Endodontic Practice US; Vol 10, No 2 Summer 2017 by MedMark, LLC

clinical articles • management advice • practice profiles • technology reviews Summer 2017 – Vol 10 No 2

Microsurgical management for correction of a procedure error in the phase of apical mechanical preparation in endodontics: apical transport Dr. Leandro A.P. Pereira

ENDODONTICS

Comparison of working length determination during root canal treatment Drs. Jorge Paredes Vieyra, Mario Ignacio Manriquez Quintana, Francisco Javier Jiménez Enríquez, and Fabian Ocampo Acosta

Problem-solving endodontics Dr. John Rhodes

Educator profile Dr. Susan Paurazas

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* 1000x magnification 1 Azarpazhooh A et al. (2016) J Endod. 42:365-370 2 Molina B et al. (2015) J Endod. 41:1701-5 3 Sigurdsson A et al. (2016) J Endod. 42:1040-48 © 2017 Sonendo, Inc. All rights reserved. SONENDO, the SONENDO logo, GENTLEWAVE, the GENTLEWAVE logo, and SOUND SCIENCE are trademarks of Sonendo, Inc. Patented: sonendo.com/intellectualproperty. MM-0308 Rev 01

ASSOCIATE EDITORS Julian Webber, BDS, MS, DGDP, FICD Pierre Machtou, DDS, FICD Richard Mounce, DDS Clifford J Ruddle, DDS John West, DDS, MSD EDITORIAL ADVISORS Paul Abbott, BDSc, MDS, FRACDS, FPFA, FADI, FIVCD Professor Michael A. Baumann Dennis G. Brave, DDS David C. Brown, BDS, MDS, MSD L. Stephen Buchanan, DDS, FICD, FACD Gary B. Carr, DDS Arnaldo Castellucci, MD, DDS Gordon J. Christensen, DDS, MSD, PhD B. David Cohen, PhD, MSc, BDS, DGDP, LDS RCS Stephen Cohen, MS, DDS, FACD, FICD Simon Cunnington, BDS, LDS RCS, MS Samuel O. Dorn, DDS Josef Dovgan, DDS, MS Tony Druttman, MSc, BSc, BChD Chris Emery, BDS, MSc. MRD, MDGDS Luiz R. Fava, DDS Robert Fleisher, DMD Stephen Frais, BDS, MSc Marcela Fridland, DDS Gerald N. Glickman, DDS, MS Kishor Gulabivala, BDS, MSc, FDS, PhD Anthony E. Hoskinson BDS, MSc Jeffrey W Hutter, DMD, MEd Syngcuk Kim, DDS, PhD Kenneth A. Koch, DMD Peter F. Kurer, LDS, MGDS, RCS Gregori M. Kurtzman, DDS, MAGD, FPFA, FACD, DICOI Howard Lloyd, BDS, MSc, FDS RCS, MRD RCS Stephen Manning, BDS, MDSc, FRACDS Joshua Moshonov, DMD Carlos Murgel, CD Yosef Nahmias, DDS, MS Garry Nervo, BDSc, LDS, MDSc, FRACDS, FICD, FPFA Wilhelm Pertot, DCSD, DEA, PhD David L. Pitts, DDS, MDSD Alison Qualtrough, BChD, MSc, PhD, FDS, MRD RCS John Regan, BDentSc, MSC, DGDP Jeremy Rees, BDS, MScD, FDS RCS, PhD Louis E. Rossman, DMD Stephen F. Schwartz, DDS, MS Ken Serota, DDS, MMSc E Steve Senia, DDS, MS, BS Michael Tagger, DMD, MS Martin Trope, BDS, DMD Peter Velvart, DMD Rick Walton, DMD, MS John Whitworth, BchD, PhD, FDS RCS CE QUALITY ASSURANCE ADVISORY BOARD Dr. Alexandra Day, BDS, VT Julian English, BA (Hons), editorial director FMC Dr. Paul Langmaid, CBE, BDS, ex chief dental officer to the Government for Wales Dr. Ellis Paul, BDS, LDS, FFGDP (UK), FICD, editor-inchief 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 © FMC 2017. 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 Orthodontic Practice US or the publisher.

Volume 10 Number 2

Shaping the future of endodontics

his is truly the golden age of endodontics. Advancements in technology, metallurgy, and manufacturing techniques have enabled the creation of revolutionary instruments that provide endodontists greater control and more precision than ever before when performing their root canal cases. The heat treatment and thermal processing of Nickel Titanium (NiTi) files in particular has changed the endodontic game. Heat treating provides files that exhibit unprecedented flexibility and resistance to cyclic fatigue, allowing practitioners to perform procedures that would be difficult, if not unimaginable, with traditional NiTi files. EdgeEndo has focused research and development in the Dr. Charles Goodis heat treatment of NiTi files and developed a proprietary process to produce our FireWire™ line of files that exhibit 2-8 times the resistance to cyclic fatigue than other NiTi files. Increased resistance to cyclic fatigue delivers a file that cannot only navigate intricately curved canals but is much more resistant to separation. Cyclic fatigue of a NiTi file occurs when the cutting blade is subjected to repeated cycles of tension and compression that lead to stress and hardening of the material. Eventually, this leads to fracture of the metal. Cyclic fatigue is the most common cause of NiTi instrument separation. Heat treatment through EdgeEndo’s FireWire process also produces a file that demonstrates incredible flexibility and superelasticity. The benefits of a flexible file seem obvious, but some endodontists aren’t accustomed to a file that doesn’t have “shape memory.” Although shape memory may seem beneficial, it can cause a file to “bounce back” in the tooth, putting pressure on the canal wall and unnecessarily removing dentin. Files that attempt to return to straight orientation not only put undue pressure on the canal wall, but also on the file itself as it tries to straighten out in the canal. Less pressure means longer file life and ease in following the natural shape of the canal. Another advantage of an extremely flexible NiTi file that doesn’t “bounce back” is the ability to prebend it prior to starting work. Flexibility not only along the length of the file, but also up to the shaft, allows better preservation of tooth structure and greatly reduces the chance of file fracture. The technological innovations and advancements in heat treatment that have increased NiTi file performance with a combination of shape memory and superelasticity have enabled endodontists to perform procedures that were unimaginable with standard Nickel Titanium files. But taking advantage of these advancements doesn’t necessarily come at a cost. In fact, EdgeEndo’s proprietary technology creates manufacturing efficiencies that allow us to offer superior NiTi files at a fraction of traditional costs. It’s an amazing time to be in the field of endodontics; the future is truly now. Innovation is occurring at a staggering rate and is being fueled by a passion for knowledge and expertise by our practitioners. We’re excited about new technologies on the horizon and continuing to boldly go where no endo has gone before!

Dr. Charles Goodis received his DDS from the University of Michigan, his GPR residency at the University of Minnesota, and his Endodontic residency at the University of Connecticut. His undergraduate major at the University of Michigan was Mechanical Engineering. Dr. Goodis has dedicated his career to constantly improving the root canal procedure, making it safer, simpler, and more efficient. His findings led him to create more effective root canal instruments and procedures. The instruments are marketed to dentists and endodontists around the world, and he conducts national seminars on advanced (safer, simpler, faster, painless) root canal procedures. Dr. Goodis also served as a commissioned officer in the Indian Health Service as Chief Dentist at the Fort Berthold Reservation. Currently, he can be found at his private endodontic practice in Albuquerque, New Mexico. Disclosure: Dr. Goodis is founder and owner of EdgeEndo.

Endodontic practice 1

INTRODUCTION

Summer 2017 - Volume 10 Number 2

TABLE OF CONTENTS

Educator profile Susan Paurazas, DDS, MHSA, MS

Sharing evidence-based principles

Clinical

Industry news...............21

Clinical 12 Problem-solving endodontics Dr. John Rhodes presents an interactive practical and problem-solving solution by discussing simple glide path management

2 Endodontic practice

Humanitarian efforts Improving lives by saving teeth Foundation for Endodontics supports charitable care in Jamaica...............22

Volume 10 Number 2

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TABLE OF CONTENTS

Continuing education Comparison of working length determination during root canal treatment Drs. Jorge Paredes Vieyra, Mario Ignacio Manriquez Quintana, Francisco Javier Jiménez Enríquez, and Fabian Ocampo Acosta examine the working length accuracy of two electronic apex locators compared with radiographs .......................................................29

Technology profile

Continuing education

Microsurgical management for correction of a procedure error in the phase of apical mechanical preparation in endodontics: apical transport

Dr. Leandro A.P. Pereira discusses treatment for one of the most common errors in endodontic treatment

XP-3D Shaper™ and XP-3D Finisher™ Minimally Invasive Anatomical Cleaning .......................................................34

Small talk

Practice development

Dr. Joel C. Small discusses methods for orderly and peaceful change .......................................................38

The importance of website lead conversion Ian McNickle, MBA, discusses how your website can lead patients to your practice.................................. 36

Leading through change

Materials & equipment.........................39

Practice management Endospective Should I consider an Associateship? Dr. Garth W. Hatch discusses the pros and cons of adding an associate ...................................................... 37

Positive expectation of success, abundance, and happiness Dr. Rich Mounce discusses turning ideas into realities............................40

Clarification: For their article, “The advantages of instrument compressibility and ProTaper NEXT,” in the Spring 2017 issue, Dr. Michael Scianamblo and Martin Flatland would like to extend their sincere appreciation for the use of images in Figures 3 and 10A-10C, originally marked NSU BIOSCIENCE RESEARCH, that were shared courtesy of Dr. Sergio Kuttler. The authors regret any misunderstanding this may have caused. 4 Endodontic practice

PUBLISHER | Lisa Moler Email: lmoler@medmarkaz.com MANAGING EDITOR | Mali Schantz-Feld, MA Email: mali@medmarkaz.com | Tel: (727) 515-5118 ASSISTANT EDITOR | Elizabeth Romanek Email: betty@medmarkaz.com NATIONAL SALES DIRECTOR | Kristin Sammarco Email: kristin@medmarkaz.com CLIENT SERVICES/SALES SUPPORT | Adrienne Good Email: agood@medmarkaz.com CREATIVE DIRECTOR/PROD. MGR. | Amanda Culver Email: amanda@medmarkaz.com WEBSITE MANAGER | Anne Watson-Barber Email: anne@medmarkaz.com E-MEDIA PROJECT COORDINATOR | Michelle Kang Email: michellekang@medmarkaz.com FRONT OFFICE MANAGER | Theresa Jones Email: tjones@medmarkaz.com MedMark, LLC 15720 N. Greenway-Hayden Loop #9 Scottsdale, AZ 85260 Tel: (480) 621-8955 Fax: (480) 629-4002 Toll-free: (866) 579-9496 www.endopracticeus.com | www.medmarkaz.com SUBSCRIPTION RATES 1 year (4 issues) $129 | 3 years (12 issues) $349

Volume 10 Number 2

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Redefining the Endo Experience X-Smart IQ is a continuous and reciprocating cordless motor controlled by an Apple® iOS® application. Portability and Freedom of Movement in the operatory with an ergonomically designed cordless handpiece. Full-Treatment Solution that supports you through every step of your endodontic process - from patient education to treatment data. Future Capabilities to grow with your practice, allowing multiple treatment devices, services and interactive tools to be integrated in one solution. Excel in your operatory. Call 1-800-662-1202 or visit dentsplysirona.com/X-SmartIQ to find out more. Apple, iPad and iPad mini are trademarks of Apple, Inc., registered in the U.S. and other countries. App Store is a service mark of Apple Inc. iOS is a trademark or registered trademark of Cisco in the U.S. and other countries and is used under license.

EDUCATOR PROFILE

Susan Paurazas, DDS, MHSA, MS Sharing evidence-based principles

What can you tell us about your background? My dental experience started as a dental assistant. I have strong ties to the Detroit area. I attended the University of Detroit Mercy and continued to work as a dental assistant. I completed dental school and a general practice residency. I received a master’s degree from the graduate endodontic program at University of Detroit Mercy. I received a master’s in Health Service Administration from the University of Michigan, spent several years teaching and practicing endodontics, and recently became a full time educator. I am a board certified endodontist and current program director of the graduate endodontic program at the University of Detroit Mercy.

What originally attracted you to the specialty of endodontics? I became interested in endodontics initially in dental school. Dr. Robert Steiman was the graduate endodontic program director who sparked my interest. He

Susan Paurazas, DDS

Speaking at the ADEA 6 Endodontic practice

stressed the importance of proper endodontic diagnosis, which can present challenges in cases of vague pain. During my general practice residency at the Veterans Administration Medical Center, I was exposed to more advanced endodontic procedures. Dr. Thomas Stein had an influential impact on my endodontics education and provided the residents with a strong foundation on the essentials of endodontic treatment. He emphasized the complexity of the anatomy

of root canal systems and the associated treatment challenges. My co-resident and I went on to specialize in endodontics. While teaching at the University of Michigan, I worked closely with the endodontic department and was intrigued by the challenges of endodontic treatment.

What aspects of your training inspired you to add “educator” to your list of accomplishments? I had experience as an educator at the University of Michigan School of Dentistry. Volume 10 Number 2

EDUCATOR PROFILE Top favorites • CBCT imaging is having a significant impact on diagnostic findings, which can influence the suggested treatment and prognosis. • Bioceramic materials such as mineral trioxide aggregate (MTA) and Biodentine® are excellent materials. These materials are used for vital pulp therapy and perforation repair. • Surgical microscopes are essential in the practice of endodontics. Particular uses include facilitating minimally invasive endodontics and identification of canal orifices. • Trauma apps — these mobile apps are very helpful to provide a source of information on how to manage dental trauma for both dental professionals and patients. • Intraosseous injection aids such as Stabident and X-tip can aid in obtaining profound local anesthesia. • There are a multitude of nickel-titanium rotary files to choose from to help preserve the natural canal curvature. • EndoActivator for sonic activation of irrigants or EndoUltra™ or UltraFlo™ for ultrasonic activation of irrigants. • Apex locators such as Root ZX, ProMark, and Detect are useful in verifying the position of the apical foramen.

Subsequently, I entered the graduate endodontic program at University of Detroit Mercy. I was encouraged to consider contributing to the profession by Dr. Robert Ellison. His teaching focused on the importance of scientific literature to support treatment decisions. Drs. John Braud, Michael Hoen, and George Goodis served as educator role models and encouraged me to consider teaching, and fostering my interest in academics. I am focused on using evidenced-based principles to support treatment recommendations.

What are your proudest moments in the clinical and teaching aspects of your life? I find it particularly gratifying when I see a student experiencing the “aha” moment when they see the big picture and are able to put the pieces of the puzzle together to understand a concept. My goal for students is for them to reach their full potential and encourage them to be lifelong learners. A proud moment is to see the completion of a resident research project that will make a positive contribution to endodontic knowledge. As new techniques, concepts, and treatments evolve, it is important to be open to new ideas, use 8 Endodontic practice

As new techniques, concepts, and treatments evolve, it is important to be open to new ideas, use evidenced-based principles, and utilize critical thinking. This will help the profession evolve to higher levels. evidenced-based principles, and utilize critical thinking. This will help the profession evolve to higher levels. It is also particularly gratifying to provide comfortable, quality endodontic treatment and help preserve the structure and function of the natural dentition.

What do you think is unique about the topics you teach? The material that I teach is constantly being updated with the most current scientific literature. I emphasize evidencedbased learning. The studies we review are ranked according to the level of evidence. With that being said, there is an emerging concept of the integration of both quantitative and qualitative studies for clinical decision making, as well as new applications in teaching methodology. I am involved in exploring various teaching methodologies to encourage student involvement such as ‘flipped classrooms,” inter-professional education and problem-based learning. The ultimate goal is to promote critical thinking skills in the application of scientific concepts to clinical treatment, thereby improving treatment outcomes.

As an educator, what have you learned from your clinicianstudents? I consider it a privilege to teach students from a variety of educational, clinical, and cultural backgrounds. The graduate endodontic residents bring a variety of experiences and strengths to the program. It is important to identify the students’ strengths and build upon them to maximize their educational experience. By sharing their unique experiences, I can learn from the students, and they can learn from one another.

What has been your biggest challenge in sharing information and educating endodontists? The sheer volume of information is increasing exponentially. There are multiple sources of information, including printed, electronic, and video sources. It can be challenging sifting through a large volume of material to select what is the most important and relevant information that should be included. Another challenge is to present material in different ways, incorporating various teaching methodologies such as team projects and interactive learning. Volume 10 Number 2

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EDUCATOR PROFILE What is the future of endodontics? There are many exciting developments in endodontics. Regenerative endodontics is an area that I find exciting and promising. It utilizes tissue-engineering principles to help replace damaged tissues and repair teeth with immature root development. The goal is to promote development of the root apex and increase thickness of the root canal wall in immature permanent teeth. The role of dental stem cells is critical in this process. The future of endodontics will include expanding other tissue-engineering applications to improve prognosis.

What advice would you give to budding endodontists? I would encourage those interested in endodontics to continue to develop their skills through continuing education and study clubs. Consider talking with the endodontists who they work with about mentoring opportunities. The American Association of Endodontistsâ&#x20AC;&#x2122; ENDODONTICS: Colleagues

for Excellence Newsletter is a great resource for dentists. The AAE Endodontic Case Difficulty and Assessment Form is used in education to determine the potential risk factors and complications related to the level of difficulty of the tooth to be treated. Case selection is important when expanding oneâ&#x20AC;&#x2122;s clinical skills.

What would you have become if you had not become a dentist? I enjoy writing, so I may have explored a career associated with journalism. My interest in writing is manifested by reading, exploring creative writing, and the publication of research articles.

What are your hobbies, and what do you do in your spare time? Not only do I read a large volume of material for school, but I also enjoy reading for pleasure. I like to fit in a round of golf when possible. I also enjoy photography and find yoga both relaxing and invigorating. EP

See Dr. Paurazas in an Endodontic Practice US Facebook Live video: http://bit.ly/EPUS_V10N2_Paurazas

Watch for It

10 Endodontic practice

Volume 10 Number 2

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CLINICAL

Problem-solving endodontics Dr. John Rhodes presents an interactive practical and problem-solving solution by discussing simple glide path management

hen preparing challenging root canals with nickel-titanium rotary and reciprocating instruments, it is important to establish a reproducible and predetermined pathway for the instruments to follow: the glide path.

The glide path Modern nickel-titanium preparation techniques provide a very efficient means of rapidly tapering the primary root canals prior to disinfection, but negotiating complex anatomy such as sclerosed canals or severe curvatures can be difficult. Iatrogenic errors that can occur during preparation include transportation, perforation, and instrument fracture, and can be avoided by ensuring that the rotary or reciprocating instruments have a predetermined and reproducible path to follow. An infected, blocked canal could result in a persistent inflammatory response and failure of treatment.

The glide path must respect the original anatomy of the primary canal, ensure patency, and be reproducible. Generally, the glide path does not need to be bigger than an ISO size 010 hand file, and indeed, as nickel-titanium instruments are more flexible than stainless steel, they are the instrument of choice in curved canals, as they tend to remain centered and avoid straightening of the canal. In this case, a glide path was prepared using READY•STEEL® (Dentsply Maillefer) hand files ISO sizes 006 and 010. Several steps will make the process of preparing challenging canals more achievable, as outlined below.

microleakage. It was, therefore, imperative that the existing restoration was removed before root canal treatment started. Removing a restoration also gives much better visualization of the pulp floor and access to the canal orifices. It is not necessary to build up the tooth at this stage as it can be adequately isolated with good rubber dam technique. Placement of a dentinbonded core after obturation and with rubber dam isolation allows much greater control of the operative field and avoids contamination with saliva, which can have a seriously detrimental effect on the complex chemistry of dentin-bonding agents.

Coronal seal

Decoding the pulp-floor map

It is important to assess the quality of coronal seal before embarking on root canal treatment. In this case, the coronal restoration consisted of multiple restorative materials and was undoubtedly allowing

Carious dentin and the roof of the pulp chamber were removed with a tungsten carbide LN bur (Dentsply Maillefer), using a light brushing technique. The pulp floor tends to be darker than the walls and is a

Figure 1: The maxillary left first molar proved difficult to root treat as the sclerosed canals could not be located or instrumented

John Rhodes, BDS(Lond), FDS RCS(Ed), MSc, MFGDP(UK), MRD RCS(Ed), is a specialist in endodontics, the author of textbooks and numerous papers, and owner of The Endodontic Practice Poole and Dorchester (England). He lectures and teaches on endodontics nationally.

12 Endodontic practice

Figure 2: The completed root canal treatment

Watch the video To see how these steps were applied, visit https://www.youtube.com/watch?v=PSry TgehepU or search Youtube for “Endo Practice – simple glide path management.” The author is happy to answer questions directly via Youtube or Twitter @johnrhodesendo.

Volume 10 Number 2

Establishing a glide path The canal orifices were gauged with an ISO size 010 READY•STEEL flexible stainless-steel hand file. Primary coronal flaring was then completed using a ProTaper Gold® SX (Dentsply Sirona) instrument. The canals were flushed with 3% sodium hypochlorite. The working length was estimated using an apex locator, EDTA lubricant (File-Eze®, Optident), and an ISO size 006 READY•STEEL hand file. The file is used with a watch-winding action and occasionally a small amplitude filing action to define

the path to the apex. Once the apex locator reaches the zero reading, the working length is measured against a reproducible reference point. The glide path was enlarged with an ISO 010 READY•STEEL hand file, using a similar action and followed by copious irrigation with sodium hypochlorite. EDTA-based lubricants and gels are generally contraindicated during preparation with nickeltitanium rotary or reciprocating instruments but can be invaluable for initial negotiation and scouting of the root canal when estimating the working length.

Tapering the canals Once a glide path has been established, rotary or reciprocating instruments can be used to rapidly and predictably taper the canal. In this case, preparation was carried out with a single Primary WaveOne® Gold (Dentsply Sirona) instrument. The canals were prepared to approximately two-thirds of the length in one pass. Patency was confirmed with an ISO size 010 file. The

glide path had to be re-established in the mesiobuccal canals at which point a diagnostic radiograph was exposed to confirm the lengths and preparation completed.

Irrigation The root canals were irrigated using 3% sodium hypochlorite agitated with an EndoActivator® (Dentsply Sirona) in a pumping action.

Obturation The root canal system was obturated using a vertically compacted guttapercha technique and AH Plus® sealer (Dentsply Maillefer).

Coronal seal Immediately after obturation, and under rubber dam isolation, a core was constructed using dual-cure composite and a fiberglass post in the palatal canal. The general dentist will restore the tooth with a cusp-coverage restoration. EP

844.880.ENDO (3636) Volume 10 Number 2

Endodontic practice 13

CLINICAL

useful guide for locating the canal orifices. In the maxillary first molar, there is often a lip of dentin covering the second mesiobuccal canal that needs to be removed in order to locate the orifice. Once the primary mesiobuccal canal was located, a smaller LN bur was used to trough between the MB1 and MB2. The orifice of the MB2 was confirmed with a DG16 endodontic probe.

CLINICAL

Endodontic management of a C-shaped mandibular first premolar using CM-Wire instruments Drs. Roberta Câmara dos Santos, Frederico José Neves Laperriere, André Augusto Franco Marques, Murilo Priori Alcalde, Lucas da Fonseca Roberti Garcia, and Fredson Marcio Acris de Carvalho discuss successful endodontic management of a challenging root canal configuration Abstract A wide anatomical variation can be observed in mandibular premolars such as the C-shaped root canal. New instruments and equipment have been proposed to allow proper preparation of this type of root canal configuration. The objective of this article is to report the successful endodontic management of a C-shaped mandibular first premolar with a supplementary root canal using CM-Wire instruments. C-shaped root canal morphology was identified after radiographic examination and cone beam computed tomographic analysis of lower left first premolar. Initially, the supplementary root canal was negotiated with sizes 10 and 15 K-type files. Next, preparation was performed using CM-Wire instruments (Easy Equipamentos Odontológicos Belo Horizonte, MG, Brazil), as follows: patency instrument .25/01 up to the working length, .25/08 for pre-widening at the cervical and middle-thirds, and .25/06 up to the working length. Due to the supplementary root canal configuration, the orifice-enlarging instrument .30/10 was not used. Filling material removal and re-instrumentation of the other treated root canals were performed with the instrument .25/08 in continuous rotary Roberta Câmara dos Santos, DDS, is an undergraduate student at the Superior School of Health Sciences, State University of Amazonas, where Dr. André Augusto Franco Marques, DDS, MSc, PhD, and Dr. Fredson Marcio Acris de Carvalho, DDS, MSc, PhD, are Adjunct Professors. Dr. Frederico José Neves Laperriere, DDS, MSc, PhD, is a Professor and Researcher at the Dental Research Center — São Leopoldo Mandic. Dr. Murilo Priori Alcalde, DDS, MSc, is a graduate student (PhD Program) at the Department of Dentistry, Endodontics and Dental Materials, Bauru School of Dentistry, University of São Paulo. Dr. Lucas da Fonseca Roberti Garcia, DDS, MSc, PhD, is Adjunct Professor at the Department of Dentistry — Endodontics Division — Health Sciences Center, Federal University of Santa Catarina. Disclosure: The authors deny any conflicts of interest related to this study.

14 Endodontic practice

Recently, instruments manufactured with CM-Wire technology were introduced to the market as the newest innovation among the systems for root canal preparation. movement. Next, filling of root canals was performed with gutta-percha cones and AH Plus® root canal sealer by continuous wave technique. The patient reported no pain during follow-up. Clinical and radiographic examinations revealed the successful endodontic management of the C-shaped mandibular first premolar.

Introduction The knowledge of root canal system morphology is fundamental for proper diagnosis, planning, and subsequent success in endodontic treatment.1 Among teeth groups, the mandibular premolars are the type that most have anatomic variations2,3; thus, complementary exams, such as cone beam computed tomographic analysis, are necessary for a meticulous analysis of their internal anatomy.4 One of the main anatomic variations observed has been the C-shaped root canal, so named because of the cross-sectional morphology of its root and root canal.2,3 Instead of having distinct entrances to the root canals, the pulp chamber floor offers a view of a ribbon-shaped canal forming a portion of a 180° arc, beginning on the mesio-lingual line and extending around the buccal surface up to the end of the distal portion of the pulp chamber.2-4 In addition, according to Fan et al.,18 C-shaped root canals in mandibular first premolars may present configurations of different complexities, as a single and continuous C-shaped

root canal, a single-semilunar buccal root canal, a combination of both (continuous and semilunar buccal C-shaped root canal), and a C-shaped root canal, which is abruptly interrupted by a root canal of different configuration. Such anatomic variations make it difficult to detect supplementary root canals, which are frequently not adequately prepared, leading to the development and maintenance of periapical lesions that cause pain and discomfort to the patient.5 Whenever endodontic treatment failures are detected, two approaches must be considered — root canal retreatment or apical surgery — because when correctly indicated, these two options may have a successful outcome.6,7 However, when root canal access is possible, endodontic retreatment should be the first option of treatment.6,7 New instruments and techniques have improved root canal preparation over the last few years.8 Single-file systems with different kinematics, in addition to special treatments applied to NiTi instruments, are some of the evolutionary advancements recently achieved.9,10 The Easy ProDesign S system (Easy Equipamentos Odontológicos; Belo Horizonte, MG, Brazil) is composed of instruments made of NiTi that undergo special thermal treatment, promoting a controlled memory (CM) effect on the alloy (CM-Wire), increasing its flexibility and resistance to cyclic fatigue.11,12 Furthermore, the Volume 10 Number 2

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CLINICAL controlled memory effect allows pre-curving of the instruments, which does not occur in conventional NiTi alloys.11,12 This feature may be an option in cases of difficult access to root canals or patients’ difficulty with mouth opening.12 This system is composed of instruments .30/10, .25/06, .25/08, and .25/01, and may have a cross section in the shape of a double, triple, or quadruple helix.11 Moreover, they may be used in both continuous rotary or reciprocating movement.11 The aim of this article was to describe a clinical case of successful endodontic management in a C-shaped mandibular first premolar, with a supplementary root canal, using this new CM-Wire-instruments system.

Case study A 39-year-old female patient was referred to the Endodontic Clinic of the School of Health Sciences, State University of Amazonas (Brazil), complaining of pain stimulated by chewing on lower left first premolar. After review of the patient’s medical and dental history, the tooth was submitted to palpation and cold tests (Hygenic EndoIce®, Coltene/Whaledent Inc., Cuyahoga Falls, Ohio), and negative responses were obtained. However, positive response was obtained to the vertical percussion test, suggestive of a pathological feature in the peri-radicular region. The tooth’s coronal area presented with a temporary restorative material (calcium sulphate-based cement), with partial loss of this material. After performing the radiographic examination, the presence of previous endodontic treatment was observed, with two root canals presenting unsatisfactory fillings. No periapical changes were observed; however, a more detailed examination of the radiograph revealed that the root of lower left first premolar did not have a conventional shape, with a discrete radiolucent line suggestive of a supplementary root canal (Figure 1). Based on the information collected up to that time, the authors opted to perform endodontic retreatment; however, a complementary exam with cone beam computed tomography (CBCT) was requested for better evaluation of the tooth root canal system anatomy. After 14 days, the patient returned with the tomographic images previously requested (Figure 2). After a meticulous tomographic images analysis, the presence of a third root canal was found in the mesial portion of the lower left first premolar, characteristic of a C-shaped mandibular premolar. After anesthesia of the tooth with 4% articaine + epinephrine (Nova DFL, Rio de 16 Endodontic practice

Janeiro, RJ, Brazil), and performing rubber dam isolation (Hygenic, Coltene/Whaledent), the temporary restorative material was removed with a round diamond bur (FG 1011, KG Sorensen, Cotia, SP, Brazil) coupled to a high-speed handpiece (EXTRAtorque 605C, KaVo, Joinville, SC, Brazil) under copious water cooling. Subsequently, the coronal access previously performed was refined with a tapered flame-shaped bur (No. 2200, KG Sorensen) coupled to a high-speed handpiece (EXTRAtorque 605C, KaVo) for localization and adequate access to the entrance of the three root canals with C-shaped configuration. To help with access and localization of the root canals entrance, an optic microscope (DF Vasconcelos, Valencia, RJ, Brazil) was used. With the aid of a size 10 K-type file (Dentsply/Maillefer, Ballaigues, Switzerland), it was possible to localize and negotiate the supplementary root canal. A size 15 K-type file was introduced next; however, it was not possible to attain the apparent working length due to the abnormal narrowing of the canal orifice into the supplementary canal. Thus, the authors opted to use instrument 25.01 of the Easy ProDesign S system (Easy Equipamentos Odontológicos) to achieve patency through the entire supplementary root canal length. Afterwards, the working length was confirmed by using an electronic apex locator (NOVAPEX, Romidan, Kiryat, Israel). The supplementary root canal was prepared with the use of the Easy ProDesign S system, in accordance with the manufacturer’s recommendations: patency instrument .25/01 up to the working length, with smooth movements in the axial direction toward the apical direction to create the glide path, at a speed of 350 rpm, and torque of 1 N. During biomechanical preparation of the supplementary root canal, the operator had trouble gaining access with the larger diameter and taper instruments, due to the position of the root canal orifice midway down the main canal. This difficulty was overcome by pre-curvature of the CM-Wire instruments (controlled memory property). Preparation began with instrument .25/08, using brush stroke movements in an amplitude of 2 mm for pre-widening, at a speed of 900 rpm, and 4 N torque. Next, the .25/06 instrument was used to the working length, with smooth back-and-forth movements in the apical direction at a speed of 350 rpm, and 1.5 N torque. Due to the supplementary root canal configuration, the orifice enlarging instrument .30/10 was

Figure 1: Initial periapical radiograph of lower left first premolar, presenting previous unsatisfactory endodontic treatment of the buccal and lingual root canals (box). Please note the discrete radiolucent line suggestive of the presence of a supplementary root canal (arrow)

Figures 2A-2D: CBCT scan of the C-shaped mandibular first premolar. (2A) Buccal and (2B) coronal view of lower left first premolar, showing the presence of a supplementary C-shaped root canal. (2C and 2D) Sagittal view showing the entrance orifice of the supplementary root canal (arrows) Volume 10 Number 2

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Dr. Richard Mounce Dr. Richard Mounce graduated Northwestern Dental School in 1985 and obtained his certificate in Endodontics from Oregon Health Service University in 1991. A practicing endodontist, he is the owner of MounceEndo.com. Disclosure: Dr. Mounce is the North American General Manager for Easy Endo USA, and MounceEndo is a distributor of Easy Endo USA products.

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CLINICAL not used. All the instruments were used in continuous rotary movement, coupled to a handpiece with 6:1 reduction (VDW.Silver Reciproc®, Dentsply Sirona Dental Systems GmbH), driven by an electric motor (VDW Silver Reciproc Motor, Dentsply Sirona Dental Systems GmbH) (Figure 3). To remove the filling material present in the previously treated root canals, a .25/08 instrument (Easy ProDesign S system) was used in gradual rotary movement, in the direction of the apex, at a speed of 950 rpm, with 4 N torque. After obturation material removal, the working length was established and verified with an electronic apical locator (NovApex ROMIDAN) (Figure 4), and re-instrumentation of the canals was performed with the .25/08 instrument, as previously described. Throughout the entire treatment, 2.5% sodium hypochlorite solution (Biodinâmica, Ibiporã, PR, Brazil) was used for irrigating the root canals, and the content of the solution was renewed at every change of instrument. At the end of biomechanical preparation, 1 mL of 17% EDTA (Biodinâmica, Brazil) was applied in each root canal and submitted to ultrasonic agitation at low power for 1 minute. On conclusion

of this stage, the canals were dried with sterile paper points and filled with AH Plus cement (Dentsply Sirona), using a continuous wave of gutta-percha compaction with the use of the Easy Termo Pack II equipment (Easy Equipamentos Odontológicos). Initially, the tooth was temporarily restored with glass ionomer cement (Vidrion R, SS White), and then it was definitively restored with resin composite (Z350, 3M ESPE, St. Paul, Minnestota).

Discussion The mandibular first premolars may present a large number of anatomic variations.2,3

Figure 3: Instruments of the Easy ProDesign S system. Instruments cross section — double, quadruple, and triple helix (left column), and instruments size/taper — .30/10, .25/01, .25/06, and .25/08 (right column)

Figure 4: Working length determination of the root canals submitted to retreatment 18 Endodontic practice

The patient returned for evaluation 4 months after conclusion of the treatment. The patient reported no pain or discomfort in this period. New palpation and percussion tests were performed, and a negative response was obtained, demonstrating the success of the treatment performed (Figure 5).

Figure 5: Follow-up radiograph after 4 months, showing the proper preparation and filling of the C-shaped mandibular first premolar Volume 10 Number 2

Volume 10 Number 2

CLINICAL

Generally, they have one single root canal; however, the literature has reported cases of teeth with two, three, four, or even five canals.2,3,13,14 In the large majority of cases, C-shaped root canals occur in the mandibular molars (first molar) and maxillary (first and second molars); but with lower incidence, they may also affect the mandibular first premolars.5 Different population groups may present divergent anatomic characteristics for any groups of teeth.15,17 In the case of mandibular premolars, previous studies have demonstrated that populations of the United States (14%), China (18%), and India (10.7%) presented variation related to the incidence of C-shaped root canals.15-17 Mandibular premolars tend to have a longitudinal groove in their roots.18 When this anatomic accident is present, the chances of finding a C-shaped root canal significantly increase.18 In a recent study, OrdinolaZapata, et al.,18 demonstrated that 67% of the mandibular first premolars evaluated in a sample of the Brazilian population, which had a longitudinal groove in the root, presented a C-shaped root canal. However, it is worth pointing out that different methodologies of analysis, such as racial divergences among the population itself of a country may lead to controversial results.18 In spite of being the auxiliary method most used for analyzing the internal anatomy of the root canal system, periapical radiographs do not have an image quality with sufficient details, even when they are well processed; moreover, they produce a 2D image of an object with three dimensions.19 For this reason, in this clinical case, the authors opted to have a complementary tomographic exam performed. Despite its limitations, CBCT produces 3D images of the area examined; with lower levels of distortion than conventional radiographic exams, allowing the professional to detect anatomic variations with precision, and plan the best conduct for each case.20 Over the past few years, endodontic instruments have undergone a series of evolutions with the purpose of enhancing root canal preparation techniques.8 With the appearance of NiTi instruments, it has become possible to safely perform instrumentation in narrow root canals, or those with severe curvatures. Due to their greater flexibility, in comparison with stainless steel instruments, NiTi instruments are capable of maintaining the original trajectory of the root canal more easily, reducing the occurrence of serious accidents, such as perforations, zip formation, or apical deviation.21,22

Endodontic practice 19

CLINICAL In turn, thermal mechanical treatment of NiTi instruments has led to the development of new types of alloys, such as M-Wire, in which changes in the alloy microstructure provide significant gains in the mechanical properties of the instruments.23,24 Recently, instruments manufactured with CM-Wire technology were introduced to the market as the newest innovation among the systems for root canal preparation.25,26 In the case of M-Wire instruments, NiTi is submitted to a thermo-mechanical treatment, in which the austenitic phase of the alloy is transformed into R-phase; an intermediate phase obtained between the transformation from the martensitic into the austenitic phase during alloy heating.23,24 Whereas CM-Wire instruments are manufactured by means of a thermo-mechanical process, in which the martensitic phase of the alloy is privileged, allowing greater control of the mechanical memory of the material, making the instruments extremely flexible.25,26 Thus, root canal preparation with accentuated anatomic challenges may be facilitated by the mechanical characteristics of the instruments manufactured with the CM-Wire technology.25,26 As previously reported in this clinical case, a size 10 K-type file was used for localization and negotiation of the supplementary root canal. After this, a size 15 K-type file was introduced; however, it was not possible to follow through the entire length of the root canal due to its abnormal narrowing of the canal orifice into the supplementary canal. For this reason, .25/01 instrument of the Easy ProDesign S system was used; following through the entire supplementary root canal, attaining patency. According to the manufacturer of the Easy ProDesign S system, initial exploration of the root canal must be performed with small diameter hand instruments. However, this exploration may be limited to the cervical and middle thirds of the root canal, as it would not be necessary to create a glide path for the following instruments. Instrument .25/01 itself would be responsible for creating the glide path, facilitating the action of the other instruments of the system, even when the anatomic characteristics of the root canal are an obstacle to this purpose, as was observed in this clinical case. Because they are manufactured of a CM-Wire alloy, as their main characteristic, the instruments of the Easy ProDesign S system present a controlled shape memory that allows a reversible plastic deformation of the instrument during its action, thereby considerably increasing its resistance to cyclic fatigue and 20 Endodontic practice

its flexibility.25,26 Furthermore, this mechanical characteristic of the instruments allowed us to gain access to the root canals more easily, due to the possibility of pre-curving the instruments. Rodrigues, et al.,26 in a recent study, demonstrated that CM-Wire instruments could also be efficient in the re-treatment of root canals. Despite not being capable of completely removing the obturation material present in the root canal, these instruments promoted apical cleaning superior to that of reciprocating instruments.26 For this reason, the authors opted to use instruments of the Easy ProDesign S system for retreatment of the other root canals in the present case. Instrument .25/08 was used both for removing the filling material and to re-instrument the previously filled root canals.

Preparation of root canals with anatomic variations, such as those of the C-shaped type may be a great challenge to professionals.2,3 In spite of the stress to which the instrument is submitted when used for the preparation of root canals with this type of configuration, the CM-Wire instruments demonstrated an adequate performance, facilitating resolution of the case.12,26 No instrument used during the treatment was fractured or presented significant deformations, proving their resistance to cyclic fatigue.27

Conclusion The patient reported no type of pain or discomfort during the follow-up period. New clinical and radiographic exams were performed regularly, proving the success of treatment. EP

REFERENCES 1. Min Y, Fan B, Cheung GS, Gutmann JL, Fan M. C-shaped canal system in mandibular second molars part III: The morphology of the pulp chamber floor. J Endod. 2006;32(12):1155-1159. 2. Cleghorn B, Christie WH, Dong C. The root and root canal morphology of the human mandibular first premolar: a literature review. J Endod. 2007;33(9):1031-1037. 3. Cleghorn BM, Christie WH, Dong CC. Anomalous mandibular premolars: a mandibular first premolar with three roots and a mandibular second premolar with a C-shaped canal system. Int Endod J. 2008;41(11):1005-1014. 4. Fan B, Yang J, Gutmann JL, Fan M. Root canal systems in mandibular first premolars with C-shaped root configurations. Part I: microcomputed tomography mapping of the radicular groove and associated root canal cross-sections. J Endod. 2008;34(11):1337-1341. 5. Jafarzadeh H, Wu YN. The C-shaped root canal configuration: a review. J Endod. 2007;33(5):517-523. 6. Siqueira JF Jr. Aetiology of root canal treatment failure: why well-treated teeth can fail. Int Endod J. 2001;34(1):1-10. 7. Hülsmann M, Drebenstedt S, Holscher C. Shaping and filling root canals during root canal retreatment. Endod Topics. 2008;19(1):74-124. 8. da Frota MF, Filho IB, Berbert FL, Sponchiado EC Jr, Marques AA, Garcia Lda F. Cleaning capacity promoted by motor-driven or manual instrumentation using ProTaper Universal system: Histological analysis. J Conserv Dent. 2013;16(1):79-82. 9. Bürklein S, Hinschitza K, Dammaschke T, Schäfer E. Shaping ability and cleaning effectiveness of two single-file systems in severely curved root canals of extracted teeth: Reciproc and WaveOne versus Mtwo and ProTaper. Int Endod J. 2012;45(5):449-461. 10. Berutti E, Paolino DS, Chiandussi G, Alovisi M, Cantatore G, Castellucci A, Pasqualini D. Root canal anatomy preservation of WaveOne reciprocating files with or without glide path. J Endod. 2012;38(1):101-104. 11. Easy Equipamentos Odontológicos [homepage]. Limas Easy ProDesign S. Available at: http://www.easy.odo.br/limas/ limas-easy-prodesign-s-tratadas/ 12. De-Deus G, Belladonna FG, Souza EM, et al. Scouting ability of 4 pathfinding instruments in moderately curved molar canals. J Endod. 2016;42(1):1540-1544. 13. Macri E, Zmener O. Five canals in a mandibular second premolar. J Endod. 2000;26(5):304-305. 14. Farmakis ET. Four-rooted mandibular second premolar. Aust Endod J. 2008;34(3):126-128. 15. Baisden MK, Kulild JC, Weller RN. Root canal configuration of the mandibular first premolar. J Endod. 1992;18(10):505-508. 16. Sikri VK, Sikri P. Mandibular premolars: aberrations in pulp space morphology. Indian J Dent Res. 1994;5(1):9-14 17. Lu TY, Yang SF, Pai SF. Complicated root canal morphology of mandibular first premolar in a Chinese population using the cross section method. J Endod. 2006;32(10):932-936. 18. Ordinola-Zapata R, Monteiro Bramante C, Gagliardi Minotti P, et al. Micro-CT evaluation of C-shaped mandibular first premolars in a Brazilian subpopulation. Int Endod J. 2015;48(8):807-813. 19. Ordinola-Zapata R, Bramante CM, Villas-Boas MH, Cavenago BC, Duarte MH, Versiani MA. Morphologic micro-computed tomography analysis of mandibular premolars with three root canals. J Endod. 2013;39(9):1130-1135. 20. Patel S, Durack C, Abella F, Shemesh H, Roig M, Lemberg K. Cone beam computed tomography in Endodontics - a review. Int Endod J. 2015;48(1):3-15. 21. Gergi R, Rjeily JA, Sader J, Naaman A. Comparison of canal transportation and centering ability of twisted files, Pathfile-ProTaper system, and stainless steel hand K-files by using computed tomography. J Endod. 2010;36(5):904-907. 22. Hartmann MS, Fontanella VR, Vanni JR, Fornari VJ, Barletta FB. CT evaluation of apical canal transportation associated with stainless steel hand files, oscillatory technique and pro taper rotary system. Braz Dent J. 2011;22(4):288-293. 23. Shen Y, Zhou HM, Zheng YF, Peng B, Haapasalo M. Current challenges and concepts of the thermomechanical treatment of nickel-titanium instruments. J Endod. 2013;39(2):163-172. 24. Gutmann JL, Gao Y. Alteration in the inherent metallic and surface properties of nickel-titanium root canal instruments to enhance performance, durability and safety: a focused review. Int Endod J. 2012;45(2):113-128. 25. Zhou HM, Shen Y, Zheng W, Li L, Zheng YF, Haapasalo M. Mechanical properties of controlled memory and superelastic nickeltitanium wires used in the manufacture of rotary endodontic instruments. J Endod. 2012;38(11):1535-1540. 26. Rodrigues CT, Duarte MA, de Almeida MM, de Andrade FB, Bernardineli N. Efficacy of CM-Wire, M-Wire, and nickel-titanium instruments for removing filling material from curved root canals: a micro-computed tomography study. J Endod. 2016;42(11):1651-1655. 27. Alcalde MP, Tanomaru-Filho M, Bramante CM, et al. Cyclic and torsional fatigue resistance of reciprocating single files manufactured by different nickel-titanium alloys. J Endod. 2017; May 17. pii: S0099-2399(17)30298-4. doi: 10.1016/j.joen.2017.03.008.

Volume 10 Number 2

Registration opens for Carestream Dental’s 2017 Global Oral Health Summit

The American Academy of Periodontology (AAP) announced that member Yvonne Kapila, DDS, PhD, is the first recipient of its new SUNSTAR Innovation Grant (SIG). The $30,000 research grant, a component of the AAP’s recent partnership with oral health and technology company SUNSTAR, provides support to an AAP member whose research endeavors show significant potenYvonne Kapila, DDS, PhD tial to advance the science and practice of periodontics. Dr. Kapila’s research project, “Natural Bacteriocins as Pre/Pro-Biotics to Promote Oral Health and Prevent Periodontal Disease,” was selected out of 15 grant submissions. This project aims to build a foundation for using pre- or probiotics containing nisin (commonly used as a food preservative) or nisin-secreting bacteria to promote the maintenance of a healthy oral microbiome and to prevent the formation of pathogenic biofilms associated with periodontal disease. For more information, visit perio.org.

Oral health professionals of all specialties are invited to take their practice to the next level at the 2017 Global Oral Health Summit. This is a 2-day immersive learning experience designed for professionals looking to enhance their workflow by either learning more about the software and equipment they already have or by introducing new technology to their practice. The Summit, hosted by Carestream Dental, takes place November 10-12, 2017, in Orlando, Florida. It builds on the success of last year’s event in Las Vegas, which combined Carestream Dental’s three separate users’ meetings of the past into one comprehensive event. In addition to courses geared toward tackling everyday challenges, discussing the latest industry trends, and exploring innovation in diagnostic techniques, Carestream Dental trainers will also lead hands-on courses specifically designed for CS OrthoTrac, CS PracticeWorks, CS SoftDent, CS WinOMS and imaging software. Whether they’re Carestream Dental technology users or not, the Summit is geared toward clinical and front office team members, endodontists, general dentists, oral and maxillofacial surgeons, orthodontists, pedodontists, periodontists, prosthodontists, and treatment coordinators. There also will be several networking and social events at the Summit designed to connect specialists and technology users with their peers. For more information, call 800-944-6365, or visit www. carestreamdental.com.

Dr. Jaleena Fischer Jessop appointed Ultradent’s Director of Clinical Affairs Ultradent Products, Inc., a global manufacturer and distributor of dental materials and equipment, announced the appointment of Dr. Jaleena Fischer Jessop as the company’s Director of Clinical Affairs. As the director of clinical affairs, Dr. Jessop, a practicing dentist, will oversee all phases of product development to ensure that the clinician’s point of view is considered in every aspect. Additionally, Dr. Jessop will head a new clinical team at Ultradent that will work with other departments to ensure clinical input and accuracy in every area of the company. Dr. Jessop will also continue to work in her dental practice 3 days a week, applying her hands-on clinical experience to her work at Ultradent. Dr. Jessop began her undergraduate work at the University of Utah, studying medical biology prior to attending dental school. She then went on to graduate with honors in oral surgery from Loma Linda University School of Dentistry in 2002. She later completed a 2-year certification for straight-wire orthodontics from the American Orthodontic Society. Dr. Jessop has served for 2 years on the Utah Dental Association board, and has served for 3 years on the national advisory board at the University of Utah Dental School. She also currently works as an adjunct professor at the University of Utah Dental School. For more information, call 800-552-5512, or visit ultradent.com.

Volume 10 Number 2

Endodontic practice 21

INDUSTRY NEWS

American Academy of Periodontology announces first recipient of SUNSTAR Innovation Grant

HUMANITARIAN EFFORTS

Improving lives by saving teeth Foundation for Endodontics supports charitable care in Jamaica

ore than 100 teeth have been saved with root canal treatment, thanks to volunteer endodontists and endodontic residents who have provided free treatment to patients in need in Treasure Beach, Jamaica. Three trips conducted over the past year are part of the Foundation for Endodontics’ Outreach Program, a new initiative to provide patients with the highest standard of care and access to treatment to save teeth that might otherwise be extracted. “A lost tooth has serious emotional, social, and physical consequences,” said Foundation for Endodontics President Dr. Peter A. Morgan. “The opportunity to preserve a tooth with root canal treatment often isn’t an option for patients who have limited access to care. Our teams are honored to be there to relieve pain, save teeth, save smiles, and improve lives.” The Foundation for Endodontics’ team provides root canal treatment at the Helping Hands Clinic in Treasure Beach, Jamaica. Foundation volunteers Dr. Fiza Singh of Boston; Dr. Juheon Seung, a resident at the University of Maryland; and Dr. Eduardo A. Cruz, a resident at Harvard School of Dental Medicine; recently returned from their charitable care trip to Jamaica. The volunteers are working in Treasure Beach’s Helping Hand Clinic, a church that has been converted into a dental clinic. The teams of endodontists work under the guidance of Drs. William Griffin and James Carney, who have a long-standing association with the facility. In addition to providing treatment, the volunteers are educating patients about the benefit of saving their teeth and working side-by-side with general dentists and predoctoral students from the United States, thereby enhancing their understanding of the endodontic specialty. “It is very emotional. I am thrilled with what we are doing,” said volunteer Dr. Daniella S. Peinado, an endodontist in Jacksonville, Florida, and a Foundation for Endodontics Trustee. “The excitement and commitment of this team is something really amazing, and the patients are so grateful that we’re able to save their teeth.” Dr. Singh added, “It was an eye-opening experience to see so many people living in 22 Endodontic practice

Helping Hand Dental Clinic in full swing as volunteers provide free dental care to members of the Treasure Beach community

Left: Foundation Trustee Dr. Daniella Peinado with two young girls from the community. Right: Every morning before the long hours of care ahead, volunteers and patients gather together for daily devotion, led by Pastor Rowe at Helping Hand Dental Clinic

Foundation Trustee Dr. Fiza Singh performing root canal therapy on a patient in need Volume 10 Number 2

med-vac insurance, and other precautionary measures. In addition, Henry Schein Cares will provide the needed dental supplies for each trip. The Foundation plans to grow this initiative and provide a wider array of opportunities at U.S. domestic locations. Plans are underway for the first Outreach USA project in collaboration with the Endodontic Residency Program at Albert Einstein Medical Center in Philadelphia. Dr. Fred Barnett, Chairman and Program Director of Endodontics, is putting the final plans together for an Outreach program at the Project HOME Clinic. Endodontic residents and faculty from his program will work at this clinic established by Sister Mary Scullion as part her well-known Project HOME. Dr. Louis Rossman, a Philadelphia endodontist and faculty member at Einstein, has worked hard to bring this project to reality. Foundation President, Dr. Peter Morgan, states that he envisions the Foundation for Endodontics funding many more such

projects. “This is a wonderful way for our Foundation to raise the standard of care for patients with limited access to care. Bringing endodontic specialists to the basic care clinics helps patients save their natural teeth and provides unique educational opportunities to all involved.” By funding these Outreach Projects, the Foundation for Endodontics continues to be a leader among dental foundations and fulfills its mission to provide care to the underserved and public awareness of the value of saving natural teeth.

The Foundation for Endodontics The mission of the Foundation for Endodontics is to support endodontics by providing resources and funding for research, education, public awareness, and access to care. The Foundation for Endodontics supports saving natural teeth for all through the efforts of endodontic specialists. For information about the Foundation for Endodontics, please visit www.aae.org/foundation. EP

A young patient listens as Foundation Trustee Dr. Fiza Singh explains the treatment plan to relieve his pain

Foundation for Endodontics volunteer team ready to treat patients who have traveled from hours away to receive specialized care

Foundation Trustee Dr. Fiza Singh educating a volunteer dental student about endodontic care Volume 10 Number 2

Endodontic practice 23

HUMANITARIAN EFFORTS

pain. They have quickly learned that they can save their teeth by having a root canal by a specialist. The result is that patients who haven’t been able to smile for years now can live and work in confidence.” For the three initial trips, the Foundation received support from Seiler Instrument, Inc., Brasseler USA®, and Patterson Dental Supply. Recently, the Henry Schein® Cares Foundation has agreed to sponsor four trips a year for 5 years. The funds provided to the Foundation by Henry Schein Cares will cover the cost for two residents and one endodontic mentor to travel to and stay in Jamaica as well as a license to practice in the country,

CONTINUING EDUCATION

Microsurgical management for correction of a procedure error in the phase of apical mechanical preparation in endodontics: apical transport Dr. Leandro A.P. Pereira discusses treatment for one of the most common errors in endodontic treatment

ndodontics is the specialty that treats or prevents pulpal pathologies and apical periodontitis. The main objectives of endodontic treatment are to clean and disinfect the entire length of the root canal system up to a healthy level (Siqueira, et al., 2000). When such objectives are achieved through meticulous treatment, success rates can exceed 94% (Imura, et al., 2007; Lazarski, et al., 2001). Seeking these results during endodontic therapy, the mechanical preparation is carried out with endodontic instruments and chemical preparation with irrigating solutions. The mechanical preparation of the root canal system is of utmost importance in the process of endodontic disinfection (Al-Sudani, Al-Shahrani, 2006). It is responsible for physically removing the infected dentin and, consequently, bacteria located within the dentinal tubules. In addition, it increases the diameter of the main canals, allowing the delivery of a larger volume of irrigating solutions into the apical third (Shuping, et al., 1999; Siqueira, et al., 2000). It also creates a favorable conical shape for endodontic filling. Therefore, it directly influences the quality of the disinfection process and, consequently, the prognosis of the case. Improper cleaning of canals, especially the apical third, predisposes endodontic failures (Sjogren, et al., 1990; Nair, et al., 1990). Procedural errors during the mechanical preparation phase may make it impossible to reach the required disinfection levels. Yousuf, et al., 2015, made a digital radiographic evaluation of 1,748 endodontically treated teeth

Professor Dr. Leandro A. P. Pereira, is a Dental Master and PhD in Pharmacology, Anesthesiology and Therapeutics UNICAMP and a Specialist in Endodontics, Dental Operating Microscopy, and Inhalation Sedation. His private practice is limited to Endodontics at Blantus Endodontic Center. Dr. Pereira is also a Professor at the São Leopoldo Mandic Dental School in Campinas, Brazil, and Professor of Endodontic Microsurgery in the Postgraduate Program at the International University of Cataluña in Barcelona, Spain. He is also a member of American Association of Endodontists.

24 Endodontic practice

Educational aims and objectives

This clinical article aims to discuss microsurgical management for correction of a procedure error in the phase of apical mechanical preparation in endodontics.

Expected outcomes

Endodontic Practice US subscribers can answer the CE questions on page 28 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: •

Realize the importance of cleaning and disinfection of the root canal system.

•

Recognize the importance of the role of the mechanical preparation of the root canal system.

•

Realize some risks of transportation of the foramen.

•

Identify the three categories of transportation of the foramen.

and found procedural errors in 32.8% (574 teeth) of them. Transportation of the apical foramen, which may or may not lead to root perforations, is among the most common errors committed during endodontic treatment, especially in curved canals (Fogarty, Montgomery, 1991; Camara, et al., 2007; Gergi, et al., 2010). According to the Glossary of Endodontic Terms of the American Association of Endodontics, canal transportation is defined as “Removal of canal wall structure on the outside curve in the apical half of the canal due to the tendency of files to restore themselves to their original shape during canal preparation; may lead to ledge formation and possible perforation.” The inadvertent use of rigid endodontic files, especially of larger calibers, without previous and meticulous analysis of the individual internal dental anatomy, increases the risk of transposition of the foramen. Transportation of the foramen may impair the disinfection of the canal system by disabling access to its original trajectory, as well as irritating the periapical tissues by extruding bacteria and their byproducts, and derailing the ideal apical adjustment of a gutta-percha cone. These technical disabilities, imposed by operational error in the cleaning and shaping phase, can negatively influence apical sealing and appropriate bacterial control (Wu, et al., 2002). As

a result, they worsen the prognosis of the clinical case involved. According to Gluskin, et al., 2008, transportation of the foramen can be classified into the following three categories: • Type I represents a minor movement of the physiologic position of the foramen. • Type II represents a moderate movement of the physiologic position of the foramen, resulting in a considerable iatrogenic relocation on the external root surface. In this type, a larger communication with the periapical space exists. • Type III represents a severe movement of the physiologic position of the foramen and the canal, resulting in a significant iatrogenic relocation. Treatment of apical transportation cases can be made by different clinical approaches. Canals with Type I transposition transportation can usually be cleaned and filled; with Type II may be filled after the application of an apical barrier to control bleeding and to serve as a physical shield to prevent extrusion of the endodontic filling material. In these situations, placing an apical plug of MTA followed by conventional endodontic filling can also be considered. However, in clinical cases with apical transportation of Type III, it is generally not possible to achieve the desirable cleaning, Volume 10 Number 2

Clinical case A female patient, 55 years old, named ASA I, visited the dental office complaining of spontaneous, constant pain, exacerbated while chewing and apical palpation in the region of teeth Nos. 13 and 11 that had been endodontically treated 3 months before. Her measured blood pressure was 128 x 78 mmHg, heart rate 82 bpm, oxygen saturation of 98%, and body temperature of 38.5ºC. The patient reported that she did not feel pain before the start of the initial endodontic treatments, and they were indicated for oral rehabilitation reasons. After the first endodontic session by another dentist,

where teeth Nos. 13 and 11 were treated at the same time, the pain began and exacerbated after the third day. On the fourth day, the patient had to receive intravenous dipyrone and ketoprofen to control the pain. Concurrently to the systemic medication, an occlusal adjustment was performed. After 2 days, the pain returned, and the patient went to another dentist who prescribed dipyrone 500 mg/ml every 4 hours and Nimesulide 100 mg every 12 hours orally for 7 days. The pain decreased but did not cease. Two days after the end of the use of systemic medication, the patient again felt pain. She then went to a third professional who initiated the endodontic reintervention of teeth Nos. 11 and 13. However, the therapy that was being performed was not able to effectively control pain. After 4 days, the patient also began presenting febrile conditions. It was reported that the rubber dam not was used in any of the previously endodontic procedures performed.

Figure 1: Initial clinical aspect of tooth No. 11 — inadequate access opening

Figure 3: Initial radiography Volume 10 Number 2

Clinical examination revealed endodontic access on teeth Nos. 13 and 11. Inadequate geometric configuration of endodontic access already suggested problems in chemical-mechanical preparation steps of the root canal system (Figures 1 and 2). Endodontic therapy started in teeth Nos. 13 and 11, and transportation of the foramen Type III was radiographically observed. On tooth No. 12, there were a full crown, metallic post, and an inadequate previously initiated endodontic therapy (Figure 3). Apical periodontitis was diagnosed on teeth Nos. 13, 12, and 11. On the CBCT, it was possible to highlight the transposition of the foramen on tooth No. 11 (Figure 4) and tooth No. 13 (Figure 5). Despite the severity of the apical deviation on teeth Nos. 13 and 11, the first clinical attempt was carry out trying to reach the original root canal pathways. The therapy was initiated with the endodontic retreatment

Figure 2: Initial clinical aspect of tooth No. 13 — inadequate access opening

Figure 4: Tomographic image demonstrating the transportation of the foramen on tooth No. 11 Endodontic practice 25

CONTINUING EDUCATION

disinfection, and proper filling. A first attempt should be tried in order to get in to the original trajectory of the root canal. Thus, these steps should be performed as best as possible followed by an apical microsurgery to remove the untreated apical region.

CONTINUING EDUCATION

Figure 5: Tomographic image demonstrating the transportation of the foramen on tooth No. 13

Figure 6: Clinical image from the operating microscope in high magnification (24X) showing the original canal trajectory and apical deviation of tooth No. 11

Microsurgical complementation can be a safe and predictable clinical option.

of tooth No. 11 followed by tooth No. 13. The canals were irrigated with sodium hypochlorite 2.5% followed by 17% EDTA, both with PUI and prepared with Reciproc® 50 (VDW®; Munich, Germany). Through the operating microscope and periapical X-rays, it was possible to visualize the apical deviation of tooth No. 11; however, it was not possible to reach the original trajectory of the main root canal (Figures 6 and 7). The same occurred with tooth No. 13. Due to the great irregularity of the root canal walls after the transposition of the foramen, it was not possible to perform the proper fit of gutta-percha master cone. For this reason, the decision was to perform an apical plug of 4 mm with MTA-HP (Angelus®, Londrina, Brazil) (Figure 8). The filling of the rest of the canals was performed using thermoplasticized gutta percha with Fillapex MTA cement. Fillapex MTA cement contains particles of MTA in its composition. However, this approach was not effective. The proper disinfection control had not been achieved. Due to that, the spontaneous pain, although decreasing, had not ceased. In this way, an additional treatment was required to achieve the desired disinfection. The recommended complementary treatment was the endodontic microsurgery. In addition, tooth No. 12 also needed a endodontic retreatment due to the apical 26 Endodontic practice

Figure 7: Radiographic image of endodontic file positioned in the apical deviation of tooth No.11

Figure 8: Apical plug with MTA-HP

Figure 9: Canal drying of tooth No.12 with SurgiTip Volume 10 Number 2

Conclusion The mechanical chemical preparation phase of the root canal system is of utmost importance for the success of endodontic therapy. Operational errors at this stage, including transportation of the foramen, can dramatically compromise the prognosis of the case. Therefore, it is extremely important to prevent them. However, depending on the severity of the error, it can be repaired. Postoperative radiographic and clinical control of this clinical case shows that microsurgical complementation can be a safe and predictable clinical option. EP Volume 10 Number 2

CONTINUING EDUCATION

periodontitis and insufficient previous endodontic treatment. However, as the prosthetic crown of this element was adapted, and microsurgery was already planned for the neighboring teeth, the decision was to perform a retrograde endodontic treatment on tooth No. 12. After the conventional endodontic retreatment, the patient underwent apical microsurgery, where the apical area corresponding to the apical iatrogenic region was removed with Piezoelectric ultrasonic tip (W1, CVDentus®; Brazil). A Piezoelectric apicoectomy was performed on tooth No. 12 with the same ultrasonic tip. The canal was retro-prepared to the depth corresponding to the apex of the metal post present. After drying the canal with a Endo Tip 0.014” (Angelus; Londrina, Brazil) coupled to a vacuum pump, the procedure continued with the retro-filling using MTA-HP (Angelus; Londrina, Brazil) (Figures 9-11). MTA has been the material of choice for sealing perforations, retrograde preparations, and apices with irregular morphology (not circular). Its superior features of marginal adaptation, biocompatibility, sealing ability in wet environments, induction, and conduction of hard tissue formation, cementogenesis with consequent formation of normal periodontal adhesion, make it the most suitable material for these clinical situations. MTA-HP is also available in powder and liquid form. It preserves all the features of traditional MTA with the addition of easier clinical handling. This characteristic of improved clinical handling is due to a change in the particle size of the MTA powder and the addition of a plasticizer to the liquid. After 5 months of microsurgery, the patient returned for clinical radiographic control. Clinically, she no longer had any complaints of pain or discomfort. Radiographically, rapid repair of the apical periodontitis was observed in the three teeth involved (Figure 12).

Figure 10: Retrofilling of tooth No. 12 with MTA-HP

Figure 11: Immediate postoperative radiography

Figure 12: Control radiography 5 months later — periapical repair

REFERENCES 1. Imura N, Pinheiro ET, Gomes BP, Zaia AA, Ferraz CC, Souza-Filho FJ. The outcome of endodontic treatment: a retrospective study of 2000 cases performed by a specialist. J Endod. 2007;33(11):1278–1282. 2. Lazarski MP, Walker WA, Flores CM, Schindler WG, Hargreaves KM. Epidemiological evaluation of the outcomes of non-surgical root canal treatment in a large cohort of insured dental patients. J Endod. 2001;27(12):791–796, 3. Al-Sudani D, Al-Shahrani S. A comparison of the canal centering ability of ProFile, K3, and RaCe Nickel Titanium rotary systems. J Endod. 2006;32(12):1198-1201. 4. Fogarty TJ, Montgomery S. Effect of preflaring on canal transportation: Evaluation of ultrasonic, sonic, and conventional techniques. Oral Surg Oral Med Oral Pathol. 1991; 72(3):345-50. 5. Camara AC, Aguiar CM, Poli de Figueiredo JA. Assessment of the deviation after biomechanical preparation of the coronal, middle, and apical thirds of root canals instrumented with three HERO rotary systems. J Endod. 2007;33(12):1460-1463. 6. Gergi R, Rjeily JA, Sader J, Naaman A. Comparison of canal transportation and centering ability of twisted files, Pathfile-ProTaper system, and stainless steel hand K-files by using computed tomography. J Endod. 2010;36(5):904-907. 7. Shuping GB, Orstavik D, Sigurdsson A, Trope M. Reduction of intracanal bacteria using nickel-titanium rotary instrumentation and various medications. J Endod. 2000;26(12):751–755. 8. Siqueira JF, Lima KC, Magalhães FA, Lopes H, de Uzeda M. Mechanical reduction of the bacterial population in the root canal by three instrumentation techniques. J Endod. 1999;25(5):332–335. 9. Sjogren U, Hagglund B, Sundqvist G, Wing K. Factors affecting the long-term results of endodontic treatment. J Endod. 1990;16(10):498-504. 10. Nair PN, Sjӧgren U, Krey G, Kahnberg KE, Sundqvist E. Intraradicular bacteria and fungi in root-filled, asymptomatic human teeth with therapy-resistant periapical lesions: a long-term light and electron microscopic follow-up study. J Endod. 1990;16(12):580-588. 11. Wu M, Fan B, Wesselink PR. Leakage along apical root fillings in curved root canals. Part I: effects of apical transportation on seal of root fillings. J Endod. 2000;26(4):210-216. 12. Gluskin AH, Peters CI, Wong RD Ming, Ruddle CJ. Retreatment of non-healing endodontic therapy and management of mishaps. In: Bakland LK, Baumgartner, J Craig, eds. Ingle’s Endodontics. 6th ed. Hamilton, Ontario: BC Decker; 2008.

Endodontic practice 27

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REF: EP V10.2 PEREIRA

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Microsurgical management for correction of a procedure error in the phase of apical mechanical preparation in endodontics: apical transport PEREIRA

1. The main objectives of endodontic treatment are to clean and disinfect the entire length of the root canal system up to a healthy level. When such objectives are achieved through meticulous treatment, success rates can exceed ______. a. 33% b. 56% c. 75% d. 94% 2. (Regarding the mechanical preparation of the root canal system) In addition, it increases the diameter of the main canals, allowing the delivery of a larger volume of irrigating solutions into the __________. a. apical half b. apical third c. periodontal ligament space d. foramen 3. (Regarding the mechanical preparation of the root canal system) It also creates a favorable ________ for endodontic filling. a. conical shape b. J-shape c. V-shape d. none of the above 4.

Transportation of the apical foramen, which _______ root perforations, is among the most common errors

28 Endodontic practice

committed during endodontic treatment, especially in curved canals. a. definitely leads to b. definitely does not lead to c. may or may not lead to d. prevents 5.

According to the Glossary of Endodontic Terms of the American Association of Endodontics, canal transportation is defined as “Removal of canal wall structure on the outside curve in the apical half of the canal due to the tendency of files to restore themselves to their original shape during canal preparation; may lead to _________.” a. ledge formation b. possible perforation c. over disinfection d. both a and b

6. The inadvertent use of _______, especially of larger calibers, without previous and meticulous analysis of the individual internal dental anatomy, increases the risk of transposition of the foramen. a. flexible files b. rigid endodontic files c. tapered files d. NiTi files 7. Transportation of the foramen may impair the disinfection of the canal system by __________.

a. disabling access to its original trajectory b. irritating the periapical tissues by extruding bacteria and their byproducts c. derailing the ideal apical adjustment of a guttapercha cone d. all of the above 8.

(According to Gluskin, et al.’s three categories) Type II represents a moderate movement of the physiologic position of the foramen, resulting in a considerable iatrogenic relocation on the external root surface. In this type, a _______ communication with the periapical space exists. a. small b. large c. miniscule d. very severe

9. Canals with Type I transposition transportation can usually be ________. a. treated with apical microsurgery b. cleaned c. filled d. both b and c 10. MTA has been the material of choice for _________. a. sealing perforations b. retrograde preparations c. apices with irregular morphology (not circular) d. all of the above

Volume 10 Number 2

CE CREDITS

ENDODONTIC PRACTICE CE

Drs. Jorge Paredes Vieyra, Mario Ignacio Manriquez Quintana, Francisco Javier Jiménez Enríquez, and Fabian Ocampo Acosta examine the working length accuracy of two electronic apex locators compared with radiographs

ccurate determination of working length (WL) during root canal treatment is a challenge. Anatomically, the apical constriction (AC), also called the minor apical diameter or minor diameter (Kuttler, 1955), is a logical location for working length since it regularly coincides with the narrowest diameter of the root canal (American Association of Endodontists, 2003). However, locating the AC clinically is problematic. Dummer, et al., 1984, concluded that it is difficult to detect the minor foramen clinically with certainty because of its location and topography. The cementodentinal junction (CDJ) has also been suggested as the position for WL because it represents the transition between pulpal and periodontal tissue (Grove, 1931). The site of the CDJ is widely accepted as being 0.50 mm to 0.75 mm coronal to the apical foramen (Ricucci, Langeland, 1998) but, as with the AC, the exact location of the CDJ is difficult to identify clinically. In general, the CDJ is considered to be co-located with the minor foramen (Stein, Corcoran, Zillich, 1990); however, this is not always the case (Dummer, McGinn, Rees, 1984). WL is defined as “the distance from a coronal reference point to the point at which canal preparation and filling should terminate” (American Association Dr. Jorge Paredes Vieyra is an endodontist and professor of endodontics and pulp therapy at the School of Dentistry, Universidad Autónoma de Baja California, Campus Tijuana, Tijuana, Baja California, Mexico. Dr. Mario Ignacio Manriquez Quintana is a professor of oral rehabilitation at the School of Dentistry, Universidad Autónoma de Baja California, Campus Tijuana, Tijuana, Baja California, Mexico. Dr. Francisco Javier Jiménez Enríquez is a professor of oral surgery and periapical surgery at the School of Dentistry, Universidad Autónoma de Baja California, Campus Tijuana, Tijuana, Baja California, Mexico. Dr. Fabian Ocampo Acosta is a histopathologist and professor at Universidad Autónoma de Baja California, Campus Tijuana, Tijuana, Mexico.

Volume 10 Number 2

Educational aims and objectives

This clinical article aims to evaluate in vivo the accuracy of two electronic apex locators — Root ZX® and CanalPro™ — for determining the working length (WL) as compared to radiographs.

Expected outcomes

Endodontic Practice US subscribers can answer the CE questions on page 33 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: •

Realize that electronic apex locators were more accurate compared to radiographs in determining working length (WL), greatly reducing the risk of instrumenting and filling beyond the apical foramen.

•

See some history behind the electronic determination of WL.

•

Realize the challenges of accurate determination of WL.

•

Identify some advantages for electronic apex locators.

•

Recognize some drawbacks to the use of electronic devices to determine WL.

EALs were more accurate compared to radiographs with the potential to greatly reduce the risk of instrumenting and filling beyond the apical foramen. of Endodontists, 2003). Radiographic determination of WL has limitations such as distortion, shortening, and elongation; interpretation variability; and lack of threedimensional representation. Even when a paralleling technique is used, elongation of images has been found to be approximately 5% (Van de Voorde, Bjordahl, 1969). A WL 1 mm short of the radiographic apex may result in over- or under-instrumentation because of the variability in distance between the terminus of the root canal (minor foramen) and the radiographic apex (Gutiérrez, Aguayo, 1995). Thus, this often used “rule” is not predictable or reliable. Custer (1918) was the first to determine WL electronically. Suzuki (1942) investigated

the electrical resistance properties of oral tissues and developed the first electronic apex locator. The device was resistancebased and measured the resistance between two electrodes to determine the location of an instrument in the canal. Later devices were impedance-based (Nekoofar, et al., 2006) and used multiple frequencies. More recently, resistance- and capacitance-based devices emerged that measure resistance and capacitance, directly and independently. The Root ZX® (J. Morita USA, Inc.) uses the “ratio method” to locate the minor foramen (Kobayashi, Suda, 1994) by the simultaneous measurement of impedance using two frequencies. The Root ZX claims to work in the presence of electrolytes and Endodontic practice 29

CONTINUING EDUCATION

Comparison of working length determination during root canal treatment

CONTINUING EDUCATION non-electrolytes and requires no calibration (Kobayashi, 1995). CanalPro™ (Coltene-Whaledent) is a modern apex locator that uses multiple frequencies. (Unlike conventional apex locators, two measuring frequencies are alternated, not mixed, eliminating noise and the need for signal filtering.) Signal intensity is used to calculate the file tip position, making the measurement immune to electromagnetic interference in an attempt to eliminate the influence of canal conditions. In addition to improving WL accuracy (Nekoofar, et al., 2006), electronic apex locators (EALs) address concerns about radiation, as they have the potential to reduce the number of radiographs taken during root canal treatment (Pagavino, Pace, Baccetti, 1998). The purpose of this study was to evaluate in vivo the accuracy of two EALs (Root ZX and CanalPro) for determining WL as compared to radiographs. The null hypothesis is that these apex locators provide identical results related to working length determination in vivo.

Materials and methods Root ZX and CanalPro apex locators (ALs) with equal working frequencies (0.4kHz and 8kHz) were used. One hundred and eighty patients, aged 28 to 75 years, contributed to the study. One hundred and sixty teeth (493 canals) with fully formed apices (confirmed by radiographic evaluation before treatment) and apical periodontitis were used (Table 1). Pulps in 31 teeth were non-vital; the rest of the teeth gave positive responses to hot and cold tests and were scheduled for extraction for periodontal or prosthodontic reasons. Approval by the institutional review and ethical board before the start of the study was obtained, and written consent was given from each patient. After local anesthesia, rubber dam isolation and access cavity preparation were prepared in such a way that straight line access to the root canals was provided, and

undercuts were avoided. After the identification of the root canals, the canals were flared coronally with size 1 and 2 Orifice Shapers (DENTSPLY Tulsa Dental Specialties) using 2.5% sodium hypochlorite for irrigation. The final rinse was aspirated, but no attempt was made to dry the canals. The AC of each tooth was located with two EALs. The working lengths were then determined by a single operator. The Root ZX and the CanalPro were used according to the manufacturers’ instructions. The lip clip was attached to the patient’s lip, and a size 15 file was coupled to the electrode of the apex locators. The minor foramen was located with the Root ZX by advancing a size 15 stainless steel K-file in the canal until the locator indicated that the minor foramen had been reached, according to the manufacturer’s instructions. The LCD showed a flashing bar between “Apex” and “1” and a flashing tooth. The silicone stop on the file was positioned at the reference point. The instrument was fixed within a removable light-curing composite pattern (ceram.x®, DENTSPLY). This was the insertion length. Then the composite pattern was removed from the tooth. The procedure was repeated in the same tooth with another instrument using the CanalPro. In each case, the composite pattern was repositioned exactly in the respective tooth. The AC was located with

Table 1: Distribution of 160 teeth (493 canals) Number of canals Tooth

Maxillary

Mandibular

Central incisor

(10)

Lateral incisor

(8)

Canine

(5)

Premolar

(17)

Molar

(120)

225

217

Total

160

263

230

the CanalPro by advancing the same size 15 K-file in the canal until the locator indicated that the minor foramen had been reached, per the manufacturer’s instructions. The stop was positioned at the reference point and the insertion length measured. The sequence of testing alternated between the two locators. According to CanalPro’s user’s guide, the apical zone is divided into 11 segments graduated from 1.0 to 0 (Apex) as visual information of file progression. When the apex is reached (read bar at the mark “0” and reading “Apex”), a solid tone is emitted. To determine the working length for shaping, it is recommended to subtract 0.5 mm from the apical length. The minor foramen was located radiographically by advancing the size 15 K-file until its tip was 1.0 mm from the radiographic apex (determined from a pretreatment parallel technique radiograph). A radiograph was exposed, and if the file tip was seen not to be 1.0 mm from the radiographic apex, the file was repositioned and another radiograph taken to ensure that it was. The distance from the stop to the tip was the insertion length. The file was then reinserted to the insertion length (1 mm from the radiographic apex) and cemented in place with Fuji II™ LC dual-cure glass ionomer cement (GC Corp). The file handle was sectioned with a high-speed bur, and the tooth was extracted without disturbing the file, placed in 6% sodium hypochlorite for 15 minutes to remove remaining tissue from the root surface, and stored in a 0.2% thymol solution. All of the clinical procedures were conducted by the principal investigator. After the tooth was removed from the solution, and with the file still in place, the apical 5 mm of the root was ground parallel to the long axis of the canal with a fine diamond bur and abrasive discs. When the file became visible, additional dentin was removed under 20x magnification (OPMI® Pico microscope, Carl Zeiss) until the file tip, the canal terminus, and the foramen were in focus.

Table 2: Distance of file tip from minor foramen determined by Root ZX, CanalPro, and radiograph (anterior teeth)

Table 3: Distance of file tip from minor foramen determined by Root ZX, CanalPro, and radiograph (premolar teeth)

Distance from minor foramen (mm)

Radiograph n = 23 (%)

Distance from minor foramen (mm)

Root ZX n = 28 (%)

Canalpro n = 28 (%)

Radiograph n = 28 (%)

Root ZX n = 23 (%)

CanalPro n = 23 (%)

-1.0

–

-1.0

–

-0.5

–

-0.5

–

Minor foramen

19 (82.60)

16 (69.56)

5 (21.7)

Minor foramen

21 (75)

18 (64.28)

8 (28.57)

+0.5

4 (17.39)

7 (30.43)

12 (52.17)

+0.5

7 (25.0)

10 (35.71)

15 (53.57)

6 (26.08)

+1.0

(+) and (-) values indicate file tip beyond (+) or short (-) of the AC 30 Endodontic practice

5 (17.85)

(+) and (-) values indicate file tip beyond (+) or short (-) of the AC Volume 10 Number 2

Distance from minor foramen (mm)

Root ZX n = 442 canals

CanalPro n = 442 canals

Radiograph n = 442 canals

-1.0

–

-0.5

–

Minor foramen

+0.5

+1.0

–

(+) and (-) values indicate file tip beyond (+) or short (-) of the AC

The first digital image was taken and stored in Adobe Photoshop 5.5, and the distance of the file tip to the minor foramen was measured. This distance was recorded as being -1.0 mm from the minor foramen; -0.5 mm from the minor foramen; at the minor foramen; +0.5 mm from the minor foramen or +1.0 mm from the minor foramen. A minus symbol (-) indicated a file short of the minor foramen; a plus symbol (+) indicated it was long. The second image was made with the repositioned composite pattern for the measurement with the Root ZX, and the third image was made with the composite pattern for the working length determination with CanalPro. Once the actual length to the minor foramen was measured visually, the distance from the minor foramen determined by the two EALs was also completed (-1.0 mm from the minor foramen; -0.5 mm from the minor foramen, etc.) by comparing their insertion lengths to the actual length (distance to the AC) (Tables 2-4). The measurements obtained by the two EALs and radiographs relative to the actual location of the minor foramen were compared using a paired samples t-test, X2 test, and a repeated measure Anova evaluation was conducted at the 0.05 level of significance.

Results For anterior teeth, the Root ZX, CanalPro, and radiographs located the minor foramen 83%, 70%, and 22% of the time, respectively. For premolar teeth, the Root ZX, CanalPro, and radiographs located the minor foramen 75%, 64%, and 28% of the time, respectively. For molar teeth, the Root ZX, CanalPro, and radiographs located the minor foramen 63%, 51%, and 14% of the time, respectively. There was no statistically significant difference between the two EALs, but there was a difference when the Volume 10 Number 2

Assessed for eligibility (n = 160 teeth) Excluded (n= 0)

Randomized (n = 493 canals)

Root ZX 442 canals

CanalPro 442 canals

Rx 442 canals

Analyzed (n = 493 canals) Anterior: 23 Premolar: 28 Molars: 442 None excluded

Figure 1: Consort flowchart for this study

EALs and radiographs were compared (Tables 2-4). For anterior premolar and molar teeth, none of the measurements were 1.0 mm short of the minor foramen. For anterior and premolar teeth, none of the measurements were 0.5 mm short of the minor foramen, but for molar teeth 1%, 7%, and 8% of the measurements using the Root ZX, CanalPro, and radiographs, respectively, were short. For anterior teeth, the Root ZX, CanalPro, and radiographs were 0.5 mm long of the minor foramen 17%, 30%, and 52% roots,

respectively. For premolar teeth, the Root ZX, CanalPro, and radiographs were 0.5 mm long of the minor foramen 25%, 85%, and 53% roots, respectively, and for molar teeth, it was 34%, 36%, and 40%, respectively. No EAL measurements were 1.0 mm long of the minor foramen for anterior, premolar, and molar teeth; but for radiographs it was 26% for anterior teeth, 18% for premolar teeth, and 31% for molar teeth. There was no statistically significant difference between the two EALs, but there was a significant difference (p = 0.05) when the EALs and radiographs were compared. Endodontic practice 31

CONTINUING EDUCATION

Table 4: Distance of file tip from minor foramen determined by Root ZX, CanalPro, and radiograph (molars)

CONTINUING EDUCATION Discussion The present in vivo study was performed to evaluate the accuracy and predictability of two EALs for determining WL as compared to radiographs. The use of electronic devices to determine WL has gained in popularity. When using them, an important consideration is being aware of the possible sources of error such as metallic restorations, salivary contamination, dehydration, etc. However, as shown in this and other studies, the accuracy of EALs is superior to radiographs (Van de Voorde, Bjorndahl, 1969; Pratten, McDonald, 1996; Venturi, Breschi, 2007). Accurate determination of the WL is a critical step for the success of endodontic treatment. Radiography is the most commonly used technique for WL determination in clinical practice. However, it has some drawbacks. Therefore, taking into consideration the limitations of conventional radiography, the present study was designed to evaluate the accuracy of WL measurements obtained with two EALs and radiograph. One of the reasons a radiographically determined WL lacks accuracy is that it is based on the radiographic apex rather than the canal terminus — the minor foramen. WL is obtained with a radiograph by positioning the tip of a file a certain distance (usually 1.0 mm) from the radiographic apex. Nonetheless, WL should be based on the position of the minor foramen rather than the apex because the foramen frequently is not at the apex (Wrbas, et al., 2007). In this study, radiographs correctly located the minor foramen 22% of the time, whereas for the Root ZX and CanalPro, it was 83% and 70% of the time, respectively. Both EALs were within ±0.5 mm from the minor foramen 85% of the time, whereas radiographs were within ±0.5 mm of 22% of cases. An in vivo study by Shabahang, et al., 1996, reported that the Root ZX was within 0.5 mm from the minor foramen 96% of the time, a value similar to the present findings. In general, this study also agrees with others (Usun, et al., 2007) that EALs are more accurate than radiographs and greatly reduce the risk of instrumenting and filling short or beyond the canal terminus. Since the minor foramen varies in location and anatomy (sharply defined, parallel, or missing), caution should be used to avoid overestimating working length (Nekoofar, et al., 2006). According to Gutierrez and Aguayo (1995), over-instrumentation of the root canal must be a common and undetected occurrence. 32 Endodontic practice

The use of electronic devices to determine WL has gained in popularity. When using them, an important consideration is being aware of the possible sources of error such as metallic restorations, salivary contamination, dehydration, etc.

An instrument passing through a necrotic pulp and through the foramen most likely carries bacteria and toxins into the apical tissues (Siqueira, et al., 2002; Siqueira, Barnett, 2004). An indication by an EAL of reaching the minor foramen or foramen is very helpful in avoiding mishaps. Indeed, this study showed that WL obtained with radiographs was 1.0 mm long of the AC 34% of the time but 0% for the two EALs. This high incidence of error is clinically important because a WL of 1.0 mm long would result in canals being instrumented outside the foramen. Using an EAL as an aid to endodontic therapy could also help to reduce radiation dose required for WL determination, thereby reducing the radiation hazard to the patient.

Under the ex vivo conditions of this study, it can be concluded that there was no significant difference between the accuracy of the two EALs in determining the WL when compared with conventional radiography.

Conclusion Under clinical conditions, the EALs identified the minor foramen with a high degree of accuracy. EALs were more accurate compared to radiographs with the potential to greatly reduce the risk of instrumenting and filling beyond the apical foramen. EP

Acknowledgment The authors thank Professor Dr. Michael Hülsmann (Göttingen, Germany) for his valuable assistance in reviewing this manuscript.

REFERENCES 1. American Association of Endodontists. Glossary of Endodontic Terms. 7th edition. 2003. 2. Custer LE. Exact methods of locating the apical foramen. J Nat Dent Assoc. 1918;5:815-819. 3. Dummer PM, McGinn JH, Rees DG. The position and topography of the apical canal constriction and apical foramen. Int Endod J. 1984;17(4):192-198. 4. Grove CJ. The value of the dentinocemental junction in pulp canal surgery. J Dent Res. 1931;11: 466-8. 5. Gutiérrez JH, Aguayo P. Apical foraminal openings in human teeth. Number and location. Oral Surg Oral Med, Oral Pathol Oral Radiol Endod. 1995;79(6):769-777. 6. Kobayashi C. Electronic canal length measurement. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1995;79(2):226-231. 7. Kobayashi C, Suda H. New electronic canal measuring device based on the ratio method. J Endod. 1994; 20(3):111-114. 8. Kuttler Y. Microscopic investigation of root apexes. J Am Dent Assoc. 1955;50(5):544-552. 9. Nekoofar MH, Ghandi MM, Hayes SJ, Dummer PM. The fundamental operating principles of electronic root canal length measurement devices. Int Endod J. 2006;39(8):595-609. 10. Pagavino G, Pace R, Baccetti T. An SEM study of in vivo accuracy of the Root ZX electronic apex locator. J Endod. 1998;24(6):438-441. 11. Pratten DH, McDonald NJ. Comparison of radiographic and electronic working lengths. J Endod. 1996;22(4):173-176. 12. 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. 13. Shabahang S, Goon WW, Gluskin AH. An in vivo evaluation of Root ZX electronic apex locator. J Endod. 1996;22(11):616-618. 14. Siqueira JF Jr, Rôças IN, Favieri A, Machado AG, Gahyva SM, Oliveira JC, Abad EC. Incidence of postoperative pain after intracanal procedures based on an antimicrobial strategy. J Endod. 2002;28(6):457-460. 15. Siqueira JF Jr, Barnett F. Interappointment pain: mechanisms, diagnosis, and treatment. Endod Topics. 2004;7:93-109. 16. Stein TJ, Corcoran JF, Zillich RM. The influence of the major and minor foramen diameters on apical electronic probe measurements. J Endod. 1990;16(11):520-522. 17. Suzuki K. Experimental study on iontophoresis. J Stomatol Soc. (Japan). 1942;16:411-417. 18. Topuz O, Uzun O, Tinaz AC, Sadik B. Accuracy of the apex locating function of TCM Endo V in simulated conditions: a comparison study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2007;103(3):e73-76. 19. Van de Voorde HE, Bjorndahl AM. Estimating endodontic “working length” with paralleling radiographs. Oral Surg, Oral Pathol, Oral Med. 1969;27(1):106-110. 20. Venturi M, Breschi L. A comparison between two electronic apex locators: an ex vivo investigation. Int Endod J. 2007;40(5):362-373. 21. Wrbas KT, Ziegler AA, Altenburger MJ, Schirrmeister JF. In vivo comparison of working length determination with two electronic apex locators. Int Endod J. 2007;40(2):133-138.

Volume 10 Number 2

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REF: EP V10.2 VIEYRA, ET AL.

CONTINUING EDUCATION BROUGHT TO YOU BY

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Please allow 28 days for the issue of the certificates to be posted.

Comparison of working length determination during root canal treatment VIEYRA, ET AL.

1. The site of the CDJ is widely accepted as being _______ coronal to the apical foramen but, as with the AC, the exact location of the CDJ is difficult to identify clinically. a. 0.50 mm to 0.75 mm b. 1 mm c. 2 mm d. 3 mm to 4 mm 2. WL is defined as â&#x20AC;&#x153;the distance from a coronal reference point to the point at which canal preparation and filling should _________â&#x20AC;? (American Association of Endodontists, 2003). a. begin b. terminate c. widen d. taper 3. A WL ________ of the radiographic apex may result in over- or under-instrumentation because of the variability in distance between the terminus of the root canal (minor foramen) and the radiographic apex. a. 1 mm short b. 2 mm short c. 3 mm short d. 4 mm short

Volume 10 Number 2

4. ________ (1918) was the first to determine WL electronically. a. Walkhoff b. Fauchard c. Custer d. Truman 5. In addition to improving WL accuracy, electronic apex locators (EALs) address concerns about radiation, as they have the potential to ______ taken during root canal treatment. a. eliminate all radiographs b. reduce the number of radiographs c. reduce the number of intraoral photographs d. change the types of radiographs 6. However, as shown in this and other studies, the accuracy of EALs is ____ to radiographs. a. inferior b. superior c. equal d. not comparable 7. In general, this study also agrees with others that EALs _______. a. are more accurate than radiographs b. greatly reduce the risk of instrumenting and

filling short or beyond the canal terminus c. are more accurate than CBCT d. both a and b 8. Since the _________ vary/varies in location and anatomy (sharply defined, parallel, or missing), caution should be used to avoid overestimating working length. a. apex b. molar teeth c. minor foramen d. anterior premolars 9. An instrument passing through a necrotic pulp and through the foramen most likely carries _______ into the apical tissues. a. bacteria b. toxins c. antibodies d. both a and b 10. Under clinical conditions, the EALs identified the minor foramen with a(n) _____ of accuracy. a. high degree b. low degree c. equal amount d. none of the above

Endodontic practice 33

CE CREDITS

ENDODONTIC PRACTICE CE

TECHNOLOGY PROFILE

XP-3D Shaper™ and XP-3D Finisher™ Minimally Invasive Anatomical Cleaning

he XP-3D Shaper addresses the shortcomings of traditional NiTi instrumentation and ushers in a new biologic standard of care in endodontic instrumentation. The XP-3D Shaper features MaxWire® NiTi technology, which allows the instrument to expand once introduced to body temperature (Figures 1-2). As it rotates, the instrument’s orbit expands and contracts to abrade the broad and narrow aspects of the canal. This intuitive micro-mechanical debridement allows the practitioner to utilize a single primary shaping instrument to safely clean and enlarge the canal while respecting the original canal morphology.

Figure 1: At or below room temperature, the instrument is very malleable and has a relaxed serpentine shape

MaxWire® with Adaptive Core™ Technology The central core of XP-3D Shaper is a size No. 30 with a 1-degree taper. This small core allows for maximum flexibility and resistance to cyclic fatigue. When introduced to body heat, the Shaper expands its virtual core to 8 degrees. The instrument will collapse (while still providing resistance) under the constraints of the canal. When engaged at 800-1000 RPMs, the Shaper efficiently debrides the root canal walls while respecting the original anatomy. The tip of the Shaper can reach up to size No. 90, but it will not expand the size of the apex unless the canal is naturally smaller than a size No. 30. The adaptive core pulsates in the canal, dislodging dentinal debris and causing significant turbulence (Figure 3).

Figure 2: When introduced to warmer temperatures (>95ºF), the instrument transitions to a more robust serpentine shape

This intuitive micro-mechanical debridement allows the practitioner to utilize a single primary shaping instrument to safely clean and enlarge the canal while respecting the original canal morphology.

Figure 3 34 Endodontic practice

Volume 10 Number 2

Figure 4

Like the XP-3D Shaper, the XP-3D Finisher utilizes MaxWire technology to adapt to the canal’s natural anatomy. The Finisher has a sickle shape at body temperature and is incredibly flexible. Unlike the XP-3D Shaper, the XP-3D Finisher is intended to clean a prepared canal and will not change the shape of the canal. The Finisher has a larger expansion capacity than the Shaper and can reach upwards of 6 mm in diameter. The Finisher has been shown in multiple studies to provide superior final irrigation/cleaning compared to ultrasonics alone. The Finisher is also used extensively for retreatment and for cases with larger abnormal anatomy (internal resorptions, immature teeth). The Finisher is available in size No. 25 and in size No. 30 and has a zero % taper.

Premixed Bioceramic Bonded Obturation In the era of modern endodontics, shaping is no longer dictated by the limitations of obturation materials. The introduction of non-shrinking bonded obturation (BC Sealer™ and BC Points™) allows practitioners to embrace the new adaptive NiTi instrumentation. Unlike traditional sealers, BC Sealer does not shrink, and it bonds to dentin and BC Points, so it is not necessary to condense gutta percha in an effort to minimize the sealer interface. With BC Sealer, the function of gutta percha is simply to take up space, provide a path for retreatment, and provide for hydraulics/delivery of the sealer (Figure 5). Figure 5

BC Sealer Setting/Hydration Reaction The calcium silicate picks up water molecules from the dentin and forms calcium hydroxide. The calcium hydroxide combines with the calcium phosphate to form hydroxyapatite (Figure 6).

Learn More Visit www.XP-3D.com to learn more about this revolutionary new product. Watch the videos to see the XP-3D Instruments in action, review the research, and schedule a no-obligation demo in the comfort of your office. EP This information was provided by Brasseler USA.

Figure 6 Volume 10 Number 2

Endodontic practice 35

TECHNOLOGY PROFILE

The XP-3D Finisher

PRACTICE DEVELOPMENT

The importance of website lead conversion Ian McNickle, MBA, discusses how your website can lead patients to your practice

hat would you say if I told you that by making some changes to your website design, content, and layout, you could generate over $100,000 in additional revenue in 12 months? You might think I’m crazy, but I encourage you to take 5 minutes to read this article. You might be very glad you did. To learn how, we need to first take a step back and discuss online marketing. When it comes to online marketing, there are two primary objectives: 1. Generate as much “relevant” traffic as possible. 2. Convert that traffic into as many new patient leads and appointments as possible. I frequently lecture at dental conferences and study clubs all over North America, and almost without exception, the clinicians and staff in attendance are not familiar with the performance metric of website lead conversion.

Website traffic To better understand this metric, let’s start with generating traffic. There are many ways to generate traffic to a website such as high search rankings on Google, Bing, Yahoo, etc., which is achieved through effective Search Engine Optimization (SEO). Driving lots of patient reviews to review sites such as Google, Facebook, Healthgrades, and Yelp also have a very positive impact on your search rankings and traffic. Social media activity, engagement, boosted posts, and paid ads can all drive traffic to a website as well. Online directories can drive traffic, and the list goes on and on.

Ian McNickle, MBA, is a national speaker, writer, and marketer. He is a Co-Founder and Partner at WEO Media, winner of the 2016 Cellerant Best of Class Award for Dental Marketing and Dental Websites. If you have questions about any marketing-related topic, please contact Ian McNickle directly at ian@ weomedia.com, or call 888-246-6906. For more information, you can visit online at www.weodental.com.

36 Endodontic practice

Lead conversion Once you’ve implemented a robust program to generate traffic, it is equally important to understand how to convert all this traffic into new patient leads. As with traffic, there are many items that affect website lead conversion such as: • having a modern website design with proper layout • the location of the phone number • appointment request buttons or forms • clear calls to action • effective use of videos • compelling offers • online scheduling links • the use of actual photos instead of stock photos • great doctor bio and team pages • patient testimonials (video and written) • helpful and accurate content An experienced online marketing agency with expertise in the dental industry like WEO Media should be consulted for best practices in this area.

How is the lead conversion rate calculated? The lead conversion rate is calculated by dividing the amount of conversion activities (phone calls, appointment requests, etc.) by your website traffic each month. By doing this, you’ll be able to develop a baseline range for how your website typically converts traffic. Consider this example: Let’s suppose your website generates 400 visits (traffic) in a month. You received 30 phone calls from the website and 10 appointment requests through the website. Your conversion rate

would be 40 conversion activities divided into 400 visits for a conversion rate of 10%. If you monitor this rate over time, you’ll be able to understand how your website is actually performing as a marketing tool.

Maximize your Return on Investment (ROI) Where this gets really interesting is when you can improve items on your website that improve your website conversion rate. Even a small improvement can result in tens of thousands or even hundreds of thousands of dollars per year in extra revenue. An average website may generate 500 visits per month with an average conversion rate of around 10%. If you can implement strategies to improve your conversion rate, and it improves to 12%, consider the impact. This slight 2% improvement equates to 10 additional new patients leads per month or 120 per year. If you can convert even 25% of these new patient leads, you’ve now generated an extra 30 patients per year. How much is that worth? The good news is most of the items that improve the website conversion rate do not involve ongoing costs, but rather specific expertise and industry experience to properly design and construct the website.

Marketing consultation If you have questions about your website, social media, or online marketing, you may contact WEO Media for a consultation to learn more about the latest industry trends and strategies. The consultation is free if you identify yourself as a reader of this publication. EP

Receive your free marketing consultation today: 888-246-6906 or info@weomedia.com Volume 10 Number 2

Dr. Garth W. Hatch discusses the pros and cons of adding an associate

he current positive trend toward group dental practices will likely continue. Reasons for this include decreased practice overhead, improved office coverage with expanded treatment times, greater personal freedom for doctors, higher percentage of graduating female dentists who, according to some studies, are less likely to own a practice than their male counterparts, and the massive debt of graduating dental students. In 2016, the average debt for graduating dental school seniors was $262,119.1,2 This does not account for additional debt likely incurred while attending an endodontic residency program. These same trends also are increasing the number of corporate dental practices. With tightening lending policies, many graduating dentists are reluctant to go further into debt to start or buy an existing practice. I favor the private group practice model for endodontists, yet believe there is room for both corporate and private group practices. Demand will continue to drive practice models that offer the consumer expanded treatment times and greater ease of business.

Associateships Associates benefit the practice with reduced overhead costs such as the building lease, equipment, utilities and even staff salaries. Greater personal freedom and peace of mind are another major benefit. The practice can continue to operate despite vacations, continuing education absences, family emergencies, or illness.

Owner considerations • Is the practice busy enough to support two endodontists? • Will the associate be willing to work part-time while the practice grows? • Am I willing to make less short-term money for spare time and greater

Garth W. Hatch, DDS, is President and Founder of Dental Specialist Institute, a dental consulting firm committed to helping specialists receive more referrals, profits, and freedom. As an actively practicing endodontist, Dr. Hatch is aware of the challenges specialists face in today’s dental and economic environment. He is a native of Riverside, California, and earned a BS in Exercise Physiology from Brigham Young University and his DDS from Indiana University School of Dentistry. Following graduation from dental school, Dr. Hatch entered the U.S. Army Dental Corps and completed a 1-year AEGD residency at Fort Jackson, South Carolina, and later completed an endodontic residency program at Fort Gordon, Georgia. After serving in Germany, he left the military and purchased an endodontic practice in Kennewick, Washington, where he still practices.

Volume 10 Number 2

autonomy long-term? Does the new associate share the practice vision? • Is the associate clinically competent, and how will he/she be received by referring dentists? • Would the associate make a good potential partner or future practice buyer?

Associate considerations • Do I share the owner’s values and practice philosophy? • Will my salary meet my financial obligations? • Is the non-compete clause reasonable? • Will I (and my spouse) assimilate well to this location?

Final recommendations For most practices, associates should be

paid a percentage of collections, and the associate should check that the practice ideally has 98% or higher collection rate. A reasonable amount for the endodontic associates earnings is currently between 35%-45% collections. For most practices, this will fairly reward the associate and ensure the practice isn’t losing money by having them onboard. We also recommend working together at least 6-12 months prior to any buy-in or purchase. It’s like dating before marriage and you need to ensure you are both a good match. If done right, Associateships can be both personally and professionally rewarding. EP REFERENCES 1.

Annual American Dental Education Association Survey of Dental School Seniors, 2016 Graduating Class: Table 17. Level of senior’s educational debt* by type of school, 2016.

Annual American Dental Education Association Survey of Dental School Seniors, 2016 Graduating Class: Table 18. Average graduating educational debt* of 1996-2016 graduates with debt, by type of school.

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Are you ready to get MORE patients, profits and freedom in your endodontic practice? “Thank you, Dental Specialist Institute! Your expertise provided exactly what we needed to smooth out the rough edges of our practice.” - John Pawluk, DDS

Get your FREE audio training!

Get it at dentalspecialisti.com/FreeCD or call 509-578-4454 Endodontic practice 37

PRACTICE MANAGEMENT

Should I consider an Associateship?

SMALL TALK

Leading through change Dr. Joel C. Small discusses methods for orderly and peaceful change

eading our staff through periods of change and uncertainty is one of the most critical roles for us as leaders. We must recognize that not everyone is comfortable with change and that which we may perceive as minor change may be viewed as a major upheaval for certain members of our team. It is important that we introduce new and different ideas or processes in a manner that reduces staff concerns and ultimately staff pushback. Here are a few tips that may assist you in bringing about orderly and peaceful change within your practice.

1. Develop trust The essential key element necessary for voluntary change to occur is trust. Unfortunately, trust takes time to develop. New practitioners, especially those who have purchased a mature practice, should avoid the fatal mistake of introducing significant change within the practice before establishing a bond of trust with the staff. This scenario will often lead to failure, frustration, and potential loss of staff.

2. Speak with one voice The entire leadership team must be unified in their support of change. For solo practitioners, this is a simple task, but when a practice manager or other doctors are involved, it is imperative that all key players present a common message in support of the suggested change. Division among the leadership team will send a negative and confusing message to the staff.

3. Be perfectly clear

Nothing incites confusion, concern, and pushback more than poor communication about a desired change. In the absence of

“Progress is impossible without change, and those who cannot change their minds cannot change anything.” — George Bernard Shaw

clarity, the staff members are left to draw their own conclusions about the nature of change and its impact on them. Unfortunately, when this lack of clarity occurs, the staff is more likely to assume the worst possible scenarios regarding the desired change.

4. Present the vision If we expect change to occur, we better have a clear vision of what the change will look like once it is implemented, and we need to be able to communicate the vision so that it is shared by our staff. Included in a well-presented vision is an explanation of why change is necessary, what will need to change for the vision to become reality, and how the change will benefit the practice and staff.

5. Seek out early adopters It is important to identify those staff members who are not threatened by change and can buy in to the vision and necessary change early in the process. These staff members will have a calming and reassuring effect on the more skeptical and uncertain members of the team. We must let these early adopters know how much their support means to us and how important their input is to achieving the overall vision.

Joel C. Small, DDS, MBA, ACC, FICD, is a practicing endodontist and the author of Face to Face: A Leadership Guide for Healthcare Professionals and Entrepreneurs. He received his MBA, with an emphasis in healthcare management, from Texas Tech University. He is a graduate of the University of Texas at Dallas postgraduate program in executive coaching and limits his coaching practice to motivated healthcare professionals. He is a nationally recognized speaker on the subjects of leadership and professional development. Dr. Small is available for speaking engagements and for coaching healthcare professionals who wish to experience personal and professional growth while taking their practices to a higher level of productivity. **To receive a free copy of my “Core Values Exercise,” please contact me at joel@joelsmall.com. I am also available for a complimentary coaching session to discuss your practice-related issues.

38 Endodontic practice

6. Engage the staff For those of us who have seasoned veterans for staff, we simply need to define the desired result and allow the staff to determine the process for achieving the result. This technique encourages maximum buy-in by the staff because by using their own creativity and resourcefulness, they feel more relevant and essential in facilitating the change and making the vision a reality. With less seasoned staff, we may need to play a bigger role in defining the process, but we should always allow the staff to provide feedback and feel like they are vital to the process.

7. Be patient and supportive Taking a supportive role is essential for our staff during a time of change. Change does not occur spontaneously or without potential issues in a healthcare practice. By accepting that there will be a learning curve and by making allowances for inevitable mistakes and miscues, we create a psychology safe environment for our staff, and they will be more willing to contribute their feedback and best efforts toward making the vision a reality. Finally, we must always remember that change is inevitable and necessary, yet change also presents a degree of uneasiness as we move beyond our familiar comfort zone toward an unfamiliar future we have yet to experience. Knowing how to guide our staff through what may be a difficult journey for them will ultimately solidify our position as leaders and provide them with the security they desperately need throughout the change process. EP

Volume 10 Number 2

M AT E R I A L S lllllllllllll & lllllllllllll EQUIPMENT ASI launches new online support ASI has just launched its new online support site at ASIsupport. com, where clinicians can find online support, such as technical guidelines and maintenance videos by category. Easily set up an account with your information to save time when ordering new parts and supplies. Use the Technician Locator to find an ASI-preferred technician in your area, or submit a question directly to the ASI support team. Visit ASI’s new website at www.asisupport.com.

Volume 10 Number 2

Dentsply Sirona Endodontics announces new X-Smart IQ digital solution Dentsply Sirona Endodontics has announced the release of its new X-Smart IQ system, a full-treatment dental care solution that supports dental professionals through every step of the endodontic process — from patient education to treatment data. The system, through its complete digital ecosystem, redefines the endo experience at every stage of the procedure. The X-Smart IQ iOS app creates customizable treatment plans based on dental professionals’ preferred techniques. In addition, the app allows synchronization of future products and immediate updates, allowing the technology to grow with the dentist’s practice. The X-Smart IQ system allows practitioners to utilize a Dentsply Sirona file sequence or create their own and save the sequence for future use. They also can utilize the app to capture treatment notes, including tooth number, working length, last file used, and obturation method. For more information, visit www.dentsplysirona.com.

Endodontic practice 39

ENDOSPECTIVE

Positive expectation of success, abundance, and happiness Dr. Rich Mounce discusses turning ideas into realities

braham Lincoln has been quoted as saying, “Most folks are as happy as they make up their minds to be.” Amen. Recently, I met a younger man who has aspirations to own and operate a dental leadership and management company. He is well motivated and capable. His professional background is such that his dreams are achievable with the right business plan and execution. After speaking with the man for the first time, I suggested we meet and talk more. As I also have a passion for the dental industry and professional development, I hoped to learn something from him and perhaps give him the benefit of my 32 years in clinical dentistry and the wider dental and endodontic industry. Several weeks later, the man, his father, and I had dinner to chat on the subject. I’m inquisitive by nature. In my view, there are few or no stupid questions. Often the best plans are those undone by someone not asking the most basic of questions. I am also a believer in the possible. No one ever walked backward to achieve great things. More often, like buffalos that advance into the storm, they tenaciously move toward their goals when many others say the goal is not possible. At the dinner, I asked a number of questions, listened carefully to the answers, and answered the questions asked of me in return. The glow in the eyes of the perspective owner was palpable as he talked about his ideas and dreams. The main challenge he faced was related to leaving the security of his present job and the uncertainly of taking the leap into the unknown. Having a wife (who worked but was very unhappy with her job) and young children at home, he was Rich Mounce, DDS, has lectured and written globally in the specialty. He owns MounceEndo. com, an endodontic supply company also based in Neskowin, Oregon. 605-791-7000. He can be reached at RichardMounce@MounceEndo. com, MounceEndo.com. Dr. Mounce is the General Manager of Easy Endo USA and has a commercial interest in ProDesign Logic Files.

40 Endodontic practice

“Most folks are as happy as they make up their minds to be.” — Abraham Lincoln

clearly torn between a duty to provide and contribute to his family and/or pursue what he was truly passionate about. As the conversation progressed, the negativity and biases of the father began to emerge verbally. In the father’s view, 99% of all startups of this nature fail, so his attitude was why even start? Also, unless someone was going to guarantee his son’s financial security, the father said he should stay where he was and risk nothing. Coincident to this thinking was the lack of any alternative models to develop the business, perhaps start small, start with one client, and scale up through profits. No, the father was having none of it. For better or worse, I spoke up quite forcefully and told the father that he should let his son pursue his dreams and try to figure out how to make them reality rather than

trying to kill them or build a wall so high and thick it could never be breached. It made for an awkward silence! Interestingly and tellingly, the father does not live a life of abundance. The son, as Lincoln said, has a choice of moving forward and determining how happy he wants to be by following his own vision. For the most part, I don’t believe in the adage, “Build it, and they will come.” Success in anything is never assured. But I do know that one day we’ll all be on our deathbed thinking about what we would have, could have, or should have done while we were able. In that moment, I am absolutely convinced that we will much more regret the things we know we should have done and did not do rather than what we actually did. What is it that you would really like to do? I welcome your feedback. EP Volume 10 Number 2

SEE BEYOND THE SURFACE

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