about the care rendered. “Differences of opinion should never be communicated in a manner that implies mistreatment. The standard of care allows for variance; reasonable minds can disagree.”5 Always try to remain positive when talking to a patient about previous treatment. Patients are not to be deceived by treatment rendered by a generalist versus a specialist; there has to be the appropriate disclosure of being a specialist or not. Ethics are derived externally from a social system such as one’s profession and refers to rules provided to the individual practitioners, whereas morals are derived internally from one’s upbringing and beliefs and refers to an individual’s own principles regarding right and wrong. The ethical codes must be followed as set by the profession, regardless of the

practitioner’s own feelings. Morals may be influenced by culture or society, but are personal principles created and upheld by the individuals themselves. There are legal guidelines that govern ethics within a particular time and place. Laws are external, written by a governing power and must be obeyed, or there can be penalties like fines or imprisonment. Ethic laws are internal codes that should be obeyed but can be violated, and then there may be disapproval from peers or disciplinary proceedings that follow. Moral law, in contrast, is sometimes thought to be synonymous with ethical guidelines. The rules of behavior originating from personal conscience are not necessarily part of legislative law and may or may not be legally enforceable. Ethics, morals, and the law all intersect similarly like other areas already referenced previously. Behavioral differences prevail between ethics and morals. Moral behavior, concerned with the principles of right and wrong, conforms to standards arising from conscience or sense of obligation. Morals define personal character, whereas ethics stresses codes of behavior in which morals are applied. Ethics is knowing what is right and wrong and choosing to do the right thing, whereas morals is choosing to do either the right or wrong thing. Law can cause conflict between ethics and morals, for example, when morality interplays where a lawyer has to ethically defend a client even when he/she knows the client is guilty. Legal ethics must override personal morals for the greater good of upholding the justice system. Also, a conflict between law and morality can exist when there are patients who may be financially compromised and are in need of dental care. In being beneficent, acting in the best interest of the patient, a practitioner may waive the co-payment of an insurance claim so the treatment can be rendered

without the patient acquiring additional financial burden.6,7 Here beneficence, morals, ethics, and integrity all interact in a conflicting way. Integrity involves a commitment to common ethical principles in which key components are sagacity and veracity. Waiving co-payments is deceptive to the patient and insurance company, and can be interpreted as a form of insurance fraud.8 When dealing with conflict, be empathetic and put yourself “in the patient’s shoes.” Find a common ground to discuss alternative solutions to the problem, and try to keep conversations on a positive note without losing one’s temper. Handling patient problems is where one can go astray and be vulnerable to litigation. A slow and quiet conversation can defuse a difficult situation. Two philosophical ideals lead to success. Dr. Herbert Schilder8 stressed to his graduate students to be the best they can be, but that they had to have the absolute desire to do so (Figure 9). He said that to obtain the knowledge to perform a skill, you had to have desire. Lacking one of the elements will undermine the goal to success. Dr. Michael Fallon9 stressed the Three “A’s” for success: Affability, Availability, and Ability (Figure 10). Affability is being able to speak to, be approachable, amicable, and gentle. Availability is to be accessible to anyone in need for whatever reason. And one must have the ability to think, to accomplish, and have the mental or physical power to do something and to do it well. Both ideals include practicing within the standard of care with integrity, ethics, and morals. Ethics and morals are the basic ingredients of integrity, which then molds character. Integrity is the commonality found in the professions of law, medicine, and dentistry and can be the determining factors for the degree of success of a

58 Endodontic practice

Volume 7 Number 2

LEGAL MATTERS

Figure 8: Ethics graphically defined

Figure 9: Schilder‘s philosophy for success

Figure 10: The Fallon doctrine for success

Figure 11: Integrity is commonality found in the three major professions along with ethics and morals

Figure 12: Misleading advertising

Figure 13: Ramifications for violating the standard of care and ethical guidelines

practitioner (Figure 11). Character is formed from the values of integrity, honesty, and consistency between words and actions. It is the interaction between what we believe and what we do. You have to practice with integrity, morals, and ethics if you want to succeed and avoid litigation. You have to know and understand your limitations and practice only within the scope of your license. Within the context of the theme of this paper, professional images can be compromised when advertisements appear the same way as a local store. Deceptive advertising slogans influence the perception of the patient after reading and hearing various slogans of who is ethical and moral and who is not. Be aware that wording can be misinterpreted, and either suggest a guarantee or be misleading. Be careful where and how you decide to advertise, and how you describe your practice. The use of catchy telephone book slogans can easily be susceptible to misunderstanding (Figure 12). For example, Gentle Dental Care as opposed to Rough Dental Care? Pain-free Dentistry as opposed to Painful Dentistry? Excellent Infection Control as opposed to No Infection Control? Safe Sterile Environment as opposed to Dirty Environment? We cater to cowards as opposed to We do not treat brave patients? The others listed in Figure 12 can also have an opposing meaning. There is a relationship between ethics

and the law. The law sets a minimum standard below which nobody should fall; ethics can set a higher standard that may be more difficult to attain. It is legal for a graduate dentist to do any phase of dentistry, but is it ethical? All practitioners should know their limitations of what they can do good or not so good. It would be appropriate to use the referral system if your competency in performing a phase of dentistry is not what it should be, or if it would fall below the standard of care. For example, a dentist had her license partially suspended in certain areas until completion of course of retraining in each such certain stated areas, given 3 year probation and a $1,000 fine because she was not proficient in doing endodontics or oral surgery, and most every case she did was incomplete and inadequate11 and required retreatment. She was legal because of her dental degree but not very ethical or moral and lacked integrity because she did not recognize her limitations. She violated the concepts of nonmaleficence and beneficence. There are ramifications that can be devastating to the practitioner and or a practice from being found guilty of various allegations (Figure 13). Licensing boards can suspend licenses, cite and set monetary fines, order retraining or continuing education, or many other remedies In summation, desire for knowledge can improve your skills. Having affability, availability, and ability helps make you

a better practitioner. To practice within the standard of care and communicate appropriately will help you avoid litigation. And finally, you must maintain character with integrity at all times coupled with adhering to ethical guidelines, have moral behavior, and use common sense. EP

Volume 7 Number 2

This article was modified from management lectures by the author.

risk

References 1. Seidberg BH. Ethics, Morals, The Law and Endodontics. In: Ingle JI, Bakland LK, Baumgartner JC, eds. Ingle’s Endodontics. 6th ed. Hamilton, Ontario: BC Decker; 2008: 66-104. 2. USAA Magazine, March 2003 3. Schwab D. Office Culture: Who We Are and What We Do. Boston University Endodontic Alumni Association meeting. Sarasota, FL, 2011. 4. American Dental Association. Principles of Ethics and Code of Professional Conduct, with Official Advisory Opinions. http://www.ada.org/194.aspx. 5. Solomon C. Schadenfreude-an all too common affliction. J Am Coll Dent. 2012;79(1):37-39. 6. Plunkett L. It may be Legal but is it also ethical. N Y State Dent J. 2012;78(3):6-8. 7. Blue R. It’s in my patients’ best interests, so what’s the problem? The ethical, legal and professional implications of waiving patient co-payments. J Leg Med. 2012;33(1):129-136. 8. Ethical Moment: What are the Ethical Considerations in Accepting Lower Reimbursement; JADA v.144(3), pp 310-311, Mar 2013. 9. Schilder H. Boston University School of Graduate Dentistry, Department of Endodontics. Class notes, 1966. 10. Fallon, Dr. Michael (Oral Maxillofacial Surgeon), Syracuse, NY: Personal communication, 2005. 11. NYSOPD v Dr. DR: Dentist, Lic No 049645, Cal. No. 25407, Nov 2010; http://www.op.nysed.gov/opd/ rasearch.htm#redd.

Endodontic practice 59

INDUSTRY NEWS

Fewer Americans fear root canals, more want to keep their natural teeth Fewer Americans fear root canal treatment, according to a recent survey by the American Association of Endodontists. Just over half of those surveyed, 54%, said root canals make them apprehensive, down from 60% in 2013 — the lowest numbers reported since the AAE began its annual survey in 2011. In addition, more than three-quarters of Americans, 76%, say they would want to avoid losing a permanent tooth, something root canal treatment can help prevent. During its eighth annual Root Canal Awareness Week, March 30 – April 5, the AAE wants to dispel myths surrounding root canal treatment and encourage general dentists to involve endodontists in case assessment and treatment planning to save patients’ natural teeth. A recent AAE study found that 94% of general practitioners have a positive or very positive perception of endodontists, and the same percentage agree that endodontists are partners in delivering quality dental care. By partnering with endodontists, general dentists can help patients feel less anxious while delivering the highest quality of care. In fact, 89% of patients report being satisfied after root canal treatment by an endodontist. To encourage collaboration between general dentists and endodontists, the AAE has several free resources available for download, and to help promote Root Canal Awareness Week, you can print the AAE poster to share in your offices or clinics. For more information, visit www.aae.org/rcaw, follow the AAE on Twitter at @savingyourteeth or search #rootcanal.

MATERIALS lllllllllllll & lllllllllllll EQUIPMENT American Dental Assistants Association X-ray update for 2014 The latest technology is included in an updated series of 10 modules from the American Dental Assistants Association Foundation. The work, in two booklets, provides up-to-theminute knowledge required for effective management of dental radiography in dentistry. Each module addresses an all important aspect of dental radiography contributing to professional growth and security as well as functioning as preparation for a national examination — it is used as a review course for the Radiation Health and Safety Exam of the Dental Assisting National Board. This renowned yet practical educational work of nearly 100 pages provides considerable information, and each module features its own self-quiz. A final exam of 70 questions is also provided, and successful completion earns 18 CEUs. Used as an adjunct textbook in many dental assisting programs, it is also recognized by some dental boards as a pathway to obtain radiology licensing for dental assistants. For more Information contact Santos Robles at SRobles@ dentalassistant.org.

Air Techniques wants to find the oldest air compressor and vacuum system still in use today Air Techniques, Inc., an innovator and manufacturer of dental equipment, is excited to announce The Oldest Air Tech Air Compressor and Vacuum System contest. This contest will run through September 30, 2014. Air Techniques was started over 50 years ago with the goal of making the highest-quality, longestlasting, hardest-working compressors and vacuums that meet the unique needs of dental offices. They still regularly hear from dentists who have their AirStar compressors or VacStar vacuum systems (or their predecessors) that were purchased and installed many, many years ago — but are still hard at work today. So Air Techniques wants to know — where are our old reliable workhorse units? Sign-up Online at www.airtechniques.com/Dental/oldest_unit_ contest.cfm. Sign-up by email by sending your information to: airtechny@gmail.com. Sign-up by snail mail (your unit must be really old!) at the address below.

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Volume 7 Number 2

Dr. John West discusses four more reasons why anatomy should matter Introduction After nine installments of Anatomy Matters,1-9 I am beginning to feel like a broken record. So, I am writing Anatomy Matters, Part 10, by taking a different perspective — rather than continuing to write about endodontic patient treatments that fail due to underfilled root canal systems, my objective is to pique your interest in a new way, by telling you that the future standard form of procedure reimbursement will be how well endodontists can prove they have filled the cleaned root canal system. It will be called “Pay for Performance” (PFP). Check out QForma on the Internet and begin to be educated that we are being graded; we are being measured; we are being watched. I have divided my article into four sections: 1) Anatomy and fees, 2) Anatomy and reputation, 3) Anatomy and longevity and 4) Anatomy and because.

Four proofs that anatomy matters 1. Anatomy and fees What this means is that some day (sooner than we think), insurance companies, government, and the consumer (our patients), will know the following: • how good dentists’ crown margins are • the rate of their veneer success/failure

Figures 1A and 1B: Anatomy and Fees. The greater the endodontic value, the greater the clinician’s value and therefore, the higher the set fee. 1A. Posttreatment perpendicular image of recent endodontic finish of maxillary left second molar. Meanwhile, maxillary left first molar had been previously treated and operator origin unknown. First molar has internal POE transportation of four canals and therefore no sealed POEs (violation of mechanical objective No. 4). Second molar has three canals and more than twice as many visibly obturated POEs. The future Pay for Performance reimbursement method will place more value on the second molar two-dimensional endodontic result than the first molar. 1B. Oblique image

Figures 2A-2E: Anatomy and reputation. Are you the “go to” endodontic resource when the treatment is challenging, or the success of the result is critical? 2A. Pretreatment image of symptomatic maxillary second premolar with two strikes against it: 1) Nonsurgical and surgical Endodontic Seal already attempted. 2) Compromised crown/root ratio and recently restored with post, foundation, and crown. Most dentists would treatment plan Figure 2A removal and replacement with implant, but since not fractured, symptoms were simply due to undersealed root canal system. Skilled nonsurgical disassembly and Endodontic Seal attempt should be in the patient’s best biologic and financial interest. Do you have the confidence, the skill, and the reputation to realistically offer nonsurgical endodontic option? 2B. Image of post removed. 2C. Post removed. 2D. Posttreatment image demonstrating significant distal POE sealed. 2E. Eight-year posttreatment image demonstrating rejuvenation of the lamina dura and periodontal ligament. The original restorative has structurally remained intact and the tooth is functioning normally

Figure 2B

Figure 2C 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 who 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 2

Figure 2D

Figure 2E

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

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ANATOMY MATTERS

Influence on Fees, Reputation, Longevity, and Because: part 10

ANATOMY MATTERS

Figure 3A

Figure 3B

Figure 3C

Figure 3D

Figure 3E

Figure 3F

Figure 3G

Figure 3H

Figure 3I

Figure 3J

Figure 3K

Figure 3L

Figure 3M

Figure 3N

Figure 3O

Figure 3P

Figures 3A-3P: Anatomy and longevity. Can you tell your patient that your endodontic treatment can predictably last them the rest of their lives? 3A. Posttreatment image of mandibular right second premolar classic nonsurgical warm gutta-percha technique obturation. 3B. 32-year posttreament image. 3C. Pretreatment and downpack image of mandibular left FPD abutment. 3D. 29-year posttreatment image. 3E. Gutta-percha traced sinus tracts from mandibular molar and premolar of previous nonsurgical followed by surgical underfilled root canal systems. 3F. Pretreatment image. 3G. 27-year posttreatment image. 3H. 27-year posttreatment clinical with no sinus tracts. 3I. Pretreatment of mandibular left second premolar with lateral LEO. 3J. First instrument to radiographic terminus. 3K. Instrument following in and through distal lateral POE. 3L. Conefit. 3M. 18-month posttreatment with arrow pointing to lateral POE position. 3N. 24-month posttreatment revealing increase in lateral LEO size increase. 3O. Post-surgical retreatment image of amalgam surgically sealing lateral POE (arrow). 3P. 34-year posttreatment image

• the number of healthy teeth in the dentists’ patient population • if their root canal obturations are solid • if their endodontic preps have continuously tapering funnel shapes • how clean the clinicians’ root canal systems are • how many visible portals of exit (POEs) they fill per shaped canal These will be the quantified measurements that will determine our value and, therefore, our fees (Figure 1). Forget that anatomy matters to some and not others. I do know this, that endodontists want more patients. And if endodontists are truly going to be paid on 62 Endodontic practice

performance, and the pretreatment and posttreatment radiographic images are our only metric, then biologic success is not the only reason to make the perfect access cavity, to remove all dentin triangles, to prepare a glide path to the canal terminus no matter what, and to produce appropriate shapes that protect the ferrule and yet are sufficient for gutta percha and sealer fluid hydraulics for 3D obturation. You may say that fee-for-service is never going to be based on the radiographic quality of my obturated properly shaped root canal system, let alone the number of POEs visibly sealed on a periapical radiograph. Who’s counting? Maybe

we should take a cone-beam computed tomography (CBCT) 3D posttreatment image, too, in order to grade and pay for our technical result. I believe that your referring dentist is counting and that your reputation is counting. 2. Anatomy and reputation Realistically, I don’t think any PFP future is near in time, but the quality of our measured technical result (the radiographs or digital imaging) does influence the endodontist’s reputation and, quite frankly, our “busy-ness” (Figure 2). For example, if an endodontist cannot predictably perform the big three “F’s” — find all the canals, Volume 7 Number 2

3. Anatomy and longevity It’s time for me to get off my “strive for quality” soapbox. Let’s just surmise that I have not made a good argument: Our fees will never be based on a radiographic image, and referring dentists don’t care about the only measure of quality, aside from patient feedback, available — the X-ray or image that the endodontist sends back to the dentist after endodontic finish. Is there any other reason to do our best and operate as if anatomy matters? Yes, the better that root canal systems are obturated, the longer they last, and the better the patient investment in saving endodontically diseased teeth.10 And since our population is aging, each new decade requests that dentistry, including endodontics, must last a longer time. It must be built to last (Figure 3).11 4. Anatomy and because The following text is an excerpt from John F. Kennedy’s “Moon Speech” at Rice University on September 12, 1962: We choose to go to the moon. We choose to go to the moon in this decade and do the other things, not because they are easy, but because they are hard, because that goal will serve to organize and measure the best of our energies and skills, because that challenge is one that we are willing to accept, one we are unwilling to postpone, and one which we intend to win. … Many years ago the great British explorer George Mallory, who was to die on Mount Everest, was asked why did he want Volume 7 Number 2

ANATOMY MATTERS

follow all the canals to their termini, and finish the canals (smooth, funnel shape, 3D clean, conefit, and 3D obturation, or at least the appearance of 3D obturation) — then the word gets out pretty fast, and that endodontist suddenly finds himself or herself competing for referrals not in the top 10% of the market but the bottom 10%. The bottom 10% seems willing to treat for the lowest fee to get some referrals. Often the bottom 10% number of referrals is insufficient for significant profitability, and these patients often lack dental value. Either way, competing in the bottom 10% is dissatisfying, de-energizing, and physically and emotionally exhausting. At least for me, when I go faster or base my treatment on time, I begin to risk making mistakes. I block; I tear; I break things. None of these outcomes is good for the reputation.

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Endodontic practice 63

ANATOMY MATTERS

Figure 4A

Figure 4B

Figure 4C

Figure 4D

Figures 4A-4E: Anatomy and because. Sometimes we do something because it is there; because we want to “organize and measure the best of our ‘energies and skills.’” 4A. Pretreatment image of seemingly hopeless tooth with gutta-percha cone tracing sinus tract to resorbed root end with sectioned silver cone. 4B. “Because it is there and possible,” patient elected to attempt nonsurgical endodontic retreatment. He did not want an implant. Image shows pack film. 4C. Same pack film placed more apically in order to show there was no apparent radiolucency around section silver cone in apical root remnant, and treatment plan was to leave the root tip unless future evidence of pathology. 4D. Two- year posttreatment with healthy gingival probing and no sinus tract. Patient has elected to proceed with connective tissue graft in order to improve gingival levels. 4E. Two-year posttreatment image with healthy attachment apparatus. Retreatment of adjacent maxillary central is scheduled with safe “walking” bleach intended to improve gingival root discoloration

Figure 4E

to climb it. He said, “Because it is there.” “Because it is there.” Well, consistently performing great endodontics is here; and while great endodontics has never been rocket science, it has always taken a certain willingness, and it has always, like the race to the moon, served to organize and measure “the best of our energies and skills” (Figure 4). It may be that the anatomy doesn’t matter. The LEO may not develop, and the LEO may heal regardless of the quality of the Endodontic Seal. Instead, it is the “Because” that is the because.

Conclusion For the purposes of this 10th installment of Anatomy Matters, I have suggested that there are at least four reasons to consider doing better endodontics and that anatomy does matter: 1) value, 2) reputation, 3) longevity, and 4) because. I would offer that for most of us, we can do better endodontics by simply slowing down, improving technical skills, or simply being more intentional. I believe any of us can do as much as we want. Start with the easy cases, and then move to the more complicated. While some people intend on having you do endodontics at a lower, lower, lower level, I guess I am intent on

having you do endodontics at a higher, higher, higher level. And I have enough experience of not only doing endodontics but also teaching it that I am right, and it can be done. Professor Herb Schilder once said, “It’s not hard to be the best. There’s no competition.” Compete in the top 10%; there is less competition there. But really, to me, this means compete in the top 10% of your own personal potential. Being and doing your best in delivering endodontic excellence has nothing to do with measuring how good I am compared to you. It has to do with how good I am compared to me. 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.

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5. West J. Anatomy matters. Root canal system anatomy only matters when it matters. Endodontic Practice US. 2013;6(2):56-58.

9. West J. Anatomy matters. Endodontic accountability: The “X” factor, part 9. Endodontic Practice US. 2014;7(1):43-47.

6. West J. Anatomy matters. Do lateral canals really matter? Part 6. Endodontic Practice US. 2013;6(3):5253

10. West JD. Implants versus endodontics: “As the pendulum swings.” Dent Today. 2014;33(1):10-12.

7. West J. Anatomy matters. “What’s it all about?” Part 7. Endodontic Practice US. 2013;6(4):52-54.

11. Kurzweil R. The Singularity is Near: When Humans Transcend Biology. New York, NY: Penguin; 2005.

8. West J. Anatomy matters. “Could it all simply be a coincidence?” Part 8. Endodontic Practice US. 2013;6(5):52-55.

Volume 7 Number 2

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