Endodontic Practice US - October 2013 - Vol 6 No 5 by MedMark, LLC

clinical articles • management advice • practice profiles • technology reviews October 2013 – Vol 6 No 5

Top ten tips

Preparation techniques

Dr. Tony Druttman

Endodontic treatment of curved root canal systems Dr. John Bogle

Practice profile Dr. Peter A. Morgan

Corporate profile Carestream Dental

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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

oes your endodontics leave the footprints you want? Does your endodontics distinguish who you are? Do your clinical endodontic skills set you apart? Are you the endodontist that you would want to go to? What are your “measurables?”

NATIONAL SALES/MARKETING MANAGER Drew Thornley Email: drew@medmarkaz.com Tel: (619) 459-9595

In today’s marketplace, it’s not good enough to be good enough, to have convenient hours, or to send referring doctors staff lunches. In order to earn the transfer of referral trust, we have to do something different. We have to deliver something that exceeds expectation. How is this done? Listed below are 10 measurables that influence the endodontic referral and create endodontic value: 1. Quality. The first step in becoming a masterful endodontic clinician is to slow down. When we slow down, we do better endodontic finishes, and we create more value to our patients and referring doctors. With greater value, we are worth more to the community, and a higher fee has been earned. If your fees are justifiably higher, you have a choice to slow down. The successful cycle then continues. Slowing down and skillful endodontic mechanics have been the focus and hallmark of my current Endodontic Practice US series entitled Anatomy Matters. What is your finishing checklist? What matters to you? 2. Only start what you can finish well. Most of us attempt to finish everything we start. This is the risk of the growth phase of endodontics. We have no time to finish anything well. Our quality and standards go down, and what once set us apart has been lost. 3. Be your dentists’ advocate/ally. Let them know they can be safe with you no matter how bad they may have had technical difficulties. Tell them their success is your job. You have their back. 4. Transfer of trust. Your referring dentists and their patients have granted you trust. Now you have to earn it. 5. Be accountable for your results. Referring dentists want an endodontist who has no excuses. Take full responsibility for a successful patient experience and treatment outcome. 6. Present alternate treatment plans. Sometimes endodontists have tunnel vision or diagnose based on their own needs. Dentists need the security and confidence that you will tell them and their patients WWIDIIWM (What would I do if it were me?). Learn the parts of the endodontic interdisciplinary mind: biology, structure, function, and esthetics. Know these domains as well as, if not better, than your referring dentists. 7. Practice team endodontics. Discover what it is in your day that you enjoy the most, and do more of that and less of what you don’t enjoy. For me, I am lost in the moment or in the Flow when I am Cleaning, Shaping, Packing, or in Surgery (Flow, Mihaly Csikszentmihalyi, 1991 by Harper Perennial). Delegate tasks that you enjoy less to trained and skilled hands. 8. Exceed your referring doctors’ and patients’ expectations. Perform at a level of competence, consistency, and confidence that exceeds the expectations of the dentist and patients. 9. Mentor an Endodontic Study Club. This study club should be designed to collaboratively learn knowledge and to make consensus diagnoses and treatment plans. It should not be about “getting referrals.” 10. Lead. Leaders take people where they have never gone before. Leaders keep their focus on the outcome they want in spite of pressure to do otherwise. They start with the answer.

PRODUCTION ASST./SUBSCRIPTION COORD. Lauren Peyton Email: lauren@medmarkaz.com Tel: (480) 621-8955

Summary

CE QUALITY ASSURANCE ADVISORY BOARD Dr. Alexandra Day BDS, VT Julian English BA (Hons), editorial director FMC Dr. Paul Langmaid CBE, BDS, ex chief dental officer to the Government for Wales Dr. Ellis Paul BDS, LDS, FFGDP (UK), FICD, editor-in-chief Private Dentistry Dr. Chris Potts BDS, DGDP (UK), business advisor and ex-head of Boots Dental, BUPA Dentalcover, Virgin Dr. Harry Shiers BDS, MSc (implant surgery), MGDS, MFDS, Harley St referral implant surgeon

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© FMC, Ltd 2013. All rights reserved. FMC is part of the specialist publishing group Springer Science+Business Media. The publisher’s written consent must be obtained before any part of this publication may be reproduced in any form whatsoever, including photocopies and information retrieval systems. While every care has been taken in the preparation of this magazine, the publisher cannot be held responsible for the accuracy of the information printed herein, or in any consequence arising from it. The views expressed herein are those of the author(s) and not necessarily the opinion of either Endodontic Practice or the publisher.

Volume 6 Number 5

If your endodontic practice is waning, does not represent you, if you are not as busy as you want to be, or you have lost the respect of your dentists, then commit to one, some, or all of these guidelines, and then observe the difference.

John West, DDS, MSD Founder and Director, Center for Endodontics, Tacoma, Washington Past President Academy of Microscope Enhanced Dentistry Past President of American Academy of Esthetic Dentistry Endodontic practice 1

INTRODUCTION

You are an endodontist: “how do you measure up?”

October 2013 - Volume 6 Number 5

TABLE OF CONTENTS

Clinical Systematic adhesive core

Practice profile

Dr. Peter A. Morgan Hard work and attention to detail lead to smooth sailing in endodontics.

build-up Dr. Ludwig Hermeler presents a clinical case using the Rebilda Post system........................................ 14

Case study Management of root resorptive lesions in maxillary incisors using computed tomography and MTA: 1-year follow-up Drs. Anil Dhingra and Marisha Bhandari delve into the advantages of MTA and CBCT imaging ......... 18

Endodontics in focus Top ten tips: Tip number 9 Preparation techniques Continuing his series on endodontics, Dr. Tony Druttman shows the importance of preparation ................................................... 24

Corporate profile

Carestream Dental

ON THE COVER

A history of proven technology, a future dedicated to innovation.

Cover photo courtesy of Dr. Ludwig Hermeler. Article begins on page 14. For the August/September issue, the cover photo was courtesy of Dr. Stanislav Geranin from Poltava, Ukraine.

2 Endodontic practice

Volume 6 Number 5

simple, adaptable

endodontic solutions

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TABLE OF CONTENTS

Practice management Growing the money tree William H. Black, Jr. discusses the financial advantages of having a good plan in place .................................48

Endospective One clinician’s means of obtaining patency and preparing the glide

The big debate

Continuing education Endodontic treatment of curved root canal systems Dr. John Bogle offers some cases to treatment plan success for tooth retention .......................................28 Root canal preparation: the path to success Dr. Omar Ikram explains the principles of taper and apical preparation and how they relate to clinical practice .....................................................32

Endo essentials The big debate Drs. Michael Norton and Julian Webber discuss — implants or endodontics?................................36

4 Endodontic practice

Legal matters Harassment – crossing the professional line Dr. Bruce H. Seidberg discusses the consequences and complications of harassment...................................38

Product profile PROTAPER NEXT™ delivers performance refined .................42

path Dr. Rich Mounce discusses a method for obtaining patency and preparing the glide path with hand files ........50

Anatomy matters “Could it all simply be a coincidence?” Part 8 Dr. John West considers the mysteries of endodontic success or failure ...........................................52

Industry news.............56 Materials & equipment ......................56

Air Techniques’ all new ScanX Swift™ Digital imaging without limits .........44

Practice development Apply current tax laws to improve patient care Bob Creamer explains Section 179 and Bonus Depreciation ...............46 Volume 6 Number 5

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

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Endodontists

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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.

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PRACTICE PROFILE

Dr. Peter A. Morgan Hard work and attention to detail lead to smooth sailing in endodontics What can you tell us about your background? I grew up in a small town on the Allegheny River in Western Pennsylvania just 20 miles outside of Pittsburgh. I attended the University of Pittsburgh for college and dental school. Because it was during the Vietnam War, I had been deferred from military service, and so I entered the U.S. Army after I graduated from dental school. I was fortunate to have a very good dental internship at Fort Bragg in North Carolina and then spent 2 additional years as a Captain in the U.S. Army Dental Corps doing general dentistry at Fort McNair in Washington DC.

Why did you decide to focus on endodontics? Because of extensive exposure to oral surgery in the military, I originally thought of specializing in oral surgery. However, as I approached the end of my Army service, I began to think about endodontics as I enjoyed saving teeth over extracting them. I visited what was then the School of Graduate Dentistry at Boston University (BU) and met Dr. Harold Levin. He eventually became a mentor and my partner in practice. We first met by chance when I walked into the school, and he was kind enough to take considerable time to explain the school and the specialty of endodontics to me. I left that meeting with tremendous excitement about the possibility of having a career in endodontics and training at BU. Not long after that, I was fortunate to have an interview with Dr. Herb Schilder. That led to a residency at BU, training under Dr. Schilder and many other talented and dedicated endodontists who were teaching there at the time.

What training undertaken?

have

you

I received a Certificate in Endodontics and a Masters of Science and served as Associate Clinical Professor at the school for many years. I am a Diplomate of the American Board of Endodontics (AAE). I have served two terms as a Trustee to the American Association of Endodontics and am currently serving as a Trustee to 6 Endodontic practice

In sailboat racing and in practice, all members of the crew need to focus on every detail to get a good outcome

the American Association of Endodontics Foundation. I am currently the managing partner of North Shore Endodontics and Brookline Endodontics in Boston and suburbs. It is my association with the AAE Foundation that has been a real eye opener to me on the real world of endodontics. I have seen that there is a tremendous need for endodontic teachers in all of the dental schools and an equally important need for research to further our understanding of the biological and technical processes that affect the outcome of the care we deliver. This revelation has only been topped by the fact that the Foundation funding to date has been a result of a tremendous outpouring of support from endodontists and from corporate partners who see the commitment our endodontist members make and value their judgment. The Foundation is the only organization exclusively dedicated to supporting endodontic research and education. It provides support to every endodontic residency program in the U.S. and Canada. The Foundation provides over 1 million dollars yearly to support research and faculty positions in endodontics.

Who has inspired you? Dr. Schilder was the best teacher I have

ever encountered. He was exceptionally smart, very demanding, and capable of explaining complex concepts in a clear way. His educational protocol allowed for little deviation from his prescribed technique. I have realized the tremendous value of this approach on countless occasions in my career when faced with difficult diagnostic and treatment cases. Herb knew that the oddities of anatomy and biology were looming out there. By giving his residents a solid understanding of diagnosis and disciplined treatment objectives, he equipped us for the real world of endodontic practice. Herb trained clinicians in an era when the specialty of endodontics was just beginning to grow. Dr. Schilderâ&#x20AC;&#x2122;s legacy continues at BU through the BU Endo Alumni Association, which provides a forum for all BU trained endodontists to collaborate.

Tell us about your practice. My career in practice began when I joined Dr. Harold Levin and Dr. Robert Rosenkranz. Over many years together, we grew the practice to a multi-office, multidoctor practice. Both of those doctors have retired from practice, and I am now fortunate to have Dr. Yuri Shamritsky and Dr. Fiza Singh as partners. Together we have continued to grow the practice, which Volume 6 Number 5

What is the most satisfying aspect of your practice? There are many aspects of Endodontic Volume 6 Number 5

practice that I find satisfying. The most rewarding feeling by far is the satisfaction of meeting a patient with significant symptoms that are life-interrupting and reversing those symptoms quickly and painlessly. Every endodontist experiences this, and I hope they all realize what a unique service it is in the health care world. It is very common in our offices for an emergency patient to be seen very soon after we get the call from his/her dentist. Not long after that,

members to take responsible roles in the practice. We have a great team, and I am very proud of them. The leader of our staff team is our Practice Manager, Michele Whitley. Michele and other staff members have taken an active role in continuing education by presenting courses at the AAE Annual Session and at other CE venues. Holly LeBlanc, another staff member, has served as a consultant to EndoVision.

Dr. Andrew Bradley

Dr. Andrea Chung Shah

Partners: Dr. Yuri Shamritsky, Dr. Fixa Singh, and Dr. Peter Morgan

Dr. Paul Talkov

we complete the emergency treatment. At a subsequent appointment, the patient returns with gratitude for having had his/ her very significant problem resolved painlessly. Patients benefit greatly from the skill of their endodontist, and the model of how we move patients between offices in response to patient need is a model that should be more frequently found in health care.

Professionally, what are you most proud of? I am very proud of our practice. While I know that group practice is not for everyone, it has been a very favorable format for my partners and me. Because we have a group of doctors, we have the opportunity to share ideas and to collaborate on cases. Because we are bigger, we have more staff, and they also bring new ideas and capabilities to the table. The biggest gains in our business management have come about as a result of empowering our staff

Dr. Morgan and two of his key team members, Cheryl Bennet-Delong and Jennifer Hamlett

This involvement in the larger world of endodontics outside our practice walls empowers our staff to bring back to our practice innovative ideas they develop in collaboration with colleagues at these educational sessions. As AAE Annual Session chair some years ago, I stressed Endodontic practice 7

PRACTICE PROFILE

now includes six offices. Dr. Yuri Shamritsky began his dental career with a Doctor of Dental Science from the University of Moscow. In the U.S., he continued his dental education at Boston University Goldman School of Dental Medicine where he received a DMD and a Certificate of Advanced Graduate Studies. He served for over 10 years as Associate Clinical Professor and Director of the Microendodontic Surgical Program. Yuri has inspired many students by his dedication to precise microsurgical techniques, and he has applied his skills to resolve many problems for his patients in our practice. Dr. Singh received her Doctorate of Dental Surgery from New York University College of Dentistry. She holds a Certificate in Endodontics, a 3-year specialty fellowship from The Harvard School of Dental Medicine, and Masters of Medical Sciences from Harvard Medical School, including 2 years of research at The Forsyth Institute. Her specialized training includes Oral Implantology and Oro-Facial Musculoskeletal Pain/TMD Disorders from the New York University College of Dentistry. Dr. Singh is also board certified in Endodontics in Canada, where she is a member of the Royal College of Dental Surgeons. We are also fortunate to have the following doctors in our practice: Dr. Paul Talkov, who completed his dental school at Tufts University and endo residency at Boston University Goldman School of Dental Medicine. Dr. Andrea Shah, who completed her dental school at Harvard University and endo residency at Tufts University. While a resident, she was recipient of a Research Grant from the AAE Foundation. Dr. Andrew Bradley, who completed his dental school at Tufts University and endo residency at Boston University Goldman School of Dental Medicine. We are very proud to have Dr. Schilder and Dr. Joe Williamâ&#x20AC;&#x2122;s former practice, Brookline Endodontics, as a part of our current practice. Many of the doctors in our practice had the benefit of Dr. Schilderâ&#x20AC;&#x2122;s teaching during their training. Continuing his treatment philosophy in the office where he practiced has been very professionally rewarding for us.

PRACTICE PROFILE

Michele Whitley, practice manager and Dr. Peter Morgan, managing partner

Dr. Morgan and his team taking a break at the EndoVision booth, from presenting at the AAE Annual Session in San Antonio

the need to incorporate more staff educational courses in our programs to fulfill this objective.

What is practice?

unique

about

your

I believe our practice is unique. It was started in Lynn, Massachusetts in 1962 by Dr. Harold Levin. At that time he was the only endodontist between Boston and Montreal, Canada. That has changed of course, and now there is competition for almost every endodontist no matter where they practice. What makes us unique is our multi-office format. Because of this, while we do face competition, we stay busy in many locations. The key to business success is having a full appointment book. This is our way of helping that to be true.

What systems do you use? I have been fortunate to practice in the time of the evolution of technology in endodontics. We all appreciate the teaching and patient education advantage of digital X-ray. However, to really appreciate it, you have to have worked for years with film. As I tell my patients, in the past I would look at the little X-ray films and tell the patients that they needed a root canal. Now I enter the room and the image is already on the big monitor, and the patient often says to me, “I guess I need a root canal.” We started with Schick digital X-ray in 1998. We made a big commitment to equip all of our locations at that time. It was immediately very helpful clinically and provided a “WOW factor” for patients as they had never seen such a thing before. 8 Endodontic practice

Our relationship with Schick continues today and has led us to an equally rewarding relationship with Sirona. We followed the integration of digital X-ray with conversion to EndoVision and an Electronic Health Record (EHR). EHR is certainly the current standard for records, and we find it to be essential for a multi-location practice. Because we have multiple doctors, we have loyalties to both Global and Zeiss operating microscopes, and surprisingly we have all become comfortable with both. More recently, we have opened our eyes even wider with the incorporation of the Sirona XG3D CT scan machine. This technology has provided exceptional value to our patients by giving us more information than ever before from which to make treatment decisions. The XG3D by Sirona provides a remarkably clear 5 cm X 5 cm focused field which is truly the current “WOW!” in 3D imaging. The availability of this technology has enhanced our relationship with referring dentists because they repeatedly see the value of the informed treatment decisions we can make in retreatment, surgical, resorption, and unusual anatomy cases. My partner, Dr. Shamritsky and I recently had the opportunity to attend a Sirona/Sicat opinion leaders conference in Bonn, Germany. I was very impressed with the application of the XG3D CT technology to the creation of surgical guides. This has the potential for application in endodontics as well as in implant placement and the creation of precision prostheses. Another recent addition to our practice is a marketing tool, the Endofone App.

This is essentially an electronic business card that uses smart phone technology to inform our patients about our practice. Accessed via a QR code, patients can instantly learn about us and get all of the essential information about us on their smart phone without having to go to the web site. These technologies help us, but I believe it is more important than ever for all endodontists to focus on true clinical skills. There is a saying, “It is a poor carpenter who blames his tools.” Herb Schilder and many of the great early endodontists did not use a microscope or digital X-ray. Yet they were instrumental in establishing many of the treatment methods we still use today. They showed cases then that would rival any case done today with enhanced vision and rotary instrumentation. I believe the future of endodontics will depend on endodontists defining the value of consistent predictably successful cases for their patients. If endodontics is defined by equipment and technology, it will allow anyone with that equipment and technology to claim the high ground.

What has been your biggest challenge? I think the most successful practices are those that know how to change to meet the challenge of the changing market for our services. The model used by my partner, Dr. Levin, when he started the practice, may not be the model for success today. The single practitioner then had more patients than the doctor could manage. They were often begging the endo department chairs to send them their next graduate. Today’s single practitioners had better find an area in need of an endodontist, or they will not have a busy schedule. In addition, starting a practice today requires Volume 6 Number 5

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

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

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

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

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

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PRACTICE PROFILE a much larger capital investment than before the days of high-powered software and technology. This increases the risk of a practice venture, and as a result, many endodontists choose to avoid this risk and work in the offices of general dentists, or for corporate dental centers. Naturally, this puts more competitive pressure on the more traditionally situated endodontist. Changing to meet these market realities is challenging. It requires constantly adapting to meet the needs of the referring dentists and their patients. Having younger endodontists in the practice helps us adapt, as they have a closer understanding of the needs and wishes of their peers.

our group, we schedule new doctors in a way to allow for them to meet patients and referring doctors at a reasonable pace. We do not require that all partners’ schedules are filled before associates get patients on their schedule. We invest a lot of time and energy in the process of selecting an associate and integrating him/her into the practice. The new associates make a big commitment also. Our goal is to give this combined effort the best possible chance for success.

What would you have become if you had not become a dentist? When I was making the final decision to

team in sailboat racing has many parallels to developing a successful practice team. Both require dedicated talented individuals who are willing to work hard to achieve success. And in both, others are trying to win too. So, in order to win, you must pay attention to every detail. I often say to our doctors and staff at the office, “We want our patients to realize that they have been referred to the right place for endodontic care.” To accomplish this, we apply the same rule that I have used with my racing crew to prepare for a sailboat race. Every detail is important and essential to give us the best opportunity for a good outcome. In our offices, this

What advice would you give to budding endodontists? I have had the advantage of working with young endodontists in our practice over the years. They have all taught me more than I have taught them. However, in general, I would advise the young graduate to find a mentor to reach out to when needed. Also, in challenging diagnostic cases, I would advise remembering that you can almost always wait a day to make a treatment decision rather than making a decision immediately that you may regret later. In talks to endo resident groups, I always stress that success for any endodontist requires you to make yourself indispensable to the practice. By this I mean that it is essential to commit to an “all in” approach. The residents I see who achieve the greatest success begin by working hard in their training and in their practice to continually improve their clinical skills. Then they must also learn to integrate successfully into the group of individuals they work with. This is extremely important as the daily challenge of practice necessitates a team approach to be successful. Also, new doctors in a practice need to recognize the absolute requirement to grow the practice. This means you, the new person, need to become the recognized established person in the practice ASAP. In addition, every doctor in a practice must accept responsibility for special projects. This means recognizing that there is more to being a successful endodontist than just doing good cases.

What are some tips for maintaining a successful practice? To help associates succeed, the partners in a practice also need to work hard to give them every opportunity to succeed. In 10 Endodontic practice

Our practice continually strives to incorporate advanced technology, such as the Sirona XG3D Cone-Beam CT machine shown above

go on to dental school, I briefly considered going to law school. I had minored in Political Science and had some good friends going on to law school. In the end, I decided that dentistry was right for me, and it has turned out to be a very satisfying career.

Tell us some more about yourself. What are your hobbies, and what do you do in your spare time? When I came to Boston, in addition to finding Boston University and an area to practice, I also met my wife, Jessie Morgan. Jessie is an accomplished painter with a studio near our home. Her abstract works can be seen in contemporary galleries, and on her website. Her paintings are held in corporate and private collections nationally and internationally. I love that her abstract work is so different from what I do. I have come to love New England. I am fortunate to live in a New England coastal community with a beautiful natural harbor. I became interested in sailboat racing and have spent many years competing in one-design sailboat racing in this area. I learned that developing a competitive

means that we will always strive to have everything from doctor and staff continuing education to incorporating the appropriate technology up to a very high standard. And it means that every contact with patients and every detail about our offices reflect our commitment to the highest standard of care. By putting our patients first, we are in essence putting our referring doctors first as well. It is a simple but powerful philosophy. We appreciate the trust referring doctors put in our practice every time they refer a patient. Our doctors and staff members work hard to exceed expectations so that the patients return with respect for their dentists for having referred them to us. EP Top favorites • Schick: A real company with great people, a great product, and great support. • Sirona: Another great company with a long history of bringing great products to dentistry. • Endovision: Henry Schein. Leading the way with practice management software for multioffice locations. • Brasseler: Great products for endodontists. • Endofone: An innovative new way to inform referred patients and referring dentists.

Volume 6 Number 5

ARE YOU A DINODONTIST? You might have the slickest looking office in town, but is your software still from the Stone Ages? At TDO, we believe you deserve a software system that helps your practice grow, not one that gets in your way. TDO Software allows you to provide the best possible patient care. Only TDO enables your staff to be their best by eliminating time-wasting inefficiencies in the office. TDO makes it easy to keep current with the latest technology, terminology, materials and techniques. With TDO you can create professional-looking referral and CBCT reports and print, email or publish them on your website with just one click. Take your practice out of the museum and into the world of modern endodontics. Evolve today with TDO Software.

This EHR Module is 2011 compliant and has been certified by an ONCDATCB in accordance with the applicable certification criteria adopted by the Secretary of Health and Human Services. This certification does not represent an endorsement by the U.S. Department of Health and Human Services or guarantee the receipt of incentive payments.

CORPORATE PROFILE

A history of proven technology, a future dedicated to innovation

ith roots that can be traced back to the 19th century, Carestream Dental certainly has a long history of innovation when it comes to dental specialties — including endodontics. This legacy carries on still, as the company continues to develop imaging systems and software and enter new markets. It’s because of this proud tradition that more than 800 million images are captured each year on products from the company’s imaging portfolio. Today, Carestream Dental is focused on providing endodontists with the products they need to facilitate treatment planning and improve patient care.

Endodontic clinical image captured with an RVG 6100 sensor

RVG 6100 sensor

History of Carestream Dental The Carestream Dental of today was built on the shoulders of major industry leaders of the past — starting in 1896 when Eastman Kodak introduced the first photographic paper designed specifically for dental X-rays. As technology improved and became more digitalized, Trophy Radiologie filed a patent for the world’s first digital intraoral sensor in 1983. Already known for producing intraoral X-ray generators, the digital intraoral sensor earned Trophy a reputation as the world’s leader in dental digital radiography. In 2000, PracticeWorks emerged as a dominant dental software company when it acquired several other software companies. PracticeWorks went on to acquire Trophy Radiologie in 2002, and was purchased the next year by Eastman Kodak to expand their presence in the dental business. With the integration of PracticeWorks/Trophy, Eastman Kodak built the industry’s leading portfolio of film, digital imaging systems, and practice management software. Then, in 2007, Onex Corporation purchased Kodak’s Health Group, and Carestream Dental was born.

The Carestream Dental Factor “We exist to make your practice better,” said Marc Gordon, Carestream Dental’s General Manager, U.S. Equipment and Software. “Our number one goal is to make user-friendly, yet sophisticated, technology 12 Endodontic practice

to put our customers’ practices at the forefront.” Carestream Dental’s dedication to advancing endodontics can be summed up by the Carestream Dental Factor; three pillars on which the company bases all of its products and services. Incorporating the key elements at the heart of Carestream Dental’s philosophy, the company’s main focus is on delivering workflow integration, humanized technology, and diagnostic excellence. Workflow integration: Administrative tasks cut into time that can be better spent communicating with and treating patients. For this reason, Carestream Dental designs systems and software to enhance treatment planning and fit seamlessly into busy endodontic practices. Ensuring that every link in the chain fits and contributes to the workflow as a whole allows endodontists to increase productivity and efficiency. Intuitive technology and software are the hallmarks of Carestream Dental. By developing imaging systems that can be quickly utilized by practitioners — and easily integrated with leading thirdparty endodontic practice management software, such as TDO — users can eliminate time that would have been spent troubleshooting problems and instead focus on patients.

Humanized technology: Patients are an integral part of every endodontic practice, so Carestream Dental is committed to providing solutions that facilitate communication between the endodontist and patient. When communication is optimized, patients are happier and healthier — allowing them to make better, more informed decisions regarding their proposed treatment plan and, in turn, increasing case acceptance. Diagnostic excellence: When evaluating canal morphology and endodontic pathology, details are everything. To facilitate faster, more reliable treatment planning, Carestream Dental has created a number of cutting-edge diagnostic tools that enable endodontists to capture sharp, high-quality images quickly. From industryleading 3D imaging systems to highresolution intraoral sensors, Carestream Dental offers a range of solutions that allow endodontists to identify areas of concern and determine the best course of action.

Technology developed for clinicians, by clinicians The Carestream Dental Factor isn’t the only thing driving user-focused and innovative products and services — the clinicians at the heart of the company also play a large role. Through meetings and forums with doctors in the field, Carestream Dental Volume 6 Number 5

CORPORATE PROFILE

CS 9000 3D Root resorption image as seen on Carestream Dental’s 3D Imaging software

is better able to understand the needs of endodontists in order to develop — and modify — products. In fact, the voice of the customer (VOC) is critical throughout the development process. To ensure quality, Carestream Dental also manages every aspect of the products they develop. “By controlling each step in the process — from development and manufacturing all the way to support — we make it easier for endodontists to deliver better patient outcomes,” said Mr. Gordon.

Innovative products to facilitate endodontic treatment planning Endodontists require high-resolution images to evaluate the morphology of the dental pulp and view the most intricate details of canals — something that Carestream Dental certainly delivers. The following is just a sample of the imaging products Carestream Dental has designed to meet the specific needs of endodontic practices: CS 9000 3D: Combining focused-field 3D technology with dedicated panoramic imaging, the affordable two-in-one CS 9000 3D system delivers the best of both worlds, offering the highest resolution and lowest radiation dose. Users can capture anatomically correct images with 1:1 measurements as well as view all of the necessary angles and slices, making it the ideal unit for root canals and procedures limited to a focused area, while the available 3D stitching module combines up to three volumes for full-arch reconstruction. Volume 6 Number 5

CS 3D Imaging Software: Included with Carestream Dental’s CBCT imaging units, CS 3D Imaging software allows practitioners to view images slice by slice in axial, coronal, sagittal, cross-sectional, and oblique views to enhance diagnostic interpretation. In addition, the images can be saved to a CD/DVD or USB drive with a complimentary copy of the software to share with the referring doctor — improving the colleague collaboration process. RVG 6100: With greater than 20 lp/ mm resolution per image, Carestream Dental’s RVG 6100 sensors deliver the highest image resolution in the industry. Each sensor undergoes rigorous testing to provide maximum durability and flexibility, and the RVG 6100 features a rear-entry cable, three different sizes, and rounded corners to improve comfort for patients and make positioning easier for users.

Comprehensive education When endodontists understand how to fully maximize their imaging capabilities, they are better able to get the most of out of their equipment. For this reason, Carestream Dental is committed to providing thorough training and education to ensure their customers have the skill and knowledge necessary to use their imaging products and software. In addition to providing web-based and in-person training, Carestream Dental holds 3D symposiums, where practitioners can learn how to use 3D imaging equipment in their daily practice. This event

features leaders in the industry who share advice and insights, as well as information on the latest industry trends in 3D, to make participants’ practices more efficient and successful.

Next steps With the launch of CS Solutions, a oneappointment CAD/CAM restoration system, Carestream Dental will once again enter an entirely new market — and it certainly will not be the last. As an integrated, openarchitecture system, practitioners can scan an impression with a CBCT unit or scan the patient’s mouth directly with the CS 3500 intraoral scanner, design the crown, inlay, or onlay using the CS Restore software, and mill the crown in-office with the CS 3000 milling machine. For doctors who would rather send the design or milling off to the lab, they can easily submit the information electronically to their dental lab of choice. As always, Carestream Dental will continue to focus on customer service. “Our number one goal is to provide superior customer experience through best-in-class products and best-in-class support,” said Mr. Gordon. To learn more about Carestream Dental’s portfolio of imaging products and software for endodontic practices, please call 800-944-6365 or visit carestreamdental.com today. EP This information was Carestream Dental.

provided

Endodontic practice 13

CLINICAL

Systematic adhesive core build-up Dr. Ludwig Hermeler presents a clinical case using the Rebilda Post system

s early as 1995, the study conducted by Ray and Trope confirmed the relevance of a good post-endodontic restoration for the successful preservation of teeth where the root canals have been treated. In today’s age of adhesive dentistry, considerable importance is awarded to preventing “leakage” and, accordingly, the risk of reinfection of the canal system (Fox, Gutteridge, 1997). The post-endodontic, adhesive core build-up with simultaneous glass fiber post luting satisfies both of these indispensable requirements for a certain long-term prognosis of severely damaged teeth. The Rebilda Post system from Voco offers a user-friendly concept in an optimally coordinated set, featuring all the necessary components.

Up-to-date post treatments The consensus today is that a root post is used to retain the coronal build-up and, consequently, for creating sufficient retention. The degree of coronal dental hard tissue loss and the expected loads on the tooth determine the type of postendodontic treatment on a case-by-case basis. In cases of low to medium levels of destruction, treatment with a plastically processed composite without postretained build-up is usually indicated. If the clinical crown displays severe substance loss, a post construction system should be employed to guarantee secure retention (taken from the shared scientific opinion of the German Academic Association of Dentistry, the German Association of Prosthodontics and Dental Materials, and the German Association of Dentists in

Ludwig Hermeler, Dr med dent, established his practice in Rheine, Germany, in 1991. He is licenced to practice medicine and gained his doctorate in 1988 at the Westfälische Wilhelms-Universität Münster. He has national and international publications in the fields of endodontics, esthetic dentistry, bleaching, and implantology. He is a member of the German Association for Oral Implantology (DGOI) and International Congress of Oral Implantologists (ICOI).

14 Endodontic practice

Figure 1: The Rebilda Post system (Voco) in its practical drawer insert

‘Aufbau endodontisch behandelter Zähne’ (2003) [English translation: Build-up of endodontically treated teeth]). A dentin margin of no less than 2 mm width is later prepared apical to the buildup in the so-called “ferrule design” in order to increase fracture resistance (Hemmings, et al., 1990; Torbjörner, Karlsson, Ödman, 1995). Root canal posts affixed with adhesives allow consistently minimally invasive preservation of intact dental hard tissue, whereby retentive areas in the region of the build-up can also be used as additional retentive surfaces. In contrast to metal, zirconium and carbon posts, glass fiberreinforced composite root posts display biomechanical behavior similar to that of dentin. Thanks to their dentin-like elasticity, arising forces can be distributed over the surrounding tooth substance without the development of punctiform force peaks in the root as in the alternatives named above. The physiological distribution of the forces, to apical and coronal, of the total adhesive composite of glass fiber, build-up composite, and preserved tooth substance reduces the risk of fractures.

Figure 2: X-ray taken prior to removal of telescopic tooth LR4

Volume 6 Number 5

The Rebilda Post system fits in dental cabinets as a complete drawer insert (Figure 1) and contains all the necessary components for stable, coronal build-ups – with or without a root post – in a maximum of five steps: dual-curing Rebilda® DC as a luting and build-up composite; Futurabond® DC as a dual-curing selfetch bond; Rebilda Post, the glass fiberreinforced composite root post with the precisely coordinated pilot and root canal drills, and Ceramic Bond, a coupling silane that strengthens the bond between Rebilda DC and Rebilda Post. Voco has complemented the existing post sizes of 1.2 mm, 1.5 mm, and 2.0 mm diameters with the new 1.0 mm post size. As a result, the available range is now perfectly suited to treating all anatomical root canal sizes safely and with minimal substance loss.

CLINICAL

The Rebilda Post system

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Clinical case The patient is a 75-year-old male. The telescopic tooth LR4 (Figure 2) was extracted and a curved clip placed on tooth LR3 (Figure 3) as an interim solution. Following adequate healing of the wound, the terminal tooth LR3 should be furnished with a telescopic crown and the existing restoration suitably reproduced on the right-hand side. Tooth LR3 is extensively filled on all sides, and its loading as a terminal abutment tooth is not insignificant. Consequently, it is equipped with a glass fiber post for the fixation of the adhesive build-up. After application of a rubber dam, removal of the fillings and a check with Caries Marker (Voco), it becomes evident that the remaining healthy substance requires an adhesive, preprosthetic restoration (Figure 4). Tooth LR3 was treated with a root canal filling in 2001, subjected to regular X-ray controls ever since, and has not displayed any symptoms at all over the whole period. Following removal of the root canal filling using a Gates-Glidden bur to achieve the planned depth, precision drilling is performed with the drill from the system corresponding to the respective post size (Figure 5). The X-ray image for measurement is performed with the Rebilda Post drill with a diameter of 2 mm (Figure 6). The image displays the correct fit with apical preservation of the root canal filling of approximately 5 mm. Optimal drilling performance is ensured by intermediate Volume 6 Number 5

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Figure 3: Initial clinical situation following extraction of telescopic tooth LR4 with already accordingly expanded partial prosthesis

Figure 4: Healthy remaining substance of tooth LR3 prior to adhesive build-up

Figure 5: Preparation of post canal with the drills of the Rebilda Post system Endodontic practice 15

CLINICAL

Figure 7: Checking the position with the Rebilda Post glass fiber post

Figure 8: Silanization with Ceramic Bond (Voco) for 60 seconds

Figure 6: X-ray image for measurement with Rebilda Post drill (diameter 2 mm)

Figure 9: Mixing of Futurabond DC (Voco) with the Single Tim applicator in the Single Dose

Figure 10: Rubbing in of the self-etch bond in the post hole with Endo Tim

Figure 11: Introduction of composite Rebilda DC (Voco) with the pliable application tip of the Quickmix syringe

Figure 12: Introduced Rebilda Post with excess composite forced out in the process

Figure 13: Fixation of the post via primary light-curing for 40 seconds

cleaning of the canal and the drill by rinsing away dentin remnants. The Rebilda Post is cleaned with alcohol before the trial insertion. During the position check in the mouth, the root post fills the canal precisely without becoming wedged (Figure 7). The post is shortened to the required length extraorally using a fine-grain diamond (not forceps or scissors due to the risk of delamination). The glass fiber post is cleaned again with alcohol, dried, and silanized for 60 seconds with the Ceramic Bond included in the system (Figure 8) before being dried with oil-free air again. Prior to the adhesive luting, the root canal is rinsed out with water and dried using paper points. Futurabond DC is activated by pressing on the marked area of the Single Dose and then mixed by piercing the film

and making circular movements with the Single Tim (Figure 9). The self-etch bond is rubbed into the canal with the fine Endo Tim (Figure 10) and over the rest of the tooth surface with the Single Tim for 20 seconds, the solvent dried with oil-free air for seconds, and any excess liquid in the channel removed using paper points. A shiny bonding layer is created, which is not light-cured. Rebilda DC is introduced directly into the root canal using the thin, pliable application tip of the Quickmix syringe (Figure 11), starting apically and keeping the cannula tip emerged in the luting composite throughout the application. The Rebilda Post is inserted with a rotary movement, with small amounts of excess material being forced out in the process. Light-curing is performed for 40 seconds to

fix the post (Figure 13), and then additional Rebilda layers are applied. The core buildup can then be light-cured for a further 40 seconds per layer; the chemical curing takes 5 minutes. Thanks to its consistency, Rebilda DC is easy to apply, and Voco also offers shaping aids for designing the build-up, which can be individually cut to size for the tooth shape using scissors. The build-up is also easy to process thanks to the dentinlike hardness of Rebilda DC. Figure 14 shows the prepared tooth; the preparation employs the ferrule effect in order to stabilize the abutment tooth and the subsequent restoration. The high radiopacity of Rebilda Post impresses in the X-ray image, and it is clear that the post and build-up composite form a homogeneous, adhesive build-up block (Figure 15). The functionality of the

16 Endodontic practice

Volume 6 Number 5

CLINICAL Figure 14: Finished, prepared tooth with Rebilda Post and Rebilda DC build-up

Figure 15: X-ray image of the homogeneous adhesive build-up block

telescopic restoration, expanded with the telescopic LR3 and then rebased, and the familiar wearing comfort are restored for the patient (Figure 16 and 17).

Conclusion Figure 16: Inserted telescopic crown tooth LR3

Modern composites and adhesive systems are of decisive importance for long-term tooth conservation in the post-endodontic treatment of severely damaged teeth. Vocoâ&#x20AC;&#x2122;s Rebilda Post system is a sophisticated, optimally coordinated, and complete set with materials that satisfy the high requirements for a stress-free, coronal build-up with a root post. EP

References Fox K, Gutteridge DL. An in vitro study of coronal microleakage in root-canaltreated teeth restored by the post and core technique. Int Endod J. 1997;30(6):361-368. Hemmings KW, King PA, Setchell DJ. Resistance to torsional forces of various post and core designs. J Prosthet Dent. 1991;66(3):325-329. Ray HA, Trope M. Periapical status of endodontically treated teeth in relation to the technical quality of the root filling and the coronal restoration. Int Endod J. 1995;28(1): 12-18. TorbjĂśrner A, Karlsson S, Odman PA. Survival rate and failure characteristics for two post designs. J Prosthet Dent. 1995;73(5):439-444.

Figure 17: The restored telescopic restoration Volume 6 Number 5

Endodontic practice 17

CASE STUDY

Management of root resorptive lesions in maxillary incisors using computed tomography and MTA: 1-year follow-up Drs. Anil Dhingra and Marisha Bhandari delve into the advantages of MTA and CBCT imaging Abstract This case presented with periapical radiolucencies and external root resorptions in maxillary incisors, tooth Nos. 11, 12, 21, 22 (FDI). To determine the exact extent of the lesions, as periapical radiographs tend to underestimate the size of the resorptive lesions, cone beam computed tomography (CBCT) was performed. Revision of root canals was performed and nonsurgical management initiated using mineral trioxide aggregrate (MTA) [Dentsply Maillefer Ballaigues, Switzerland] and thermoplasticized gutta percha (Obtura, Obtura Spartan® Endodontics). Followup radiographs after regular intervals showed healing of the periradicular tissues, demonstrating the effectiveness of MTA as a clinical filling material of choice.

Figure 2

Figure 1

Introduction The management of endodontic problems is reliant on radiographs to assess the anatomy of the tooth and its surrounding anatomy. Such radiographic images have inherent limitations, the major limitation being the lack of the three-dimensional nature of the radiographs and masking of areas of interest by overlying anatomic (anatomic noise), which are of relevance in endodontics (S. Patel, 2009). Resorptive defects are challenging to diagnose correctly, which may result in inappropriate treatment being carried out (Chapnick L,1989). Cone beam computed tomography reconstructed images have

Anil Dhingra, BDS, MDS, FAGE, is a Professor in the Department of Conservative Dentistry & Endodontics, Subharti Dental College, Subharti University, Meerut, India. Dr. Dhingra can be reached at anildhingra5000@ yahoo.co.in. Marisha Bhandari, BDS, is from the Post Graduate Department of Conservative Dentistry and Endodontics, Subharti Dental College, Subharti University, Meerut, India.

18 Endodontic practice

Figure 3

Figure 4

been successfully used in diagnosis and management of resorptive lesions (Maini A, Durning P, Drage N, Resorption 2008). It is able to reveal the true nature and exact location of the lesion, determine the “portal of entry” of the resorptive lesion, and also reveal previously undetected resorptive lesions (Cohenca N, Simon JH, Marthur A, Malfaz JM, 2007). Root resorption is inhibited by the protective unmineralized innermost pre-dentin and outermost pre-cementum surfaces of the root (Lindskog S, Blomlof L, Hammarstrom

L, 1983). Channels extend into dentin and interconnect within the periodontal ligament. As the lesion advances, bonelike material (replacement resorption) might also become deposited within the lesion and also in direct contact with the adjacent dentin; this indicates that the lesion is not destructive but attempting to repair itself (Shanon Patel, Shalini Kanagasingam, Thomas Pitt Ford, 2005). Few studies have determined the ability of cone beam computed tomography to improve diagnosis of root resorptive lesions. Volume 6 Number 5

CASE STUDY

Figure 5

Figure 6

Figure 7

Figure 9

Figure 10

dimensional reconstruction, a diagnosis of severe external root resorption in relation to tooth Nos. 11, 12 and periradicular lesions in relation to tooth Nos. 11, 12, 21, 22 (FDI) was determined (Figures 2 and 3). The patient was informed of the diagnosis, treatment plan alternatives, and prognosis of the case. An informed consent was obtained from the patient, and nonsurgical root canal therapy was initiated. On the basis of tomography findings, revision of root canal was carried out using ProTaper® Retreatment files D1, D2, D3 (Dentsply Maillefer, Ballaigues, Switzerland) [Figures 4, 5, 6, 7]. The root canals were cleaned and shaped using the ProTaper system (Dentsply Maillefer, Ballaigues, Switzerland). Tooth Nos. 11 and 12 (FDI) were cleaned and shaped up to a F5 ProTaper (Dentsply Maillefer, Ballaigues, Switzerland). Tooth Nos. 12 and 22 were cleaned and shaped up to F3 ProTaper (Dentsply Maillefer, Ballaigues, Switzerland). Intracanal irrigation was performed with 1ml 1.25% sodium

hypochlorite in between every instrument, and two final irrigations of 1ml 17% EDTA, followed by 1.25% NaOCl were performed before drying the canal with paper point (Dentsply Maillefer Ballaigues, Switzerland).The canals were obturated with white ProRoot® MTA (Dentsply Maillefer, Ballaigues, Switzerland), to obtain an apical stop of 5-6 mm with some extrusion of the material apically. The apical stop method involved size 50 MAF with 5/7 endodontic pluggers. After drying the coronal aspect of the MTA plug with paper points, the canals were further obturated with thermoplasticized gutta percha, Obtura (Obtura Spartan Endodontics) and the sealer. AH Plus™ (Dentsply Maillefer, Ballaigues, Switzerland) was restored with composite. An X-ray film was recorded, which showed that the resorptive defects were filled with MTA (Dentsply Maillefer, Ballaigues, Switzerland) [Figures 8, 9, 10, 11]. An occlusal radiographic film recorded after a 2-month, 6-month, and 12-month interval showed the teeth had

Figure 8

Case report A 30-year-old male patient reported to the Department of Conservative Dentistry and Endodontics, Subharti Dental College, Meerut, Uttar Pradesh, India with the chief complaint of pain and mobility in the upper anterior tooth region for the past 12 months. The patient’s medical history was noncontributory. The patient reported trauma to his upper anterior teeth more than 15 years ago, for which root canal treatment was performed. On examination, it was observed that tooth Nos. 11, 12, 21, 22 (FDI) were tender on percussion, with Grade II mobility in relation to tooth Nos. 11 and 21 (FDI) with no discoloration. Radiographic examination revealed incomplete root canal treated teeth with overextended obturation and multiple periradicular lesions in relation to tooth Nos. 11, 12, 21, 22 (FDI) [Figure 1]. In order to determine the extent and depth of the lesion in three spatial levels, we decided to opt for CBCT imaging in relation to the maxillary anterior tooth region. Based on the CBCT images and threeVolume 6 Number 5

Endodontic practice 19

CASE STUDY

Figure 11

Figure 12

Figure 13

Figure 14

Figure 15

Figure 16

remained completely asymptomatic, and the periapical lesion showed healing or healing in progress of the lesion present at the beginning of the treatment procedure (Figures 12-18).

Discussion Root resorption in this case may have been produced by the trauma to the teeth reported by the patient during his childhood and due to incomplete root canal therapy. Root resorption is the loss of hard tissue (i.e., cementum and dentin) as a result of odontoclastic action. Cone beam computed tomography appears to be a promising diagnostic tool for confirming the presence, appreciating the true nature, and managing external root resorption (Shanon Patel, Shalini Kanagasingam, Thomas Pitt Ford, 2005). As with CBCT, a threedimensional volume of data is acquired in the course of a single sweep of the scanner, using a simple, direct relationship between the sensor and source, which rotates synchronously 180-360 degrees around the patient’s head. The X-ray beam is cone-shaped (hence the name of the technique) and captures a cylindrical or spherical volume of data. This has an advantage of reducing the patient radiation dose. The radiographic outcome of root 20 Endodontic practice

Figure 17

Figure 18

canal treatment is more successful when teeth are treated and obvious radiographic signs of periapical disease are detected (S. Patel, 2009). Thus, earlier identification of periradicular radiolucent changes with CBCT may result in earlier diagnosis and more effective management of endodontic disease (Cotton TP, Geisler TM, Holden DT, et al., 2007). In situations where patients have poorly localized symptoms associated with an untreated or previously root treated tooth and clinical and periapical examination show no evidence of disease, CBCT may reveal the presence of previously undiagnosed pathosis.

CBCT images are geometrically accurate (Murmulla R, Wortche R, Muhling J, et al., 2005) and the problem of anatomical noise seen with periapical eliminated. Serial sets of linear and volumetric measurements obtained with CBCT technology could therefore be used to provide a more objective and accurate representation of osseous changes (healing) over time (Pinky HM, Dyda A, et al., 2006). Future research may show that periapical tissues, which appear to have “healed” on conventional radiographs, may still have signs of periapical diseases when imaged using CBCT (S. Patel, 2009). Volume 6 Number 5

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CASE STUDY

Mineral trioxide aggregrate has emerged as a reliable bioactive material with extended applications in endodontics that include the obturation of the root canal space. It provides an effective seal against dentin and cementum, and also promotes biologic repair and regeneration of the periodontal ligament. The chemical composition of MTA was determined by Torabinejad, et al. The material consisted of fine hydrophilic particles, and the main components were tricalcium silicate, tricalcium aluminate, tricalcium oxide, and silicate oxides. Bismuth oxide acts as a radiopacifier. They declared that calcium and phosphorus were the main ions in MTA (Hashem Ahmed Adel Rahman, et al., 2008). It appears that teeth obturated with MTA might not only increase their fracture resistance with time, but bacteria might be effectively entombed and neutralized in severely infected teeth. Unsuccessful root canal treatments compromised by microleakage, large periapical lesions, perforations, and inadequate cleaning and shaping can demonstrate superior healing rates when this osteoinductive and cementogenic material is used to restore the root canal system. MTA provides an effective seal against dentin and cementum and also promotes biologic repair and regeneration of the periodontal ligament. It not only fulfills the ideal requirement of being baceriostatic, but might have potential bactericidal properties. The release of hydroxyl

References Patel S. New dimensions in endodontic imaging: Part 2. Cone beam computed tomography. Int Endod J. 2009;42(6):463-475. Chapnick L. External root resorption: an experimental radiographic evaluation. Oral Surg Oral Med Oral Pathol. 1989;67(5):578-582. Maini A, Durning P, Drage N. Resorption: within or without? The benefit of cone-beam computed tomography when diagnosing a case of an internal/ external resorption defect. Br Dent J. 2008;204(3):135137.

ions, a sustained high pH for extended periods, and the formation of a mineralized interstitial layer might provide a challenging environment for bacterial survival. The cured cement creates a potentially impervious seal that might be difficult for microorganisms to penetrate. This unique sealing property, combined with an initially high pH that increases to 12.5 after curing, might provide a suitable mechanism for bacterial entombment, neutralization, and inhibition within the canal system. These factors are important when considering nonsurgical patients with large periapical lesions associated with initial root canal treatment or in cases presenting with refractory endodontic disease diagnosed for retreatment (George Bogen, et al., 2009). There are many factors involved in the healing of periapical lesions, such as the apical limit of root canal instrumentation and obturation (Riccuci D, Langeland K, 2005) and follow-up time (Leonardo MR, Barnett F, Debelian G, et al., 2007) It is necessary to perform further recall in this case to confirm total healing of the lesion. Estrela, et al., tested the reliability of a periapical X-ray film, and the images obtained by CBCT to detect periapical lesions; they found that the best results were obtained with the CBCT group. In the clinical case presented here, we observed that the extent of resorption could not be detected in conventional X-ray film, hence, the need for the use of CBCT.

Schindler WG. Endodontic applications of cone-beam volumetric tomography. J Endod. 2007;33:1121-1132. Marmulla R, Wörtche R, Mühling J, Hassfeld S. Geometric accuracy of the NewTom 9000 Cone Beam CT. Dentomaxillofac Radiol. 2005;34(1):28-31. Pinsky HM, Dyda S, Pinsky RW, Misch KA, Sarment DP. Accuracy of three-dimensional measurements using cone-beam CT. Dentomaxillofac Radiol. 2006;35(6):410-416. Patel S. New dimensions in endodontic imaging: Part 2. Cone beam computed tomography. Int Endod J. 2009;42(6):463-475.

Cohenca N, Simon JH, Mathur A, Malfaz JM. Clinical indications for digital imaging in dento-alveolar trauma. Part 2: root resorption. Dent Traumatol. 2007;23(2):105113.

Hashem AA, Hassanien EE. ProRoot MTA, MTAAngelus and IRM used to repair large furcation perforations: sealability study. J Endod. 2008;34(1):5961.

Lindskog S, Blomlöf L, Hammarström L. Repair of periodontal tissues in vivo and in vitro. J Clin Periodontol. 1983;10(2):188-205.

Bogen G, Kuttler S. Mineral trioxide aggregate obturation: a review and case series. J Endod. 2009;35(6):777-790.

Patel S, Kanagasingam S, Pitt Ford T. External cervical resorption: a review. J Endod. 2009;35(5):616-625.

Estrela C, Bueno MR, Leles CR, Azevedo B, Azevedo JR. Accuracy of cone beam computed tomography and panoramic and periapical radiography for detection of apical periodontitis. J Endod. 2008;34(3):273-279.

Cotton TP, Geisler TM, Holden DT, Schwartz SA,

22 Endodontic practice

Conclusion Cone beam computed tomography technology is improving at a rapid pace. It overcomes most of limitations of intraoral radiography. The increased diagnostic data should result in more accurate diagnosis and monitoring, and therefore, improved decision making for the management of complex endodontic problems. It is a desirable addition to the endodontist’s armamentarium. When indicated, threedimensional CBCT scans may supplement conventional two-dimensional radiographic techniques, which at present have higher resolution than CBCT images. In this way, the benefits of each system may be harnessed. In this case, the patient tried to save his teeth and accepted the treatment accordingly. Twelve months after treatment, the teeth were asymptomatic, there was no periapical radiolucency, and the conventional X-ray film showed healing or healing in progress of the periapical lesion present at the beginning of the treatment procedure.

Acknowledgement The authors thank Dr. Shibani Grover, Professor and Head of the Department, Department of Conservative Dentistry and Endodontics, Subharti Dental College, Meerut, India for her eminent support and guidance. EP

Ricucci D, Langeland K. Apical limit of root canal instrumentation and obturation, part 2. A histological study. Int Endod J. 1998;31(6):394-409. Holland R, Mazuqueli L, de Souza V, Murata SS, Dezan Júnior E, Suzuki P. Influence of the type of vehicle and limit of obturation on apical and periapical tissue response in dogs’ teeth after root canal filling with mineral trioxide aggregrate. J Endod. 2007;33(6):693697. Leonardo MR, Barnett F, Debelian GJ, de Pontes Lima RK, Bezerra da Silva LA. Root canal adhesive fillings in dogs’ teeth with or without coronal restoration: a histopathological evaluation. J Endod. 2007;33(11):1299-1303. American Association of Endodontists. Appropriateness of care and quality assurance guidelines of the American Association of Endodontists. Chicago, IL: 1994. Holland R, Sant’Anna Júnior A, Souza Vd, Dezan Junior E, Otoboni Filho JA, Bernabé PF, Nery MJ, Murata SS. Influence of apical patency and filling material on healing process of dogs’ teeth with vital pulp after root canal therapy. Braz Dent J. 2005;16(1):9-16

Volume 6 Number 5

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ENDODONTICS IN FOCUS

Top ten tips: Tip number 9 - Preparation techniques Continuing his series on endodontics, Dr. Tony Druttman shows the importance of preparation

his is the article that brings the previous eight together, starting with knowledge of the anatomy of the root canal system. The primary purpose of root canal preparation is the removal of all vital and necrotic tissue, microorganisms and their by-products from the root canal system. This involves opening up the canal or canals to allow irrigants to reach as much of the root canal system as possible. It also permits shaping of the canal(s) to facilitate obturation (Figure 1). Many of the problems that clinicians experience with obturation are in fact due to incorrect canal preparation. Canal preparation is the area of endodontics that has gone through the most significant change in the last 20 years. The nickel-titanium revolution has made canal preparation so much easier, faster, and more predictable. Since the introduction of the first rotary files, there have been many developments that have reduced the number of files required and made the process more efficient. Two of the latest rotary file systems Reciproc® (VDW, Munich, Germany) and WaveOne® (Dentsply Tulsa Dental Specialties) claim that canals can be prepared with just one rotary file, and the Reciproc technique even claims that the use of hand files to prepare a glide path is not necessary. Another, the Self Adjusting File (ReDent Nova, Ra’anana, Israel) prepares the canal wall by adjusting itself to the contours of the canal. This is an interesting concept, and recent research shows encouraging results.1 Like with everything else in life that claims that one-size-fits-all, there are those situations where the claims can be borne out, and those where they cannot, and it is important to understand the difference. Root canals come in all shapes and sizes, from the immature central incisor with an

Tony Druttman, MSc, BChD, BSc, is an endodontist working in central London. He is also a part-time teacher at the Eastman Dental Institute, University of London, and lectures in the UK and abroad.

24 Endodontic practice

open apex to the severely curved canal, to the sclerosed canal that is only apparent in the middle third of the root. They all require a different approach, and this is what makes endodontics so challenging. Hand instrumentation is as important as it ever was, although nowadays instead of being used to prepare the whole canal, hand instruments are used predominately at the beginning to create a glide path and towards the end of preparation to gauge the size of the apical preparation. The cleaning and shaping objectives are as follows: • create a continuously tapering preparation • have the narrowest diameter of the canal apically • maintain the original anatomy of the canal centered within the preparation • maintain the position of the foramen • keep the foramen as small as is practicable

Figure 1: Ideal preparation shape

Creation of a glide path This is one of the most critical parts of the preparation sequence. With large canals, it is not a challenge, but with curved and sclerosed canals, blockages and ledges are either naturally present, or can all too easily be created even with the first instruments introduced into the canal. Once the canal entrance has been identified, a small K file (my preference is for a size 10 Maillefer FlexoFiles®) should be introduced through a well of sodium hypochlorite and gently advanced into the canal to about two-thirds of the estimated length. If any resistance is encountered, then smaller files, size 08 or even 06, should be used, and once these files move freely, then the size 10 is reintroduced. There are many techniques associated with different rotary file systems, and the recommended sequence of instrumentation should always be followed. In an article of this nature, it is impossible to give precise advice for every situation that may be encountered, however, there are some basic principles that should be followed.

Figure 2: Creation of a zip by incorrect preparation techniques

Figure 3: Patency filing

Volume 6 Number 5

Figure 7: Although the distal canals of this lower molar have been cleaned, the isthmus has not Figure 6: Preparation of curved canals using the Mtwo rotary system

Figure 4: Apical delta obturated because patency filing was used in the preparation

Hand instruments should be used delicately. The tactile sense in the fingers is very refined, and with practice, it should be possible to read the canal. Placing a gentle curve at the tip of the file will often overcome a ledge. Excessive force is likely to ledge the canal further. In curved canals, an apical zip, or even a perforation, can be created as successively larger files are

“screwed” into the canal in an attempt to maintain working length (Figure 2). The balanced force technique should be used. This requires the following sequence: • Place the file into the canal and turn it 90 degrees clockwise, using light pressure • Turn the file 120 degrees counterclockwise using firm apical pressure – this advances the file into the

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canal and cuts the dentin • Turn the file clockwise in the canal without pressure to clean the canal

Patency filing This technique is predicated on the concept that the apex of the canal should be kept open to allow irrigants to reach the apex of the root, rather than creating an apical

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Volume 6 Number 5

Endodontic practice 25

ENDODONTICS IN FOCUS

Figure 5: Mtwo® (VDW, Munich, Germany) nickel-titanium files 10/04-25/06

ENDODONTICS IN FOCUS

Figure 8: Pre-curved ultrasonic K file

stop and blocking the terminus with dentin chips (infected or otherwise) [Figures 3 and 4]. The patency file (size 10) should be introduced no further than 1 mm beyond the working length and should be used at intervals in the preparation sequence to ensure that the apical constriction has not been blocked with debris.

Apical gauging The question, “What is the ideal size of the preparation?” is one that will be hotly debated for a long time to come. Some of the literature recommends larger apical sizes with a less tapered preparation,2 while other papers recommend smaller apical sizes and greater tapers.3 The decision will often depend on a variety of factors including the canal geometry, not only the dimensions, but the angle and radius of curvature. Another factor is the irrigant and irrigation technique. I have recommended in the previous article on irrigation, that it is important that the irrigant penetrates as far as possible into the root canal system. Once the canal has been prepared to a considered optimal size, for example with a size 25 rotary file with an 06 taper to the working length, a size 30 hand file (with an 02 taper) is placed gently into the canal. If resistance is met approximately 1 mm from the working length, then it should not be necessary to prepare the canal to a larger size. If it reaches the working length without resistance, then the master apical file size (the final size of file that is used to working length) should be increased.

Which rotary file system is best? There is no best system for everyone. This is like asking which is the best car — we all have our favorites (Figures 5 and 6). In my opinion, the best file system should have the following features: • Cut efficiently 26 Endodontic practice

Figure 9: C-shaped canals in lower second molar requiring additional ultrasonic preparation

• Have great strength and flexibility • Be safe to use • Have enough instruments in the range to be used in the majority of situations • Have a safe cutting tip, so as not to over enlarge the apical preparation • Be versatile enough so that the instrument can be used by hand when necessary • Can be pre-curved to overcome ledges (when used by hand) The best way to evaluate a system is to read the literature about it, decide what features and benefits are important to you, and then try the system. It is important to follow the manufacturer’s recommendations and to use the appropriate type of motor and handpiece. As new instruments are being developed, re-evaluation is advisable. It is important to remember that because a canal has been prepared to a certain length, with a file of a certain size and taper, that does not mean that the canal system is clean (Figure 7). Many canals are irregular in cross section and may have areas such as an isthmus between canals that harbor necrotic tissue and bacteria.4 A variety of preparation and irrigation techniques and armamentaria have to be used to ensure optimal canal cleanliness. My own preference is to use an ultrasonically energized K file, which can be adapted to the canal curvature (Figures 8-10). Areas of the canal system that have not been cleaned adequately with rotary instrumentation can be visually identified with the use of the operating microscope and addressed in a controlled manner with ultrasonics. During preparation and before the canals are obturated, the canal length should be checked. This is particularly important with curved canals, because as the size increases, the working length

Figure 10: C-shaped canal viewed from the pulp chamber after obturation

Figure 11: Cone fit of gutta-percha cones to ensure that correct working length has been established

may reduce. This can be done either by rechecking working lengths electronically or radiographically by cone fitting the guttapercha points (Figure 11). In conclusion, the careful use of both hand and rotary instrumentation will deal with many of the situations that we are faced with. It is important to understand the anatomy of the canal system and to “read” both the canals and the instruments. When canal preparation is done in a controlled and considered way, obturation is a relatively straightforward matter. EP

References 1. De-Deus G, Souza EM, Barino B, Maia J, Zamolyi RQ, Reis C, Kfir A. The self-adjusting file optimizes debridement quality in oval-shaped root canals. J Endod. 2011;37(5):701-705. 2. Usman N, Baumgartner JC, Marshall JG. Influence of instrument size on root canal debridement. J Endod. 2004;30(2):110-112. 3. Yared GM, Dagher FE. Influence of apical enlargement on bacterial infection during treatment of apical periodontitis. J Endod. 1994;20(11):535537. 4. Wu MK, R’oris A, Barkis D, Wesselink PR. Prevalence and extent of long oval canals in the apical third. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2000;89(6):739-743.

Volume 6 Number 5

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CONTINUING EDUCATION

Endodontic treatment of curved root canal systems Dr. John Bogle offers some cases to treatment plan success for tooth retention

he goal of quality endodontic therapy has remained the same since its inception. Appropriate removal of pulpal tissues with proper cleaning and shaping followed by an obturation system and coronal seal will satisfy both mechanical and biological objectives.1 As clinicians we need to appreciate each of these aspects and know that our therapy’s success is dictated by the weakest element of our treatment. One area that has the potential for improvement is our ability to accurately instrument root canal systems in a manner that maintains the original path of curvature in both significant and multiple curvature systems. Failing to realize canal curvature before treatment can lead to preparation errors (i.e., apical zips, perforations, canal blockages, or instrument separation), which can leave the canal unprepared and lead to continued pathology compromising the outcome of treatment.2 The question now becomes, “How do we treat these excessively curved cases appropriately?” The purpose of this paper is to provide dentists with the available tools and knowledge to treatment plan success for tooth retention through endodontic therapy on curved root canal systems. Cases will be provided to demonstrate a sample treatment sequence.

Step 1 – Strategize your approach to success The most logical approach to begin treating these intricate root systems is to start with a clear vision of what you are trying to accomplish. Understanding the anatomy prior to the onset of treatment allows the clinician to anticipate potential challenges and work to prevent procedural errors. Several tools can be beneficial in this regard, one of these being the American

Dr. John Bogle, DMD, MS, FRCD(C), is an endodontic specialist and maintains a private practice limited to endodontics in Calgary, Alberta. He is a mentor in several local study clubs and presents to multiple groups on various endodontic topics. Dr. Bogle has no conflict of interest related to this article.

28 Endodontic practice

Educational aims and objectives This article aims to discuss the treatment of excessively curved root canal systems. Expected outcomes Correctly answering the questions on page 31, worth 2 hours of CE, will demonstrate the reader can: • Recognize the intricate anatomy of these root systems to anticipate potential challenges. • Realize the necessity for various tools for treatment. • Recognize how to use these tools appropriately.

Figure 1: Pruett’s method to calculate the radius of curvature5

Association of Endodontists (AAE) case difficulty assessment form.3 In a checklist format, a dentist can use this form to select whether the patient falls into a minimal, moderate, or high difficulty ranging from radiographic analysis, canal calcification, and medical history to tooth access. This document is readily available online and there to assist with treatment planning. A key point within this form is “Canal and Root Morphology.” Justifiably, the degree of curvature or multiple curvatures increases the difficulty of the case from minimal to high levels of difficulty. The degree of curvature and number of curves within the tooth can produce challenges for appropriate shaping of the canal system.4 Prior to initiation of treatment, the clinician should consider both the angle and radius of curvature, as this has been suggested as a more accurate resemblance of true canal anatomy.5 The greater the angle of curvature and the smaller the radius of curvature, the greater the complexity of the case (Figure 1).

However, the disadvantage of conventional periapical radiographs is that they only provide information in two dimensions. Another critical tool is the radiographic evaluation of the tooth. Conventional periapical radiographs are important with endodontic treatment. These images can provide information regarding the curvature of a canal or root. While conventional and panoramic radiographs allow the operator to visualize the root structures in two dimensions, the advent of three-dimensional radiography allows for accurate assessment of the root canal space in multiple planes.6 Threedimensional imaging can allow the clinician to view proximal views with a high degree of accuracy. This is beneficial because many teeth have curvatures that are only present in a proximal view.7 One example of a cone beam CT machine is the Kodak 9000 3D. It has been shown to accurately depict the relationship of the internal canal anatomy compared radiographically and histologically.8 Volume 6 Number 5

Figure 3: Tulsa Dentsply Flex NTK® hand files

Step 2 – Have the tools necessary to make this success a reality

decrease the forces applied to each file used during instrumentation, minimizing chances for instrument failure. Hand files should be used in a watch-winding, or preferably, the balanced force technique.12 Rotary instruments should never be forced apically to avoid unnecessary strains and possible failure/fracture of instruments.13 Two types of failure occur with root canal instruments: torsional loading and cyclic fatigue. Torsional loading occurs if a file binds within the canal and continues to rotate to the point of separation (torsional failure). Cyclic fatigue is the result of continued forces being placed on an instrument as it operates around curves. This results in repeated strain on the file resulting in eventual work hardening and fracture.14 In root canals with significant curves, cyclic fatigue is always a concern during treatment. The literature has demonstrated two key points. One, using CM files increases the resistance to fracture versus non-treated NiTi rotary files. Two, operating CM instruments in the presence of fluid increased resistance to fracture versus use in a dry environment by over 200%.15 Clinicians should always operate endodontic rotary instruments with canals flooded. This increases contact time between the internal root surface and the disinfectant as well as decreases potential for instrument separation. Now that the steps to treat curved canal systems have been discussed, I would like to present a few cases that show the utilization of these steps and techniques.

In the treatment of curved canals, several key products are instrumental in achieving true success. These include small stainless steel hand files, nickel-titanium hand files, and rotary nickel-titanium files. First, the stainless steel hand files are used to assist with creating a glide path. Passive movement with a light touch is necessary to debride pulpal tissues and negotiate apical anatomy. However, larger stainless steel instruments can alter the internal structure of the canal (i.e., increased canal transportation) when compared to nickeltitanium instruments.9 Nickel-titanium hand files can be used to increase the diameter of the glide path while maintaining the canal anatomy. Nickel–titanium rotary files are flexible, but multiple curves or significant curves can still put incredible strain on these instruments. Recently, a new product, Typhoon Controlled Memory (Clinician’s Choice), has been developed that uses thermal treated NiTi alloy that enhances the mechanical properties of nickel-titanium.10 These files have been shown to be more resistant to cyclic fatigue than standard nickel-titanium files.11 These three tools: small stainless steel hand files, moderate-sized nickel-titanium hand files, and rotary Controlled Memory or CM files, are essential for treating the moderately to severely curved canal systems predictably.

Step 3 – Use the tools appropriately Each instrument has a specific function and should be used in the correct manner. Endodontic files are designed to create additional space within the root canal to decrease contact with subsequent files. Endodontic files should have minimal contact along the root canal. Slow, consistent enlargement of the canal can Volume 6 Number 5

Figure 4: Preoperative CBCT image (S curve on DB root and significant curve on MB root)

Case 1 A 17-year-old male with non-contributory medical history presented for evaluation of Quadrant 1. Vitality tests confirmed a diagnosis of irreversible pulpitis with acute apical periodontitis for tooth 1.6.

Cone beam CT images (Kodak) confirm pronounced curve in MB canals and S curvature in DB canal. Dental caries were removed, and aseptic treatment was maintained with a resin-modified glass ionomer cement (Fugi II, GC Corporation). Vital tissue in 5 (MB1/2/3, DB, and P) canals was confirmed upon pulp chamber access. Initial coronal debridement with a rotary Sx file (Dentsply Tulsa Dental Specialties) in conjunction with stainless steel hand files to remove pulpal tissues. A glide path was created using a combination of stainless steel hand files and NiTi hand files (Flex Files, Dentsply Tulsa Dental Specialties). After achieving repeatable patency measurements with the Elements Apex Locator (Sybron Endo) and 15 NTK®, a 20/04 Typhoon (Clinician’s Choice) rotary file was introduced into each canal. Passive movement into each canal allowed for appropriate cleaning and shaping of the canal system. If the file appeared to stop moving apically while in the canal, the instrument was withdrawn, irrigation and recapitulation with a 15 NTK® hand file. In an apical enlargement approach, initial instrumentation with a 20 and 25 NTK® was used. Subsequent 25/04 through 35/04 instruments were used in all buccal canals and a 45/04 for the palatal canal. After disinfection was completed, obturation with master gutta-percha cones, Kerr EWT sealer (Sybron Endo) and Calamus® gutta percha (Dentsply Tulsa Dental Specialties) was completed. The floor of the chamber was sealed with a resin-modified glass ionomer cement (Fugi IX, GC Corporation) and temporized with Cavit™ (3M).

Case 2 A 39-year-old female with non-contributory medical history presented for evaluation of Quadrant 4. Vitality tests confirmed a diagnosis of necrotic pulp with Endodontic practice 29

CONTINUING EDUCATION

Figure 2: Typhoon CM rotary files

CONTINUING EDUCATION

Figure 5: Postoperative radiograph with obturation complete

Figure 6: Postoperative radiograph with distal angulation

symptomatic periradicular periodontitis for tooth No. 4.6. Cone beam CT images indicate significant mesial and distal canal curvatures. Access through the porcelainfused-to-metal crown was completed with a combination of coarse #2 diamond and #557 carbide burs (NeoBurr®, Microcopy). Necrotic tissue in two distal canals and vital tissue in three mesial canals were confirmed upon pulp chamber access. Similar instrumentation completed as in Case 1 with the MB/ML canals shaped to a 35/04, the middle mesial to a 25/04 and the distal canals to a 40/04.

Conclusion Although manufacturers often tout a preassembled system for root canal debridement, it is imperative for the clinician to assess each tooth or canals on a case by case situation and realize which instruments or techniques give the best chance of success. It is often far too easy to adhere to the “cookie cutter” pamphlet included in the packet of files rather than take the time to strategize the correct sequence to treat a tooth. Each tooth, and furthermore each canal of a tooth, is unique and requires diligent attention to detail for success to be possible. For example, the palatal canal of Case 1 was relatively straightforward. A standard cleaning and shaping protocol could be applied to produce a good result. However, when we approach the buccal canals, our strategy needs to be much more detailed and calculated to ensure appropriate treatment. Our role is to think biologically rather than operate as a technician. Do not misinterpret what is being presented. We are all capable of providing excellent endodontic therapy. I would like to challenge each of you to push for that higher level of treatment. As the complexity of the system increases, so must your expertise in this field. Appropriate courses can help you advance your craft. Utilize your local endodontic specialist’s knowledge and discuss cases 30 Endodontic practice

Figure 7: Preoperative CBCT image (radius of curvature on M root)

Figure 9: Postoperative radiograph

during local study club events. Follow the current literature on new products and resources. Our profession prides itself on an evidence-based approach to treat our patients in the highest standards possible. Apply these resources and focus on the end result. EP

References 1. Schilder H. Cleaning and shaping the root canal. Dent Clin North Am. 1974;18:269-296. 2. Peters OA, Peters CI. Cleaning and shaping the root canal system. In: Cohen S, Hargreaves KM, eds. Pathways of the Pulp. 9th ed. St. Louis, MO: Mosby, Inc.; 2006: 290357. 3. American Association of Endodontists. AAE Endodontic Case Difficulty Assessment Form and Guidelines. http://www.aae.org/uploadedFiles/Dental_ Professionals/Endodontic_Case_Assessment/2006Case DifficultyAssessmentFormB_Edited2010.pdf. Accessed February 16, 2013. 4. Schäfer E, Diez C, Hoppe W, Tepel J. Roentgenographic investigation of frequency and degree of canal curvatures in human permanent teeth. J Endod. 2002;28(3):211-216. 5. Pruett JP, Clement DJ, Carnes DL Jr. Cyclic fatigue testing of nickel-titanium endodontic instruments. J Endod. 1997;23(2):77–85. 6. Patel S, Dawood A, Ford TP, Whaites E. The potential applications of cone beam computed tomography in the management of endodontic problems. Int Endod J. 2007;40(10):818-830. 7. American Association of Endodontists. Cone Beam-Computed Tomography in Endodontics [position statement]. http://www.aae.org/uploadedFiles/ Publications_and_Research/Endodontics_Colleagues_ for_Excellence_Newsletter/ecfe%20summer%2011%20 FINAL.pdf. Accessed February 16, 2013.

Figure 8: Preoperative CBCT image (coronal view demonstrating three canals in mesial root)

Figure 10: Postoperative radiograph with distal angulation (obturation of three mesial canals)

Acknowledgements: I would like to thank Dr. Joe Petrino for his professional review and advice regarding this manuscript. This article was reprinted with permission from Oral Health.

8. Michetti J, Maret D, Mallet JP, Diemer F. Validation of cone beam computed tomography as a tool to explore root canal anatomy. J Endod. 2010;36(7):1187-1190. 9. Esposito PT, Cunningham CJ. A comparison of canal preparation with nickel-titanium and stainless steel instruments. J Endod. 1995;21:173-176. 10. Gambarini G, Plotino G, Grande NM, Al-Sudani D, De Luca M, Testarelli L. Mechanical properties of nickel-titanium rotary instruments produced with a new manufacturing technique. Int Endod J. 2011;44(4):337341. 11. Shen Y, Qian W, Abtin H, Gao Y, Haapasalo M. Fatigue testing of controlled memory wire nickel-titanium rotary instruments. J Endod. 2011;37(7):997-1001. 12. Roane JB, Sabala CL, Duncanson MG Jr. The “balanced force” concept for instrumentation of curved canals. J Endod. 1985;11(5):203-211. 13. Peters OA, Barbakow F. Dynamic torque and apical forces of ProFile.04 rotary instruments during preparation of curved canals. Int Endod J. 2002;35(4):379-389. 14. Haïkel Y, Serfaty R, Bateman G, Senger B, Allemann C. Dynamic and cyclic fatigue of engine-driven rotary nickel-titanium endodontic instruments. J Endod. 1999;25(6):434-440. 15. Shen Y, Qian W, Abtin H, Gao Y, Haapasalo M. Effect of environment on fatigue failure of controlled memory wire nickel-titanium rotary instruments. J Endod. 2012;38(3):376-380.

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Endodontic treatment of curved root canal systems 1. _______can produce challenges for appropriate shaping of the canal system. a. The degree of curvature b. The number of curves within the tooth c. The shade of the tooth d. Both a and b 2. First, ______are used to assist with creating a glide path. a. the stainless steel hand files b. the nickel-titanium hand files c. the rotary nickel-titanium files d. barbed broaches 3. _______can be used to increase the diameter of the glide path while maintaining the canal anatomy. a. Stainless steel files b. Nickel-titanium hand files c. Rotary instruments d. NCM files 4. Endodontic files are designed to create additional space within the root canal to _____ contact with subsequent files. a. increase b. maintain

Volume 6 Number 5

c. decrease d. augment 5. _______enlargement of the canal can decrease the forces applied to each file used during instrumentation, minimizing chances for instrument failure. a. Quick b. Slow c. Consistent d. Both b and c 6. ______occurs if a file binds within the canal and continues to rotate to the point of separation (torsional failure). a. Torsional loading b. Cyclic fatigue c. Aseptic syndrome d. Passive separation 7. ________is the result of continued forces being placed on an instrument as it operates around curves. a. Torsional loading b. Cyclic fatigue c. Winding failure d. Strain fracture

8. One, using CM files _____the resistance to fracture versus non-treated NiTi rotary files. a. increases b. decreases c. maintains d. has no effect on 9. Two, operating CM instruments in the presence of fluid increased resistance to fracture versus use in a dry environment by ______. a. less than 20% b. about 50% c. 75% d. over 200% 10. Clinicians should always operate endodontic rotary instruments with canals flooded. This ______contact time between the internal root surface and the disinfectant as well as decreases potential for instrument separation. a. decreases b. increases c. eliminates d. slows

Endodontic practice 31

CE CREDITS

ENDODONTIC PRACTICE CE

CONTINUING EDUCATION

Root canal preparation: the path to success Dr. Omar Ikram explains the principles of taper and apical preparation and how they relate to clinical practice Introduction In endodontics, a successful outcome is defined as a lack of clinical signs and symptoms, as well as radiographic healing or continued absence of periapical disease. As clinicians, we are all trying to achieve the same outcome, but have you ever wondered why the method for preparing a root canal differs so much between practitioners? The question of what size to make the apical preparation was a much-debated topic during my days as an undergraduate student. Since then, nickel-titanium instruments have introduced the concept of taper to our preparations. As if the apical preparation wasn’t enough to think about, all of a sudden we have to consider what taper we should choose for our preparation. I have discussed the topic of root canal preparation with colleagues, both as an undergraduate student and as a specialist practitioner. The results of which have made me realize the subject of root canal preparation is one of the most misunderstood areas of endodontics. The purpose of this article is to help the reader understand the principles of taper and apical preparation, so they may relate these to clinical practice and improve the care they provide for their patients.

Educational aims and objectives This clinical article aims to explain the principles of taper and apical preparation. Expected outcomes Correctly answering the questions on page 35, worth 2 hours of CE, will demonstrate the reader can recognize the principles of taper and apical preparation.

Figure 1

Two schools of thought Dr. Omar Ikram was born in Christchurch, New Zealand, and attained his bachelor of dental surgery qualification from Otago University, Dunedin. During his time at Otago, he was awarded the Craddock Prize and distinction in removable prosthodontics. After graduation, Dr. Ikram worked in private practice in New Zealand and then moved to the UK where he attained significant experience in endodontics. In 2005, he completed his fellowship of the Royal Australasian College of Dental Surgeons and began the specialist training course in endodontology at King’s College, London. His research at King’s, entitled “Micro-computed tomography of tooth tissue changes following root canal treatment and post space preparation,” enabled him to lecture in the United States, the United Kingdom, Australia and Malaysia. He currently practices at Sydney Dental Hospital and is in private practice at Specialist Endo Crows Nest in Sydney, Australia. He also runs the Specialist Endo Crows Nest Facebook page, which currently has more than 1,000 members worldwide.

32 Endodontic practice

Like many undergraduate students, I was taught that the size with which to finish the apical preparation should be three sizes larger than the first file that bound in this region. I recall being mystified by this rather arbitrary concept; the first file that bound at the apex of a mesial canal in a lower molar tooth was approximately a size 8 (0.08 mm) hand file. Using this rule for preparation, the final apical size for this mesial canal would be a size 20! The instruments we were using at dental school were made from stainless steel and had a 2% taper. I prepared many canals to these small narrow sizes and remember being unable to insert the irrigation needle more than halfway down

the root canal. It was no wonder many undergraduate students believed that the purpose of irrigation was mainly to remove the debris created during root canal preparation rather than playing a major role in disinfection. After graduating I discussed the subject of preparation with more experienced practitioners and found many of them prepared all their cases to a size 25 or 30 (2% tapered) hand file. By doing so, my colleagues were preparing root canals to an arbitrary size, just so the postoperative radiograph showed enough density of gutta percha within the canal to be able to claim a satisfactory result. Unfortunately, the canals were being prepared with only the obturation in mind, without considering Volume 6 Number 5

Figure 2

the benefits of irrigation. A wise clinician prepares a canal with consideration to both irrigation and obturation. Preparing the root canal using stainless steel hand files alone had two disadvantages: 1. Stainless steel hand files are less flexible above a size 15 (2% taper), making transportation and perforation of the canal more likely when large sizes are used. 2. Creating a greater tapered preparation wider than 2% is time consuming and highly technique sensitive. There was a need to improve on these two deficiencies, and the creation of nickel-titanium instruments, which were flexible even at greater tapers, allowed this. But with the invention of nickel-titanium instruments came the additional question of: “How wide should I make the taper of the preparation?” This essentially split clinicians into two schools of thought: 1. Those who prepare the apex to large apical sizes, such as 40 and above but use narrow tapers (4%) 2. Those who prefer less apical preparation size 20 or size 25 but use a wide taper (6% and above) Each group claimed that they were removing less dentin than the other in the “critical area.”

Preparation facilitates irrigation One of the biggest misunderstandings when it comes to root canal preparation is that we remove enough of the biofilm and infected dentin by preparation alone to get a successful outcome. This is definitely not the case. If it were true, then we would not require irrigants to help disinfect the root canal system. A micro-computed tomographic study showed that even with rotary instruments 35% or more of the canal surface area Volume 6 Number 5

remains free from instrumentation (Peters, et al., 2001). There have been many studies showing that irrigation with sodium hypochlorite is essential to being able to disinfect the root canal system (Bystrom, Sundqvist, 1983). A classic study showed that just using hand files to prepare root canals only removed all cultivable bacteria from 50% of the teeth (Bystrom, Sundqvist, 1981). In this study, mechanical preparation only achieved half of what we are attempting to do clinically. But in complex root canal systems, it probably does far less than this. Now that we have the ability to make tapered preparations quickly, we can allow the irrigant solutions to reach the apical region. In some situations, this means that very little apical instrumentation is required, and that preparation of the apex using large sizes may be removing apical dentin unnecessarily. Conversely, if we make the taper of the preparation too wide, this predisposes the tooth to fracture. The aim of preparation should be to make the canal wide enough to allow irrigants to reach the apex and easy to obturate. But the most important factor to think about when preparing a root canal is to consider the anatomy of the root that is being prepared, as preparation can only be done within the confines of what the anatomy will permit.

Choosing the apical size and taper for the root canal Although some clinicians would like to finish every preparation using their favorite finishing file of a certain size or taper, the reality is that every canal is different in some way. The tapers are different, the curvatures vary, communications with other canals join at different levels, and the lengths and apical sizes are almost always different between cases. So we cannot

treat every single tooth using just one preparation technique. We need to choose how we are going to treat each canal on a case-by-case basis.

Principles of apical preparation Historically, the theory of preparing the apex served two purposes. Firstly, it was thought that removing dentin and bacteria from the most difficult to reach region would aid disinfection of the canal and, secondly, it created an apical stop just before the apical foramen. It was this apical stop that allowed condensation of gutta percha without extrusion of the filling material. Research has shown that even using three file sizes larger than the first file that binds does not achieve full mechanical debridement of the apical region (Wu, et al., 2002). Therefore, removing apical dentin in the hope that it will disinfect the apical region only serves to weaken this region of the root. Through our continued use of gutta percha as a root canal filling material, the creation of an apical stop for our root filling to be condensed against remains an important feature of preparation. However, if the material we use to fill the canal is not gutta percha, as in the case of mineral trioxide aggregate (MTA), then the creation of this apical stop becomes less important. In a tooth with a very large apical foramen – due to immaturity or resorption (such as 0.6 mm size 60 and above) – I would elect not to instrument the canal and obturate apically with mineral trioxide aggregate rather than gutta percha (Figure 1). No preparation is done, as activation of the irrigants accomplishes more disinfection than removing dentin from an already wide apex. Mineral trioxide aggregate is chosen as it seals these aberrant defects far more effectively than a round cone of gutta percha and sealer (Figure 2). Endodontic practice 33

CONTINUING EDUCATION

Figure 3

Figure 4

Figure 5

The idea of this apical seal is to prevent exudate from the periapical tissues moving back up the root canal by capillary action and keeping any remaining proteolytic bacteria viable, as well as preventing bacterial endotoxins escaping from the canal into the apical tissues, to keep the inflammatory process going.

root canal treatments, there is no need for a wide taper or large apical preparation. Depending on the case, stainless steel hand files with a 2% taper may be all that is necessary. However, in necrotic cases with large periapical lesions, irrigating to the apical region becomes critical. Some investigators recommend the irrigation needle be placed 1 mm from the working length (Chow, 1983). But in reality, we can move the irrigant solutions to the apex by using sonic or ultrasonic activation, so having the irrigation needle this close to the apex may be unnecessary.

Conclusion

Principles of taper preparation The concept of taper was made possible by the introduction of nickel-titanium alloy root canal files. This alloy allowed the construction of files with wide tapers that maintained their flexibility and therefore the ability to negotiate the curves of a root canal (Figures 3, 4, and 5). Preparing root canals with a greater taper serves two purposes: it allows the irrigant solutions that are so important for disinfection to reach the apical regions, as well as allowing us a shape that is easy to obturate using gutta percha.

Factors to consider preparing a root canal

when

Pulp status An important factor to consider when preparing a root canal is to establish where the bacteria are likely to be situated. In acutely inflamed cases, the microorganisms are located in the coronal region of the root canal, and there are very few, if any, microorganisms in the apical region. In necrotic cases, we have to assume they are throughout the root canal system and in the apical ramifications. The way in which we prepare the canals of these two very different situations should also be different. In inflamed cases or elective 34 Endodontic practice

Anatomy of the root being treated Probably one of the most important factors to consider when preparing a root canal is the shape of the root being treated, because the preparation must be made within the confines of this anatomy. In narrow roots, using a wide taper or large apical size to prepare the canal can risk strip perforation or predispose the tooth to fracture in the future. In teeth with thin roots that have large periapical lesions (such as lower incisors), my preference is to prepare the canal using a file with a small apical size, but one that has a wide taper for the first few millimeters. This preserves dentin at the apex but creates a region where the irrigant solutions can reach the apex. If the anatomy does not permit the preparation to be made wide enough to allow irrigants to reach the apex, then activation of the irrigants and placement of an antibacterial medicament becomes a more important factor.

The subject of root canal preparation is one of the most misunderstood topics in modern endodontics. Root canal preparation should not only be seen as a means for removing bacterial biofilms and infected dentin, but more importantly as a way to create a shape to facilitate irrigation and obturation. Every canal is different and, as a result, not all canals have to be prepared in exactly the same way. The method in which a canal is prepared should consider such factors as the existing apical size and taper as well as the status of the pulp. But ultimately the preparation must be made within the confines of the anatomy. The preparation of a root canal should be seen as the path by which a successful outcome in endodontics is achieved. EP

References Bystrรถm A, Sundqvist G. Bacteriologic evaluation of the efficacy of mechanical root canal instrumentation in endodontic therapy. Scand J Dent Res. 1981;89(4):321-328. Bystrรถm A, Sundqvist G. Bacteriologic evaluation of the effect of 0.5 percent sodium hypochlorite in endodontic therapy. Oral Surg Oral Med Oral Pathol. 1983;55(3):307-312. Chow TW. Mechanical effectiveness of root canal irrigation. J Endod. 1983;9(11):475-479. Peters OA, Schรถnenberger K, Laib A. Effects of four Ni-Ti preparation techniques on root canal geometry assessed by micro computed tomography. Int Endod J. 2001;34(3):221-230. Wu MK, Barkis D, Roris A, Wesselink PR. Does the first file to bind correspond to the diameter of the canal in the apical region. Int Endod J. 2002;35(3):264-267.

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Root canal preparation: the path to success 1. In endodontics, a successful outcome is defined as __________, as well as radiographic healing or continued absence of periapical disease. a. lack of clinical signs and symptoms b. radiographic healing c. continued absence of periapical disease d. all of the above 2. A micro-computed tomographic study showed that even with rotary instruments ______ or more of the canal surface area remains free from instrumentation. a. 25% b. 35% c. 45% d. 55% 3. There have been many studies showing that irrigation with _______ is essential to being able to disinfect the root canal system. a. sodium hypochlorite b. hydrogen peroxide c. iodine d. chelating agents 4. A classic study showed that just using hand files to prepare root canals only removed all cultivable bacteria from ______ of the teeth.

Volume 6 Number 5

a. 20% b. 30% c. 50% d. 60% 5. Now that we have the ability to make tapered preparations quickly, we can allow the irrigant solutions to ______. a. enter the dentin b. reach the apical region c. soak the gutta percha d. replace the MTA 6. The aim of preparation should be to make the canal wide enough _______. a. to remove the apical region b. to allow irrigants to reach the apex c. to be easy to obturate d. both b and c 7. Research has shown that even using three file sizes ______than the first file that binds does not achieve full mechanical debridement of the apical region. a. smaller b. larger c. shorter d. longer

8. The concept of taper was made possible by the introduction of _______ root canal files. a. nickel-titanium alloy b. stainless steel c. non-tapered d. none of the above 9. Probably one of the most important factors to consider when preparing a root canal is the _____of the root being treated, because the preparation must be made within the confines of this anatomy. a. enamel thickness b. perforation c. cementum thickness d. shape 10. If the anatomy does not permit the preparation to be made wide enough to allow irrigants to reach the apex, then _________ becomes a more important factor. a. activation of the irrigants b. placement of an antibacterial medicament c. the brand of gutta percha d. both a and b

Endodontic practice 35

CE CREDITS

ENDODONTIC PRACTICE CE

ENDO ESSENTIALS

The big debate Drs. Michael Norton and Julian Webber discuss — implants or endodontics?

ndodontics or implants? It’s a question that’s been keeping dental philosophers occupied since Professor Brånemark discovered osseointegration – and it’s taken one step closer to being answered. The treatments went head to head as two of Harley Street’s (London, England) finest took to the stage to fight their corner. Dr. Michael Norton – pulling aside the veil on dental implants – faced off against Dr. Julian Webber, eloquently arguing in favor of endodontics. The topic for debate was “Implants versus endodontics: addressing a contemporary conundrum.” But anyone hoping the evening would descend into a free-for-all was set to be disappointed. Dr. Webber, presenting his lecture first, set the tone by declaring an early ceasefire. “It’s not a battle,” he said. “We’re on the same wavelength.” Dr. Norton was quick to agree, explaining how closely he has worked with Dr. Webber over the years – and acknowledging how “bizarre” it was that they were very good referrers to one another. He paid tribute to the positive effect that relationship has had on his own practice, adding: “I’ve had the good fortune to work with two great endodontists, and there is no question that doing so has refocused my approach to my own implant dentistry.”

Julian Webber, BDS, MS (Endo), DGDP, FICD, is the director of the Harley Street Centre for Endodontics, a state-of-the-art facility dedicated to endodontic excellence. He has been a practicing specialist in the West End of London, England for more than 30 years and was the first UK dentist to receive a Masters Degree in Endodontics from Northwestern University Dental School, a university in Chicago, Illinois. He is currently editor-in-chief of Endodontic Practice Journal and lectures widely on the subject. www.roottreatmentuk.com. Dr. Michael Norton, who was formally visiting professor at Marquette University Dental School in Milwaukee, Wisconsin has recently taken up a new faculty position as Adjunct Clinical Professor at the internationally renowned Ivy League University of Pennsylvania dental school (UPenn). Dr Norton will be working with colleagues in the Department of Periodontology on joint educational and research activities related to dental implant therapy and treatment of peri-implantitis.

36 Endodontic practice

Working in harmony Ignoring the enmity that has sprung up between adherents of each treatment in recent years, the pair sent out a very clear message: implants and endodontics can work in harmony to the benefit of patients. The entente cordiale continued as the evening wore on, treating the audience to an eloquent, reasoned – but still passionate – debate on how the two approaches fit together in modern dentistry. And if anything, the two clinicians were united against a common enemy, with traditional measures of success swiftly coming into the firing line. Dr. Webber said: “The problem with endodontics and implants is that if we’re going to compare the two treatment modalities, then we need to define our success criteria. It’s interesting, because the success criteria are very different between the two. For dental implant studies, success is measured in terms of survival. For endodontics, it’s measured in terms of ability to cure existing disease – and endodontic success studies measure both that and the occurrence of new disease.

where we – from both the endodontic and the implant side – find ourselves with something of a problem.” The quality of the scientific literature came under scrutiny from both speakers, who pointed to the pronounced imbalance between who performs the treatment. Most implant studies concentrate on work carried out by specialists or in hospital settings, they argued, while the majority of endodontic papers look at work by general practitioners or students. When dealing with a more level playing field – and excluding anything not of a higher caliber, as in Iqbal and Kim’s 2007 paper – the long-term results for both treatments are comparable. Quoting from Iqbal, Dr. Norton added: “The decision to treat a tooth endodontically or replace it with an implant must be based on factors other than treatment outcomes.”

Save first, replace last The ultimate factor, both speakers argued, was that every decision should be made with the best interest of patients in mind – but if a tooth can be saved, they should always be given the option. Dr. Norton said: “If I

...The pair sent out a very clear message: implants and endodontics can work in harmony to the benefit of patients. “So the success criteria are different. And that’s a problem: you can’t compare apples with oranges.”

Difficult reading Dr. Norton backed this up: “Historically, there’s been confusion in the implant literature, and a free exchange of the terms ‘survival’ and ‘success’ – and these are not the same thing.” And he agreed with Dr. Webber’s problem with the current literature on the debate, adding: “Currently, no guidelines are really set forth to help us make a decision about when to go one way, and when to go the other. And that’s

can save a tooth, even if it’s just in the short term, then I will. Implant treatment cannot be justified for a restorable tooth needing first time root canal treatment. Where the debate starts is with teeth requiring further treatment. Problems set in when teeth are endodontically mismanaged for too long. Failed endo cases are usually associated with longstanding chronic infection, which damages the bone and causes problems for implant treatment.” The criteria for establishing the suitability of a case for endodontic treatment do not have to be complicated, Dr. Webber added. He said: “In my view, Volume 6 Number 5

ENDO ESSENTIALS

Dr. Julian Webber

Dr. Michael Norton

Drs. Michael Norton and Julian Webber field questions at their lecture

endodontic therapy should be given priority in treatment planning for periodontally sound single teeth with pulpal and periradicular pathology that are restorable. And to me, that’s very simple. Implants should be given priority in treatment planning for teeth that are planned for extraction.” Dr. Webber was happy to explain his cut-off for referring patients for implant treatment. “It’s pretty simple,” he explained. ‘”If you can’t restore it, and it’s periodontally unsound – it’s time to go.”

When treatment fails Both clinicians agreed that trying to root treat a hopeless case was damaging, with the critical decision resting on when to “pull the plug.” “Endodontic treatment on a hopeless tooth is just as unethical as implant treatment on a tooth that could be restored,” said Dr. Webber. And Dr. Norton corroborated this, adding: “The problem with endodontics is that if it’s done badly, you scar that patient’s attitude towards endodontics forevermore. Perhaps dentists doing bad endodontics make it easier for patients to make the wrong decision about retreatment.” There is no mystery about why a lot of root canal treatment fails, Dr. Webber Volume 6 Number 5

explained. “Without doubt,” he said. “One of the biggest causes of failure in endodontics is lack of coronal seal.” And he warned: “If you’re going to embrace endodontics – if you want it to be successful – then you’ve got to embrace the technology as well. Modern endodontics is driven by the technology, but you’ve got to come out of the dark ages to see that.” Keeping up with technology is also a must when it comes to implant placement, said Dr. Norton. And complications are just as important to bear in mind when considering either treatment. He asked: “What about the potential for procedural complications? We all know that not every implant case is a slam dunk, either.” “If I see that the risks of extracting a tooth to replace it with an implant are possibly greater than the risks of keeping the tooth, then I will encourage the patient to give endodontics a try. What have we got to lose?” He concluded: “If it’s not a good implant candidate, it’s going to be a disaster. Implants are an expensive alternative to root canal treatment, so they need to be better in every way.”

Complementary closure Despite the very different makeup of

the speakers’ practices, there was only one message to the evening. Forget the competition, because endodontics and implants complement each other. That sentiment was even echoed by the sponsors for the evening, with Dentsply Implants and Dentsply jointly supporting the debate. Drs. Webber and Norton regularly refer patients to one another, and their cast-iron belief that this is the best possible way forward for patients was evident throughout. Dr. Norton closed his lecture by quoting from the AAE guidelines that both speakers referred to throughout their presentations. He said: “Endodontic and implant treatment are most predictable procedures when undertaken with complete care and attention to diagnosis, planning, and execution of treatment.” “The natural tooth is the ultimate implant,” Dr. Webber said, quoting endodontist Cliff Ruddle in his own closing remarks. “The question of when to save and when to replace comes down to the considerations for treatment planning. One of the main considerations is ethics. So before you answer it, first ask yourself this: what’s best for the patient?” EP Endodontic practice 37

LEGAL MATTERS

Harassment – crossing the professional line * Dr. Bruce H. Seidberg discusses the consequences and complications of harassment

exual misconduct, verbal abuse, physical abuse, hostile environment, stalking, menacing, cyberstalking, and electronic communication are all considered under the umbrella definition of harassment (Figure 1). They occur more frequently in the workplace than is actually known. Most sexual assaults are never reported to law enforcement, and even of those reported most are never successfully prosecuted unless there is sufficient evidence made available for the truly egregious allegations. This is a source of frustration for survivors, victim advocates, and members of the criminal justice system.1 However, hoping not to be caught is not a reason to cross the professional line. Quid-pro-quo harassment (employer using inducements to employee for sexual favors) and hostile environment harassment (providing an atmosphere of discriminatory conditions that interfere with the employees work) [Figure 2] are unlawful under Title VII of the Federal Civil Rights Act of 1964, according to the 1980 regulations of the Equal Employment Opportunity Commission. These types of allegations are more likely to be successfully prosecuted. In 2008, over 46,000 harassment complaints were filed with the EEOC resulting in monetary benefits of more than $122 million, making harassment claims, allegations, and lawsuits a popular area of compliance violations in employment law.2 The dental office is no different than a medical office or hospital setting. It is not immune. It is a viable venue conducive for harassment to occur. When harassment in a dental office is mentioned, one would think that sexual harassment is the most common. This is not true. Verbal

Bruce H. Seidberg, DDS, MScD, JD, is a practicing Endodontist in Liverpool, NY (suburb of Syracuse), Past President of the American College of Legal Medicine and of the Onondaga County Dental Society in New York State. He received his MScD in Endodontics from Boston University School of Graduate Dentistry. 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. He lectures about Risk Management issues in the dental office. He can be reached at bseidbergddsjd@me.com.

38 Endodontic practice

harassment is, in fact, the most common form. Physical harassment is the least. Both can be implied in various ways. Any type of harassment in the dental office is intolerable and taboo in any of its actual or suggestive forms. The harassing dentist is likely to jeopardize his/her license, develop a negative reputation, and the practice will adversely be affected. It is essential that the dentist-employer have a harassment policy that all employees understand. Conduct in an office or at any office function must remain respectful and professional. Harassment is usually defined as the conduct that is directional to a specific individual that would cause a reasonable person’s interpretation that there is a credible threat to a person’s safety or to that of his/her family. States define criminal harassment in different ways, but it is usually when the behavior of a harasser is meant to alarm, annoy, torment, or terrorize another. There are other legal theories and definitions between local, state, and federal laws (Figure 3). Included are the physical attributes of assault and battery. Civil harassment includes workplace discrimination and most acts of sexual, verbal, and physical abuse. It is all about perceptions and reactions. The charges can range from a Class 1 Misdemeanor to a Class 5 Felony, each of which can carry consequences of minimal fines, restraining orders, and loss of license to incarceration and being registered as sex offenders, or any other remedy available to the court. In a recent survey, 20% of dentists admitted dating dental patients. Dentists practicing in the urban area (35%) were more likely to be involved with harassment than those in suburban (13%) or rural (15%) practices; male (21%) involvement was more common than female (13%), and generalists (80%) slightly more involved than specialists (76%).3 Dentists face potential liability whenever any of the types of workplace violence occurs inside the office boundaries or at an office function, especially if they do not have a harassment policy in place. Verbal harassment can be any type

Harassment Classification Sexual Verbal Physical Stalking Menacing Cyberstalking Electronic Hostile Environment Figure 1: Classification of harassment charges

Hostile Environment Conditions Indecent Propositions Inappropriate Discussions of Sexual Activities Obscene or Discriminatory Jokes Displaying Sexually Suggestive or Racial Pictures Crude and Offensive Language Ethnic Slurs, Pranks, and Negative Stereotyping Figure 2: Characteristics of a hostile work environment

Legal Theories Applicable to Harassment Negligence Under State Law Sexual Harassment Under Federal Law Americans With Disabilities Act Violation Under Federal Law Criminal Harassment Under State Law Figure 3: Legal theories of harassment Volume 6 Number 5

type of harassment, it is not reported as frequently as sexual harassment for unknown reasons. Nevertheless, it occurs too frequently when there is a perceived conflict between employer and employee. Conflicts usually occur when a dentist feels superiority or is arrogant, and the employee resents the “talking down to attitude.” These are the stepping stones to a hostile workplace. Sexual harassment is a risk to employer dentists and their employees. While not a malpractice risk itself, failure to manage risk among employees can cause bad attitudes and irrational actions towards patients. Unwelcomed or unwanted sexual advances, requests for sexual favors, and other conduct of a sexual nature directed at an individual whose submission to or rejection of this conduct is used explicitly or implicitly as a fact in decisions affecting his/her hiring, evaluation, promotion, or other aspects of employment, has no place in the profession. Sexual harassment also encompasses conduct that substantially interferes with a person’s employment or

creates a hostile, intimidating, or offensive work environment. Sexual harassment can apply to same sex situations as well. The EEOC brought suit under Title VII of the FCRA of 1964 against Monarch Dental in the US District Court for the Northern District of Texas, Dallas Division (3:10-CV1903-K) alleging that the dentist subjected employees to a sexually hostile work environment.4 The allegations contended that the harassment of two female employees was subjected to include unwanted sexual comments, touching in a sexual manner, and making sexual comments about female patients. They settled for $175,000 for each employee, but the dental office was also reprimanded with remedies, and the dentist lost his job. It is never appropriate for a dentist to engage in a sexual relationship with a patient or an employee. Period! The ramifications of both can be devastating to the practice with regard to a doctor-patient relationship. The practice runs the risk of losing the patient and a referral source. In addition, the practice will be tarnished

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Volume 6 Number 5

Endodontic practice 39

LEGAL MATTERS

of inappropriate communication: one-toone, electronic, or telephonic. Typically there are lewd comments, off-color jokes, or comments about appearance or body parts. A staff person can feel verbally abused if disciplined or corrected in front of a patient with a harsh tone of voice. Verbal abuse is demeaning and embarrassing, especially in a public setting or in front of patients or other staff. If a dentist feels that a staff person is acting or talking inappropriately, the corrective session should be done in the privacy of an office. If a staff person is critiqued in front of a patient, the perception is that of a non-caring, non-compassionate, and non-professional dentist. Methods of communication between dentist and staff, dentist and patient, or staff and patient should always be at the highest level of compassion, sensitivity, and understanding, and in the appropriate setting. Discussions with staff should always be constructive and educational rather than destructive and confrontational. Although verbal abuse is the most common

LEGAL MATTERS when the allegations are made public. If the relationship is with an employee, there would be a loss of productivity. Pennsylvania recognized the danger, and in 2007 made a regulation that barred dentists from dating patients unless they were married or living together. The new law also stated “… sexual misconduct regulations will prohibit dentists, dental hygienists, and expanded function dental assistants from engaging in any sexual conduct with a current patient…This includes words, gestures, expressions, actions, or any combination thereof which are sexual in nature or which may be construed by a reasonable person as sexual in nature.”5 Violation of the regulation carries disciplinary action from the Pennsylvania State Board of Dentistry. Consent is not an accepted defense for sexual misconduct. NYSDA addressed this issue in a memo to members in 1995 and outlined some of the examples of sexual harassment (Figure 4)6. In California, sexual harassment must occur in the context of a relationship; it is illegal when there is a business, service, or professional relationship between the harasser and the victim, such as that of the doctor-patient or doctor-staff relationship. Harassment charges include, but are not limited to, those listed in Figure 4. State Boards in Iowa, Maine, Mississippi, and others have similarly addressed this issue. One of the most egregious cases reported in 2009 was that of a dentist from Woodland, California, who was charged with placing his bare hand underneath the bras of patients and touching their nipples, or touching breasts over clothing in 2007.7 He claimed that his massaging of chest muscles was treatment to help relieve TMD symptoms. He would make comments telling the patients that they had nice breasts, asked if they had implants and complimented any augmentations. Closing arguments raised the question if the massaging of woman’s breasts was for the doctor’s own sexual arousal or a legitimate process to help relieve pain from women suffering from jaw disorders. We know that fondling a breast does not relieve TMD. The dentist faced a potential prison sentence of 20 years from the allegations of 27 accusers for 19 felonies (felony assault: skin to skin contact) and one misdemeanor (touching over clothing). His license was revoked. He was married and had children. How devastating to them. Physical harassment can be in the form of assault and battery, when a reasonable 40 Endodontic practice

person fears that he/she will be threatened to be touched in an unwanted manner, or is actually restrained and touched. Dentists have been sued because of purposely or accidently touching a female patient’s breasts. It should be policy to have a staff person in the operatory at all times when treating any patient regardless of gender. A patient claiming a hostile work environment under Title VII of the Federal Civil Rights Act of 1964 has to show that he suffered from intentional discrimination because of being a member of a protective class (Figure 5), that it would have detrimentally affected a reasonable person in like circumstances. For employer liability to be present, there has to be evidence that there was harassment by the employer, supervisor, or co-worker that the employer failed to remedy.8 In Stone v Howard & Howard, DDS9, the claim included allegations that a former employee was forced to work in an office environment filled with references, materials, gestures, and discussions that included being forced to endure pornographic materials in print, magazine, and digital form, and was subjected to unwelcomed physical touching by the dentist who allegedly repeatedly placed his hands around her neck while making inappropriate sexual comments. Other notable harassment cases include, but are not limited to: the 2007 case of a Chicago dentist sued in EEOC et al., v. James L. Orrington D.M.D., Ltd., 07 C 5317. The EEOC alleged that James L. Orrington, D.M.D., Ltd. discriminated against 18 employees by subjecting them to sexual harassment, including sexual propositions, comments, and touching; forcing them to engage in Scientology religious practices, and learn about Scientology as conditions of their employment; and/or retaliating against employees who complained about the sexual or religious harassment. He ultimately settled for $425,000 and was ordered to receive corrective behavioral instruction.10 In Shiner v SUNY Buffalo11, a clerk for the dental school alleged that two administrators allegedly committed multiple acts of assault and made a series of sexually explicit and inappropriate comments at holiday parties in 2008 and 2009. The lawsuit was filed in the US District Court for the Western District of New York. A civil lawsuit was filed in federal court by two former female employees against

Examples of Sexual Harassment Allegations May Include

Inappropriate Touching

Making Sexual Advances

Pursuing After-Hour Relationship

Using Indirect Sexual Language

Making Sexual Requests

Making Demands for Sexual Compliance

Quid-Pro-Quo: Employer’s Benefits for Sexual Favors Demands for Sexual Favors for Favorable Employment

Repeated Sexual Jokes

Flirtations

Graphic Verbal Commentary about Individual’s Body

Leering, Pinching, Gestures

Sexually Suggestive Pictures or Objects in Office

Figure 4: Sexual harassment allegations applicable to all workplace situations; examples from California and New York State memorandums

Volume 6 Number 5

LEGAL MATTERS

Protected Classes for Discriminatory Actions

Race

Color

National Origin

Sexual Orientation

Sex Including Pregnancy or Related Conditions

Disability

Religion

Figure 5: Antidiscriminatory actions based on federal, state, and city/county laws

References 1. Campbell R, Patterson D, Bybee D. Prosecution of adult sexual assault cases. Violence Against Women. 2012;18(2):223-244. 2. Twigg T, Crane R. Harassment: avoiding the nightmare. Dental Economics. 2010;100(3). http:// www.dentaleconomics.com/articles/print/volume-100/ issue-3/columns/staff-issues/harassment-avoiding-thenightmare.html. Accessed August 2013. 3. DuMolin J, Frey J. The Wealthy Dentist. TWD Survey: Patient dating. http://thewealthydentist.com/ surveyresults/38_dentalpatientromance_results.htm. Accessed August 2013. 4. EEOC v David Mikitka, DDS. 3:10-CV-1903-K (ND Tex 2011).

Volume 6 Number 5

a pediatric dentist working at Children’s Dentistry in Wichita, Kansas,12 who was accused of watching pornography in front of sedated patients, engaging in sexually offensive and racially harassing behavior towards patients, keeping photos of naked women in his office, and having had sexual relationships with other female employees in the office. In summary, all offices must have a “no tolerance harassment policy” in place and understood by all employees. Always have an assistant in your operatories when treating patients regardless of the patient’s gender. Never scold, belittle, or raise a voice to an assistant, unless in the privacy of a private office and away from earshot of others, certainly never in front of a patient. Use common sense and offer constructive criticism in the appropriate manner and setting rather than destructive criticism.

5. Associated Press. Pa. dentists barred from dating patients. Pittsburgh Post Gazette. 2008. http://www. post-gazette.com/stories/local/breaking/pa-dentistsbarred-from-dating-patients-617546/. Accessed August 2013. 6. New York State Dental Association. Policy Statement: Sexual Harassment in the Professional Workplace. Albany, NY: New York State Dental Association; 1995. 7. Associated Press. Woodland Dentists Faces Sexual Harassment Charges. February 2009. 8. Ginsburg v Aria Health Physician Services, 2012 WL 3778110 (E.D.Pa.2012). 9. Asbury K. Stone v Howard & Howard, DDS; Kanawha Circuit Court, case no. 09-C-2103. West Virginia Legal Journal. Accessed August 5, 2013.

You can compliment your assistants and patients, but not with sexual innuendos. Any complaint should be fully investigated and appropriate corrective action taken. Any form of harassment will have a negative effect on the dental office and its personnel, attitudes, and work performance. It makes the office “stale” and eventually affects patients who can read into the unhappy office atmosphere. Avoid harassment charges by learning to communicate with compassion, constructively, having a harassment policy in place, and always have a third party (assistant) in the operatory. Think about your actions and relations before you act. *Summarized from Risk Management Lectures, session on Harassment, presented by the author. EP

10. Dentist settles sex harassment lawsuit [press release]. US Equal Employment Opportunity Commission; January 13 2009. http://www. stephenslawfirm.com/index.php/155. 11. Shiner v State University of New York (W.D.N.Y. 2013); Resnick Law Group. Holiday party results in sexual harassment lawsuit. http:// thenjemploymentlawfirmblog.com/2013/01/holidayparty-results-in-sexua.html. Accessed September 16, 2013. 12. Tarr J. Wichita Dentist Facing Sexual Harassment, Discrimination Lawsuit. Kake.com. August, 2012. http://www.kake.com/home/headlines/WichitaDentist-Facing-Sexual-Harassment-DiscriminationLawsuit-165184386.html; Potter T. Lawsuit: Wichita dentist watched porn in front of sedated child patients. The Wichita Eagle. August, 2012. http://www.kansas. com/2012/08/06/2437944/lawsuit-wichita-dentistwatched.html.

Endodontic practice 41

PRODUCT PROFILE

PROTAPER NEXT™ delivers performance refined ProTaper® Universal rotary files are valued for their progressive taper design and system-based efficiency. DENTSPLY Tulsa Dental Specialties recently introduced the next generation of the ProTaper family of files. PROTAPER NEXT creates the same progressively tapered canals, while featuring several design refinements to enhance performance.

Rectangular cross section ProTaper Universal files feature a convex triangular cross section that creates a balanced, symmetrical rotary motion as the file progresses down the canal. Its triangular shape means the file continually touches the canal walls at three points as it rotates. PROTAPER NEXT files retain the familiar progressive taper, but feature instead an off-centered, rectangular cross section. Because the patented design’s axis of rotation differs from the center of mass, only two points of the cross section touch the canal wall at any time. The result of this advanced design is greater strength for the file.

Unique asymmetric rotary (AR) motion In addition to increasing file strength, PROTAPER NEXT’s rectangular cross section impacts how the file moves down the canal. This unique AR motion enables clinicians to achieve a fully tapered canal with fewer files for greater procedural efficiency.1 This distinction is reflected in the PROTAPER NEXT technique, which requires fewer files than ProTaper Universal.

Shorter handles As an added advantage, PROTAPER NEXT features handles that are 2 mm shorter than its predecessor files. These 11 mm handles allow improved access.

Presterilized for single-patient use PROTAPER NEXT continues to offer system-based efficiency with corresponding absorbent points, guttapercha points, and obturators designed to match the variable tapered shapes created by the files. Consistent with today’s best practices, the files are also designed for single-patient use. PROTAPER NEXT files arrive presterilized in blister packs and ready to use.

The next evolution of ProTaper performance Many clinicians have relied on ProTaper Universal files throughout their careers, and these files continue to be available. As the next evolution of the world’s leading file system, PROTAPER NEXT files bring a new dimension to the ProTaper offering with their increased strength and flexibility. Visit www.TulsaDentalSpecialties.com for more information, including videos on PROTAPER NEXT’s unique AR motion, technique videos, or to request an in-office demo. EP This information was provided DENTSPLY Tulsa Dental Specialties.

M-Wire® NiTi alloy

Unlike ProTaper Universal’s convex triangular cross section, PROTAPER NEXT (right) features a patented rectangular cross section and asymmetric motion. 42 Endodontic practice

As a leader in endodontic instrument design and alloy technology, DENTSPLY Tulsa Dental Specialties introduced the first nickeltitanium (NiTi) rotary file to endodontics in 1994. The company developed a special NiTi alloy in 2007 known as M-Wire nickel-titanium. PROTAPER NEXT files are made with this patented M-Wire NiTi, which is proven to provide greater flexibility than traditional NiTi. This characteristic is especially apparent and advantageous when navigating challenging, curved canals. M-Wire NiTi also provides greater resistance to cyclic fatigue, which is the leading cause of file separation.2

PROTAPER NEXT creates the same progressively tapered canals, while featuring several design refinements to enhance performance.

References 1. Internal testing. Data on file. 2. Shen Y, Cheung GS, Bian Z, Peng B. Comparison of defects in ProFile and ProTaper systems after clinical use. J Endod. 2006;32(1):61-65.

Volume 6 Number 5

h t s I

s e s

d n n a o i t ls a a ig n r r a I C e l al d r e e e t La n N e ha t T a

r er t e tt n e e B P

Ultrasonic Irrigator • Distributes and ultrasonically activates sodium hypochlorite to increase debridement of lateral canals and isthmuses • Ratcheting syringe permits controlled delivery of 0.2 ml of solution with each audible click Benefits of Continuous Ultrasonic Irrigation: • Removes significantly more debris from narrow isthmuses better than conventional needle irrigation* • Significantly increases the penetration of irrigation solutions into lateral canals** *Adcock et al, J.Endod. 2011; 37 (4) **Castelo-Baz et al, J. Endod. 2012; 38 (5)

235 Ascot Parkway | Cuyahoga Falls, OH 44223 Tel. USA & Canada 800.221.3046 | 330.916.8800 | coltene.com PATENT PENDING

PRODUCT PROFILE

The all new ScanX Swift™ Digital imaging without limits

s a leading innovator and manufacturer of dental equipment, Air Techniques introduces the ScanX Swift, a chairside digital system that can generate digital X-ray images in as little as 9 seconds. Once connected to a computer, just take the X-ray and place the phosphor sensor into the Swift, and the image is then displayed on the screen. The quick 9 seconds of digital developing does not disrupt treatment continuity. Besides helping to streamline workflow, ScanX Swift’s flexible phosphor sensors are designed to provide a large image area and exceptionally clear X-rays that reduce the need for retakes, while boosting dentists’ diagnostic capabilities. Swift’s phosphor sensors are available in sizes 0, 1, and 2; the system’s cordless phosphor sensors eliminate the bulk associated with hard digital sensors. Swift offers the ultimate in patient comfort — phosphor sensors, which are 30 times thinner than rigid sensors, enable easy placement, and help increase access to posterior regions of the oral cavity. Swift is a complete dentistry solution with digital images that easily integrate with the dentists’ existing software for maximum patient management efficiency. If you’re looking to upgrade your system software, Air Techniques’ Visix imaging software is both efficient and user-friendly. ScanX Swift’s digital X-ray workflow makes it easy for dentists to present cases to their patients, increases case acceptance, facilitates recordkeeping, and speeds up insurance reimbursement. The scanning unit’s small footprint readily fits on operatory countertops. Thanks to a workflow that’s virtually identical to filmbased radiography, dentists who switch to the Swift system can use the same familiar techniques while generating crisp digital images in a fraction of the time — and without costly chemicals. Less expensive than rigid digital sensors and more comfortable for patients, thin, flexible, and durable ScanX Swift phosphor sensors can be reused hundreds of times. They won’t break or get damaged when dropped and still require the same lower radiation as hard sensors. 44 Endodontic practice

Featuring fast scanning and a familiar, filmlike workflow, Air Techniques’ new system expedites imaging procedures, while providing high-contrast digital X-rays that help improve both clinical efficiency and diagnostic utility.

For more information, visit: http:// www.airtechniques.com. EP This information was provided by Air Techniques.

Volume 6 Number 5

Your Imaging Future Starts Today Continuing Innovation | Dependable Performance | Comprehensive Solutions

Continuing Innovation Intuitive user interface with SmartLogic™ stores the most frequently used settings for optimized workflow.

Dependable Performance EasyPosition™ system allows for reproducible patient positioning and consistent imaging results.

Comprehensive Solutions

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With a voxel size as small as .085mm, the all-new SRT™ reduces artifacts from metal and radio-opaque objects such as endodontic files to provide clear, high-resolution images. Scan without SRT

Scan with SRT

PRACTICE DEVELOPMENT

Apply current tax laws to improve patient care Bob Creamer explains Section 179 and Bonus Depreciation

hriving dental practices understand that patients are the lifeblood of the dental practice. Indeed, without patients, a dental practice does not exist. Success is therefore determined by the quality of patient care provided and the overall patient experience. In the last decade, we have seen many important and amazing advancements in dental equipment that have assisted dentists in the delivery of ultimate patient care. One of the newest, but well-proven advancements is with 3D CBCT technologies. Investing in equipment and technology upgrades can provide a number of benefits for your practice – a competitive advantage, expanded services, improved efficiency, and overall patient comfort. These advantages can certainly make a difference to your bottom line, especially when you incorporate significant tax incentives for investing in your practice and yourself. In recent years, we have enjoyed a series of tax laws enabling dentists to take accelerated tax deductions when purchasing equipment and technology. A couple of tax code provisions that have been very beneficial to dentists are known as Section 179 and Bonus Depreciation. Both provisions allow for accelerated deductions even when purchases are financed. These laws are so advantageous that I am often asked, “Should I purchase some new equipment this year to help reduce taxes?” I trust their true objective in upgrading their practice is not to simply create a tax deduction, but rather to provide better services and improved care. Patients recognize and appreciate the dentist who makes patient care the focal point of the practice. During the recent

Bob Creamer, CPA, is president of the accounting firm Creamer & Associates, PC, specializing in financial and retirement planning, dental transitions, practice enhancement, wealth creation, tax savings and related services. He is also a founding member of the Academy of Dental CPAs. Bob can be reached at 800-248-1120 or Bob@bestcpas.com.

46 Endodontic practice

struggles in our country’s economy, I witnessed that dentists who invested in their practices to improve the quality of care they provided, attracted a loyal patient following and a market share that continued to increase even while others struggled. It is with these practices that patients were willing to spend their precious dental dollars. However, investing in the practice provides a reward for dentists far beyond income and tax deductions – the peace of mind of knowing that they are delivering the highest level of patient care possible.

Section 179 and Bonus Depreciation Section 179 of the IRS Tax Code was introduced as a way to stimulate the economy by allowing business owners to deduct the full cost of a qualified asset in the year it is acquired, rather than spreading deductions over the normal depreciable life or many years. During its early years, Section 179 allowed a maximum accelerated tax deduction of $10,000 to $24,000. This amount has varied as needed to spur

Volume 6 Number 5

economic growth, and was increased to a very generous $500,000 maximum deduction in 2010 and 2011. That amount dropped to a $139,000 deduction for 2012, but was retroactively raised after the first of this year back to $500,000 for tax calculation purposes for 2012. Additionally, the maximum deduction for Section 179 for 2013 was originally set at $25,000. However, during Congressional wrangling early in the year to address the ominous “fiscal cliff” predictions, Congress adjusted the law to again allow a maximum Section 179 deduction in the amount of $500,000, with a spending cap of $2,000,000 before phase-outs begin. Looking ahead, the law as currently written (as of the writing of this article) has deduction limits scheduled to drop all the way down to $25,000 for 2014, unless Congress acts to change the law and keep the deduction limit elevated. Therefore, there may be a drastic reduction in deduction limits for those who wait until next year to make their purchases. Section 179 provides tax incentives for purchasing both new and used equipment and technology. The complementary

Bonus Depreciation provides incentives for new purchases only. For new equipment and technology purchases in 2013, a dentist can take a 50% Bonus Depreciation deduction on all purchases without purchase limitation. While Section 179 has a $2,000,000 cap with a dollar phase-out for every dollar spent over the cap, Bonus Depreciation has no spending cap. Unlike Section 179, which is scheduled to simply be reduced, Bonus Depreciation is currently scheduled to end on January 1, 2014. Today’s tax laws allowing accelerated deductions have led many dentists to rightfully consider them as a key aspect of their yearly tax and financial planning. As the tax rates continue to increase, there is greater incentive to invest in yourself and your practice. In addition to tax laws that make practice investments attractive and accessible, historically low interest rates on equipment loans have made it easier to incorporate practice upgrades that may have seemed out of reach just a few years ago. While today’s accelerated tax

deductions can be highly advantageous from a business perspective, they are not permanent as I have already illustrated. When considering the forthcoming expiration or reduced deduction laws, and the recent significant tax rates increases for those making $250,000 or more, it certainly makes sense to invest in equipment and technology where needed. When you couple this with low interest rates, which may soon be on the rise, there seems to be a window of opportunity for dentists to make their purchases during 2013. I strongly advise my doctors to invest in their practices and purchase equipment and technology, provided it’s for the right reasons. After all, it is not tax rates, accelerated tax deductions, or even low interest rates that determine whether or not you need to invest in your practice, it’s the need to continually take extraordinary care of your patients. So if you need to invest to deliver the care you desire, why wouldn’t you take advantage of Section 179 and Bonus Depreciation to help you accomplish your professional goals? It only makes great sense! EP

Volume 6 Number 5 Endodontic practice 47

PRACTICE DEVELOPMENT

Patients recognize and appreciate the dentist who makes patient care the focal point of the practice. During the recent struggles in our country’s economy, I witnessed that dentists who invested in their practices to improve the quality of care they provided, attracted a loyal patient following and a market share that continued to increase even while others struggled. It is with these practices that patients were willing to spend their precious dental dollars. However, investing in the practice provides a reward for dentists far beyond income and tax deductions – the peace of mind of knowing that they are delivering the highest level of patient care possible.

PRACTICE MANAGEMENT

Growing the money tree William H. Black, Jr. discusses the financial advantages of having a good plan in place

our practice is established. You have a good reputation and a good management team in place. Gone are the days of building the practice and putting all profit back toward growth. That’s the good part! But success creates other questions and concerns. When clients first come to us they typically have the same refrain: “I am paying salaries, sick pay, vacation pay, major medical, matching Social Security and Medicare, paying into unemployment and Workman’s Comp. I have to pay a lot of money in income taxes…How do I keep more of what I make? No one has any solutions for me!” What I’ve found clients really mean is they want an idea that is not “outside the box,” that won’t increase their audit profile, an idea that won’t get them in trouble with Internal Revenue. The simple answer is to consider a custom-designed qualified plan! In other words, consider a form of a pension plan (known as “qualified” because the contribution qualifies for an income tax deduction). Think about it this way: there is not a company on the New York Stock Exchange, a union, or government agency that doesn’t have a pension plan. So using the rules that are on the books to create a custom-designed plan for the closely held professional practice may be the answer.

• Plan assets grow tax deferred • Plan assets are protected from judgment creditor claims1 • Plan assets are eligible for tax-free rollover to one’s IRA account • Qualified plans receive up-front approval from Internal Revenue in the form of a Favorable Determination Letter Let me clear up a few myths straightaway. These plans are not about retirement; they are about the tax benefits and asset accumulation features, i.e., your money tree. Who’s worried about retirement? It’s the employees putting $25 a week into their 401(k) plan. More power to those employees, but we, as business owners, are past that. Look at a plan as a way to pay yourself on a tax-favored basis! Here is how to look at the merits. Assume a 39% federal income tax rate and assume a 6% state income tax rate. So, for brevity, we will assume an overall tax rate of 45%. Since there is no requirement to have a plan, what does it look like without one? For every $10,000 in taxable income, what does it look like with a plan or without one? (We use $10,000 in this analysis because it is scalable. Want to know what $50,000 would do? Multiply by 5. $75,000? Multiply by 7.5, etc.) Here is where it gets interesting. On one hand you have $10,000 working for

Consider the benefits: • Contributions are income tax deductible

William H. Black, Jr. has been in the pension administration business for 34 years. The firm Pension Services, Inc. administers both defined contribution and defined benefit plans, employs an ERISA attorney, an Enrolled Actuary, and complete clerical staff. Mr. Black is qualified to give continuing education to CPAs in 47 different states. He has spoken nationally and internationally on retirement plans, has been quoted in USA Today, written articles for several industry journals and has appeared on many financial radio shows discussing the topic of retirement and financial matters. He may be contacted at bill@pensionsite.org.

48 Endodontic practice

you; on the other, you have $5,500. The tax benefits alone give you 81% more (10,000 ÷ 5,500) right out of the gate. Now, consider the plan’s assets grow tax deferred while the non-plan grows taxably. Add it all together, and you can see the benefits growing with every passing year! Many believe, initially, that the plan will cause all employees to come in, with contributions for all, and any employee is entitled to take his/her contribution out immediately. While plans like that do exist, they are not well designed or well thought out. ERISA, the Employee Retirement Income Security Act of 1974, gives us 39 years of instruction on how to design a plan. In other words, these plans are black and white, really no gray area. Now the question becomes how to design a plan to benefit the rainmaker? That is the easy part! Many different options exist, hence the need for customization. Many “cookie cutter” plans are out there, a one-size-fitsall approach. These are commonly referred to as “bundled” plans. While those plan designs have their place, they cannot be all things to all people. What to do? Start with a checklist of basic questions. What is the annual budget for the contribution? How is the business set up, as a Corporation either

Without a Plan

With a Plan

Taxable Income

$10,000

Tax at 45%

$4,500

After-tax Balance

$5,500

$10,000

Comments on graph: • No tax on the “with a plan” column as the contribution is income tax deductible. • After-tax balance is as of the present day. In the future, monies coming out of an IRA or qualified plan are subject to ordinary income taxes. • The chart does not take into account asset protection benefits. • This is scalable. Considering a $50,000 contribution? The values are five times as much, etc.

Volume 6 Number 5

us they typically have the same refrain: “I am paying salaries, sick pay, vacation pay, major medical, matching Social Security and Medicare, paying into unemployment and Workman’s Comp. I have to pay a lot of money in income taxes…How do I keep more of what I make?

S or C, as an LLC, LLP, PA, Partnership, or Sole Proprietor? How many employees? Are there existing plans in place now? How is the ownership structured, all in the hands of one person, or two or more? With the above, and an employee census, i.e., employee names, dates of birth and dates of hire, job titles and annual salaries, a projection can be created that will show, in black and white, what the benefits and detriments are. Look at it in conjunction with your CPA and make a

business decision on what is right for your situation. EP This discussion is not intended as tax advice. The determination of how the tax laws affect a taxpayer is dependent on the taxpayer’s particular situation. A taxpayer may be affected by exceptions to the general rules and by other laws not discussed here. Taxpayers are encouraged to seek help from a competent tax professional for advice

about the proper application of the laws to their situation.

References 1. Patterson v. Schumate (http:// financial-dictionary.thefreedictionary.com/ Patterson+v.+Shumate)

Volume 6 Number 5 Endodontic practice 49

PRACTICE MANAGEMENT

When clients first come to

ENDOSPECTIVE

One clinician’s means of obtaining patency and preparing the glide path Dr. Rich Mounce discusses a method for obtaining patency and preparing the glide path with hand files

sing hand files correctly to negotiate canals and prepare a glide path is often the difference between an excellent clinical result and one less so. Intelligent hand file use allows the clinician to fully appreciate canal anatomy and guide subsequent treatment. For example, learning canal curvature, length, and calcification through proper hand file exploration, the clinician can decide to subsequently use a crown down or a step-back approach, reciprocated nickel-titanium methods, or a hybrid of these. Intimate canal knowledge via tactile feedback gained from hand files is also the first and most important step in reducing iatrogenic misadventure. This column was written to discuss one method (among many valid clinical approaches) for obtaining patency and preparing the glide path with hand files to provide the benefits above. Obtaining patency is dependent on correct orifice management. Optimal tactile and visual control of the orifice requires straightline access and includes removal of the cervical dentinal triangle and eliminating restrictive coronal third dentin. This action provides unrestricted hand file access to the point of first canal curvature — the hand file reaches the first canal curvature without deflecting off canal walls. Benefits of straightline access and early restrictive dentin removal in the coronal third include less canal blockage and transportation, greater tactile control, and easier apical negotiation. Once straightline access is prepared, and the cervical dentinal triangle removed, pre-curved stainless steel hand files (in this approach utilizing Mani® K files and D Finders) are inserted to begin negotiation. Given the resistance to apical hand file

Rich Mounce, DDS, is in full-time endodontic practice in Rapid City, South Dakota. He has lectured and written globally in the specialty. He owns MounceEndo, LLC, marketing the rotary nickel-titanium MounceFile in Controlled Memory© and Standard NiTi. He can be reached at RichardMounce@MounceEndo.com, MounceEndo.com. Twitter: @MounceEndo

50 Endodontic practice

advancement, the clinician can determine if the canal is easily negotiable, how much pressure is needed to advance, what hand file size, length and type are needed, and what canal curvature is present based on the shape of the stainless steel hand file that emerges upon removal. In essence, the tactile feedback received during initial hand file insertion tells the clinician what steps are required to negotiate the canal. For example, to use a longer or shorter hand file, a larger or smaller one, a stiffer or more flexible file, etc. In my hands, the first hand file used to negotiate most canal is either a pre-curved stainless steel Mani D Finder Nos. 8, 10, 12, 15, or a Mani hand K file Nos. 6, 8, 10, 12, or 15. The hand file type, tip size, and length are dependent on the degree of curvature, calcification, and length of the canal. The smaller and more complex the

Using hand files correctly to negotiate canals and prepare a glide path is often the difference between an excellent clinical result and one less so. curvature, the smaller the hand file used in initial negotiation. The less complex the canal, the larger the first file used. Mani D Finders are designed for negotiation of calcified canals. They allow more vertical pressure to be placed upon them than K files without deformation. If the clinician has estimated a preoperative working length from the initial radiograph, once this length is reached, the electronic (true) working length should be determined. Often, a tactile “pop” of the hand file can be felt as the minor constriction of the apical foramen is reached. Optimally, irrigation should follow every hand file insertion, and all hand file work takes place in the presence of irrigation and lubrication. Clinically, once the electronic working length is determined, if the first file that reaches the MC is tightly bound, the

canal can be enlarged manually, or the file reciprocated with the W&H WA 62A reciprocating hand piece attachment. The W&H WA 62A attachment fits on an endodontic motor with an E type coupling. Reciprocation of hand K files and NT Mani Flare Files is safe, effective, and easily accomplished. Reciprocation reduces hand fatigue and is efficient relative to hand filing. Clinically, if the first file is tightly bound at the MC, once reciprocated adequately, it should spin freely at the MC. The next larger file is then reciprocated, etc. Sequentially, once the canal is enlarged to a minimum size No. 15 Mani hand K file, .05 tapered nickel-titanium (NT) Mani Flare Nos.15 and 20 files can be used as needed to complete the glide path. Mani NT Flare files can be safely reciprocated. Such a glide path provides an optimal platform for subsequent rotary nickel-titanium canal enlargement. After preparing the glide path, while many methods are available for bulk canal shaping, one deserves a special mention in the context of canal negotiation, glide path creation, and canal preparation, the versatile .08/25 MounceFile (MF) CM instrument. It acts as both an orifice opener and canal shaper. The MF .08/25 CM can reach the apex of many canals without the use of additional rotary instruments. In essence, this instrument often connects orifice enlargement and canal shaping (after the glide path is prepared) without involving complex sequences of additional instruments, in part because of the benefits of CM technology. CM technology allows the file to remain curved as it rotates through the canal, instead of exhibiting shape memory as other nickel-titanium instruments do — an action that both reduces fracture risk and transportation, and improves cutting ability. In the near future, a new reciprocating NT system will be introduced, the MounceFile “RStar” instruments, which can be used alone or in combination with MounceFile CM instruments to enlarge canals once the glide path has been prepared. I welcome your feedback. EP Volume 6 Number 5

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ANATOMY MATTERS

“Could it all simply be a coincidence?” Part 8 Dr. John West considers the mysteries of endodontic success or failure Introduction It is fascinating to me that after seven “Anatomy Matters” articles in Endodontic Practice US about the incidence and examples of underfilled endodontic portals of exit in endodontic failure that no one has written a challenge to my case reports. After all, these have not been randomized controlled studies that I have submitted. They are case reports of my patients of record. They could have been called anecdotal, bias, tunnel vision, or even self-serving. Indeed, there is a contrarian and adamant thinking in the endodontic literature that sterilization of the root canal system is currently technically impossible, and therefore, there are certain patients who simply will not heal. It has been further suggested over the years, and even currently, that some patients’ root canal treatments are considered “mysterious failures.” I will tell you that I would be the first to say that it is impossible to achieve endodontic success every time. But how close can we get, and to what degree do we influence our getting there? We cannot control all the variables; the least of which are the host and host resistance to bacteria. The other control and the biggest variable of all is the clinician. How thorough are we? Do we control our practice size? In other words, do we only START the number of endodontic treatments that we can FINISH well? Or do we attempt to FINISH everything that we START. If our practice style is the latter, then the entire Anatomy

Matters conversation and examples are of little interest or significance. These are columns that have been designed to ask a different question: Not “What is good enough?” but rather “What is possible?” After being a clinician and an endodontic educator for over 35 years, I have been humbled a few times…quite a few times. However, my humbling has not been failure of the biology but failure of my capacity to treat the biology. Or maybe it has been a failure from time to time to be willing to treat the biology…to slow down even more…to schedule another session where there are no adjacent patients, and we have a fresh start. If there were several

Figures 1A-1F: Staightforward case. Nothing special, just predictable healing

Figure 1A: Pretreatment mandibular right molar with apparent LEO

Figure 1B: Clinical of buccal sinus tract. Gingival crevice probes within normal limits

Figure 1C: Radiographic image of gutta-percha cone tracing sinus tract

Figure 1D: Perpendicular pack image demonstrating four canals and multiple POEs filled

Figure 1E: Oblique image of Figure 1D

Figure 1F: Clinical image of healed sinus tract at 6-month posttreatment. Patient scheduled for cuspal coverage

John West, DDS, MSD, the founder and director of the Center for Endodontics, continues to be recognized as one of the premier educators in clinical and interdisciplinary endodontics. Dr. West received his DDS from the University of Washington in 1971 where he is an affiliate associate professor. He then received his MSD in endodontics at Boston University Henry M. Goldman School of Dental Medicine in 1975 where he is a clinical instructor and has been awarded the Distinguished Alumni Award. Dr. West has presented more than 400 days of continuing education in North America, South America, and Europe while maintaining a private practice in Tacoma, Washington. He co-authored “Obturation of the Radicular Space” with Dr. John Ingle in Ingle’s 1994 and 2002 editions of Endodontics and was senior author of “Cleaning and Shaping the Root Canal System” in Cohen and Burns 1994 and 1998 Pathways of the Pulp. He has authored “Endodontic Predictability” in Dr. Michael Cohen’s 2008 Quintessence text Interdisciplinary Treatment Planning: Principles, Design, Implementation, as well as Dr. Michael Cohen’s soon to be published Quintessence text Interdisciplinary Treatment Planning Volume II: Comprehensive Case Studies. Dr. West’s memberships include: 2009 president and fellow of the American Academy of Esthetic Dentistry, and 2010 president of the Academy of Microscope Enhanced Dentistry, the Northwest Network for Dental Excellence, and the International College of Dentists. He is a 2010 consultant for the ADA’s prestigious ADA Board of Trustees where he serves as a consultant to the ADA Council on Dental Practice. Dr. West further serves on the Henry M. Goldman School of Dental Medicine’s Boston University Alumni Board. He is a Thought Leader for Kodak Digital Dental Systems, and serves on the editorial advisory boards for: The Journal of Esthetic and Restorative Dentistry, Practical Procedures and Aesthetic Dentistry, and The Journal of Microscope Enhanced Dentistry. Visit www.centerforendodontics.com, or email: johnwest@centerforendodontics.com, phone 1-800-900-7668 (ROOT), fax 253-473-6328.

52 Endodontic practice

canals, maybe I could finish the ones I can, and by later “dividing and conquering,” I could focus on a single canal for as long as it took. Someday within the next 15 years, approximately, research suggests that we will be able to grow a biomimetic and/or biological tooth that is structural, functional, and esthetically successful. At some point, we probably all have a time where we give up. What Anatomy Matters is all about is to stretch that point to a level that perhaps we did not think possible. Then we have created a new standard for ourselves. I made up a quote some time ago that goes like this: “If it’s been done before, it’s probably possible.” If we have

done it before, then we know it is possible. Following are four examples of patients where, once again, it cannot be proven that the anatomy matters or that it mattered in order to heal. Without a control, it may simply be an observation. You be the judge. Patient No. 1: “Straightforward case. Nothing special. Just predictable healing.” (Figures 1A-1F) This patient presented with a buccal sinus tract, a nonvital pulp, and a gingival crevice that probed within normal limits. The diagnosis was lesion of endodontic origin Volume 6 Number 5

Patient No. 2: “Good enough, or what’s possible?” (Figures 2A-2D) This patient is referred with slight palpation tenderness buccal to mesiobuccal root of maxillary right first molar. What would you do? Try this scenario: what if the crown were the third attempt at matching this patient’s high smile-line esthetics, what if the post were bonded, and what if the patient were a top Microsoft executive and wants the most efficient, noninvasive, most predictable treatment? What if the referring dentist told you that there is minimal ferrule, and that is why the post was chosen to help hold the foundation, and the dentist was concerned that a nonsurgical retreatment would cause micromovement in the crown that could later cause microleakage? Also, what if the dentist did not want you to risk reducing any of the marginal ferrule in a new access? Most of us would think twice about nonsurgical retreatment, especially if the endodontics were 20 years old. Maybe the palatal and distobuccal have demonstrated that they will be successful for another 20 years, and all you have to do is surgically bevel, prep, and seal the MB underfilled system. But what about the unfilled second MB canal that is suggested by the MBD radiographic rule Volume 6 Number 5

Figures 2A-D: Good enough or what’s possible?

Figure 2A: Pretreatment image of maxillary right first molar. MB area is palpation tender with no swelling

Figure 2B: Posttreatment image demonstrating two MB canals sealed, correction of internal palatal transportation, and several DB portals of exit discovered on packing

Figure 2C: Oblique posttreatment image of Figure 2B

Figure 2D: Three-month nonsurgical retreatment posttreatment. Patient is asymptomatic, and lamina dura and periodontal ligament are beginning radiographic repair. Next 6-month post care visit scheduled to validate complete healing

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Endodontic practice 53

ANATOMY MATTERS

and nonsurgical endodontics treatment planned. The sinus tract closed 3 days after access and cleaning. After packing, I count four canals and eight POEs filled. Please be aware that I am exceedingly liberal about the number of foramina that I count and consider visibly sealed, but I do have a fair amount of experience reading endodontic images relative to interpreting actual ToothAtlas.com teeth during studies identifying optimal cleaning solutions and protocol. The sinus tract and LEO continue healing at 6-month posttreatment. I am thinking right now that most of the clinicians reading this article would agree the shapes are appropriate in design and size for the root that surrounds them. But what is intriguing to me is how important does each of you think the perpendicular pack film looks? Honestly, I suspect I could have cemented four single cones without any compaction and gotten the same clinical and radiographic result. But what might have happened a decade from now? I am not so sure. At some point, we have done enough. We just never know where that point is, and so my premise of Anatomy Matters stands: do all you can, and then plan on doing it even better in your future.2-8

ANATOMY MATTERS and verified with a CBCT image? What if the crown was loose, or caries and new crown were planned? What if you knew the post was cemented with zinc phosphate cement? Most of you would treatment plan a nonsurgical retreatment. The biologic, structural, and esthetic options must always be weighed and have to be patient appropriate. Then the option with the most treatment value should be offered to the patient, and let him/her make an informed decision along with your coaching. Of course, you should always privately and publically tell the patient WWIDIIWM (What would I do if it were me?). Herein is always the proper answer. And so, while the crown was not loose in this particular patient, I did review the pluses and minuses of nonsurgical versus surgical. I also allowed the patient the options of treating the MB system alone or removing the post if I could and retreating the entire root canal system. The patient chose to have me retreat the entire tooth, and I was content with that choice, though I could have supported him choosing just the MB system or surgery. I think the patient made the best option with the greatest value. Who knows what anatomy will have been significant? And who knows how long this patient will live? Sometimes we forget time as a major consideration. It has been suggested by scientists, doctors, and futurists that the first person to live to be 150 years old is alive today. Meanwhile, a mesiopalatal canal was discovered, we corrected the internally transported MB, DB, and palatal canals, and restored the access. Time will tell, but I am betting on this one. Patient No. 3: “Which POE don’t you want?” (Figures 3A-3F) This patient was referred for surgical retreatment of maxillary right second molar. The tooth has been endodontically attempted 3 months previously and had been percussion sensitive since then. The dentist reported that she could not “negotiate” any deeper. What would you do? Sometimes you can make a dentist “look better” by doing treatment that appears to be an extension or an additional treatment. But what is needed here, of course and for a variety of reasons, is simple and thorough nonsurgical retreatment.

54 Endodontic practice

Figures 3A-3F: Which POE don’t you want?

Figure 3A: Pretreatment image of maxillary right second molar. Endodontics was attempted 3 months earlier, and the tooth has been percussion sensitive ever since. The dentist said he could not “negotiate” any deeper and referred the patient for surgical retreatment

Figure 3B: Downpack image

Figure 3D: Perpendicular posttreatment image

Figure 3C: Oblique downpack image

Figure 3E: Oblique posttreatment image

A predictable result is what makes the dentist look good, and a case like this is an excellent opportunity for you to invite a conversation about many aspects of endodontics that will help the dentist in the future. Now, if I were to ask you which POE you didn’t want, what would you say? Go ahead, count them. You should come up with around 10, give or take. Actually, if you are like me, you want them all. How could anyone possibly say that this one or that one probably won’t matter? And that is precisely my whole point of writing, documenting, archiving, and chronicling this series of Anatomy Matters.

Figure 3F: Clinical of MB adjacent MP joining orifice

Patient No. 4: “Does POE location matter?” (Figures 4A-4F) The patient presents with a clinically duplicable pulpitis: paroxysmal pain to heat that is immediately relieved with ice. The pain started the day before, and the day after was unbearable. Local anesthetic eliminated the pain, and endodontics was started with complete relief that evening. Endodontics was scheduled and completed. A furcal canal was staring me right in the eye (I mean microscope), and I had a decision to simply place sealed in the chamber and pack it or “follow” the furcal canal to its terminus, clean, and make a short preparation, cone fit, and pack just

Volume 6 Number 5

like any other canal, though much shorter. Was this necessary? I (we) will never know. Hopefully, I will not have to, nor will you, in your future.

Challenge/invitation Figure 4A: Pretreatment image of pulpitic mandibular right second molar

Figure 4B: Modified periapical image “following” furcal canal to radiographic and then adjusted to physiologic terminus

Figure 4D: Perpendicular posttreatment image. Four canals and eight POEs sealed

Figure 4C: Furcal conefit after downpack image

Figure 4E: Oblique posttreatment image

I make an invitation to anyone to submit contrarian documentation about Anatomy Doesn’t Matter. I believe it will be just as difficult to prove anatomy doesn’t matter as to prove that it does matter. What matters to me, however, is not so much that Anatomy Matters at all…at least biologically. What matters to me is that in order to discover, clean, fit cones, obturate, eliminate the root canal system’s LEO to source, and finish the coronal seal, I must do all the right things the right way. The details and fundamentals are not trifle. They are, instead, a measure of my thoroughness, my commitment, my declaration to the patient, staff, and referring doctors. Mandating that Anatomy Matters means that I take a stand to do all these things and more. Anatomy is a way of being, a way of practicing, and a way of thinking. It is a belief system; something we make up. But that made-up belief that for this patient that Anatomy Matters is truly a philosophy that allows us to experience those endodontic miracles, joy, and satisfaction. That Anatomy Matters is essential to your today’s signature, your today’s signature becomes tomorrow’s reputation, and your tomorrow’s reputation, becomes your legacy; the footprint you leave to all of us when your work is finished. EP

Figure 4F: Slightly oblique posttreatment image in order to better discern furcal canal minimal shaping

References 1. West J, Chivian N, Arens DE, Sigurdsson A. Endodontics and esthetic dentistry. In: Goldstein RE, Lee EA, Stappert CFJ, Chu S, eds. Esthetics in Dentistry. 2nd ed. Shelton, CT: People’s Medical Publishing House—USA; 2014. In press. 2. West J. Anatomy matters. Endodontic Practice US. 2012;5(2):14-16.

Volume 6 Number 5

3. West J. Anatomy matters — part 2. Endodontic Practice US. 2012;5(4):26-27. 4. West J. Anatomy matters part 3. Furcal endodontic seal heals furcal lesion of endodontic origin. Endodontic Practice US. 2012;5(6):22-24. 5. West J. Anatomy matters. Long-term case report. Endodontic Practice US. 2013;6(1):50-51.

6. West J. Anatomy matters. Root canal system anatomy only matters when it matters. Endodontic Practice US. 2013;6(2):56-58. 7. West J. Anatomy matters. Do lateral canals really matter? Part 6. Endodontic Practice US. 2013;6(3):5253 8. West J. Anatomy matters. “What’s it all about?” Part 7. Endodontic Practice US. 2013;6(4):52-54.

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Figures 4A-4F: Does POE location matter?

INDUSTRY NEWS J. Morita USA hires senior vice president of sales and marketing J. Morita USA announced recently that Travis Harrison has been hired as senior vice president of sales and marketing. In this role, he will assume responsibility for sales management, marketing programs, and strategic partnerships for the company’s capital equipment, small equipment, and consumable product lines. Mr. Harrison comes to Morita with more than 8 years of sales and marketing experience in imaging technologies.

Henry Schein CFO, Steven Paladino recognized for outstanding achievement, exemplary performance, leadership, and integrity Long Island Business News awarded its 2013 CFO Lifetime Achievement Award to Steven Paladino, Executive Vice President and Chief Financial Officer of Henry Schein, Inc., the world’s largest provider of health care products and services to office-based dental, animal health, and medical professionals.

DENTSPLY Tulsa Dental Specialties’ substantial donation used to outfit state-of-the-art facility with latest endodontic technology DENTSPLY Tulsa Dental Specialties, a manufacturer and marketer of innovative products for endodontics (ProTaper NEXT®, WaveOne®, GuttaCore®, ProUltra®) recently made a significant donation to help establish the University of Tennessee’s new Advanced Specialty Education Program in Endodontics. The university used the funds to purchase endodontic equipment featuring the latest technology that is housed in a newly renovated, state-of-the-art teaching facility located on the university’s Health Science Center campus in Memphis, Tennessee. The new clinic is named after the company in honor of its contribution. Previously, University of Tennessee dental students had to leave the state to receive endodontic training. The addition of the Advanced Specialty Education Program in Endodontics was a long-time goal of the university’s College of Dentistry and a demonstration of its commitment to giving patients in the community more options when a higher level of endodontic care is necessary. With the new clinic, students can learn in a total digital operatory with custom endodontic carts, digital radiography, practice management software, and microscopes connected to highdefinition plasma screens. For more information about the Advanced Specialty Education Program in Endodontics, visit http://www.uthsc.edu/dentistry/Grad/Endo/.

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56 Endodontic practice

Clinician’s Choice introduces a full line of products designed for both general dentists and endodontic specialists. New products to the CLINICIAN’S CHOICE endo line are TUNNEL VISION™ - a water soluble 19% EDTA solution for effective lubricating, chelating, and debridement of root canal preparations, as well as TRUE CAL™ 35% Calcium Hydroxide Paste. With a high 12.5pH, TRUE CAL is ideal for use as an intermediate interappointment canal treatment, as well as for a superior antimicrobial agent for apexification procedures. Both products are syringe delivered directly to the apex via an EndoFlex Tip for the ultimate in efficiency and precise placement. CLINICIAN’S CHOICE can be counted on for every day endodontic essentials, such as access burs, cordless obturation and backfill units, rotary instrumentation systems, ultrasonic units and tips, gutta percha, paper points, esthetic fiber posts, and core material. The company’s flagship endodontic product, TYPHOON™ Infinite Flex NiTi Files, was one of the first files on the market to offer controlled memory NiTi™ technology. For more information, contact CLINICIAN’S CHOICE at 1-800265-3444 or visit www.clinicianschoice.com.

Volume 6 Number 5

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